LECTURES ON MATERIA MEDICA AND THERAPEUTICS, DELIVERED IN THB COLLEGE OF PHYSICIANS AND SURGEONS OF THE UNIVERSITY OF THE STATE OF NEWYORK. BY JOHN B. BECK, M.D., LATE PROFESSOR OF MATERIA MEDICA AND MEDICAL JURISPRUDENCE. PREP ABED FOR THE PRESS BY HIS FRIEND, C. R. GILMAIn, M.D., PROFESSOR OF OBSTETRICS, ETC., IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 47. Y. i LI BRAKY j SURGEON GENERAL'S 0F r iCE [ Njv.-so um /7b'' ' & • NEWYORK: SAMUEL S. & WILLIAM WOOD, 389 BROADWAY. 1856. QV pM i/ Entered according to Act of Congress, in the year 1851, by A. S. BECK, In the Clerk's Office of the District Court of the United States for the Southern District of New York. E. CRAIGHEAD, PRINTER, 53 Vesey Street. TO THE alumni of tjje College OF PHYSICIANS AND SURGEONS OF THE of % State of ftefo fTork Gentlemen : I dedicate these Lectures to you in the hope that in their present shape they may meet with a portion of that favor with which you received them when they came from the lips of the Author. C. R. GILMAN. PREFACE TO THE FIRST EDITION. In presenting these Lectures to the friends and admirers of the late De. Beck, and especially to the Alumni of the College in which he labored so long and so faithfully, a word or two explaining my own connexion with them seems to be proper. After the death of my friend I was informed that he had partly prepared his Lectures for the press, and I was requested to look at the papers and give an opinion as to whether they were in a state tit for publication, and if so to prepare them for the press. With this request I felt very reluctant to comply. Quite a number of circumstances seemed to me to point out another person for this duty ; and for myself, I felt that neither by previous study nor by habits of thought was I at all reasonably fitted for this task. There existed, indeed, but one reason why I should be selected, and that, having undertaken the duty, I have placed with a pride deeply mingled with sorrow upon the title»-page. We were friends. For twentyfive years of constant intercourse, no shade of doubt, distrust, or ill-feeling, passed between us. This, and deference to the wishes of one whose devotion to his happiness when living, is only equalled by her zealous interest in his fame when dead, induced me to undertake this labor. I found, on examination, that on most subjects the Lectures had been re-written with apparent care; on others, this was done only partially; and in VI PREFACE TO THE FIRST EDITION. one or two instances the leaves of the old Lectures were intermingled with very small portions of the new manuscript. Such was the form in which these Lectures came into my hands. Though well aware of the great amount of labor which the preparing of such a mass of matter for publication would involve, I did not shrink from it; I believed that the Lectures contained a valuable digest of the present state of knowledge in this department, and that they would be acceptable to the profession and useful to medical students. "Whether my estimate was the dictate of sound judgment or of partial friendship, the profession into whose hands I now commit the work will, of course, decide for themselves. In preparing the work for the press my agency has been merely ministerial. Where the manuscript was re-written, and free from verbal inaccuracies, it passed out of my hands untouched ; where it seemed to me that the language could be made more clear, verbal alterations have been made ; where, as happened in a very few instances, a fact was stated inaccurately, the statement was corrected; further than this I did not feel at liberty to go. The opinions are those of Dr. Beck, not of his Editor. In some cases these opinions are contrary to those which I have formed, and been in the habit of teaching; still they were his, and I did not attempt to modify or impugn them. In a few places I have added a few words where I thought by doing so I could make the book useful for students: in all cases these additions, " ne illo imputantur" are included in brackets. To these remarks there are two exceptions of sufficient importance to be specially noticed and explained. On examining the manuscripts I found proof of a fact of which I was before cognizant, viz. that on many of what are called the " New Remedies," Dr. Beck did not lecture. He was in truth, as these Lectures in almost every page will prove, not a runner after new things ; his study was much more into the indications of treatment, the circumstances modifying the operation of medicine, and those kindred topics which I should call the philosophy of Materia Medica, than into the character and claims of new and fashionable therapeutic agents. This explains the fact that many " new things" PREFACE TO THE FIRST EDITION. VII found no place in his Lectures. I had no disposition to alter them: in this respect I shared his opinions, and concurred heartily in his plan of teaching. Still there were two subjects which I supposed it proper to introduce into the book, although I found no notice of them in the Lectures. One was, to be sure, a new and fashionable, and a most extravagantly vaunted agent, Cod Liver Oil; still it appeared to me that in a matter with which the mind of the profession is at present so much occupied, something ought to be said. I have, therefore, prepared an article which I hope may not be useless. The other subject to which I referred is Anaesthetics. These agents have been introduced during the period of Dr. Beck's failing health, and he never lectured on them. #116 knew that they were noticed incidentally by two of his colleagues, Dr. Parker and myself, and that I devoted considerable time to a rather full consideration of the whole subject; hence he felt the less necessity for treating of them. When, however, his Lectures came to be presented to the profession " in a book," and especially when they were offered to students as a text-book of Materia Medica and Therapeutics, it was obviously proper that a consideration of those agents, whose use is so wide-spread, and whose utility is scarce now a subject of doubt, should appear in it. I accordingly prepared an article on Anaesthetics, in which I have tried to do justice to a class of remedies, the introduction of which into practice is, I firmly believe, a great boon to humanity. In conclusion, I have to acknowledge valuable assistance from Professor Lewis C. Beck, in the revision of the article on Proximate Principles; and to confess my own obligations for the matter I have added, to Pereira, whose book, a great storehouse of valuable knowledge in the whole subject of Materia Medica, I have consulted with confidence, and used when I needed it with freedom. PREFACE TO THE SECOND EDITION. In preparing this edition for the press, the editor has felt it his duty to make only such changes in matters of detail as shall render the book more useful to students, as presenting an accurate view of the present state of knowledge on the subject of Materia Medica. It is the boast of the cultivators of Medical Science that theirs is in a pre-eminent degree a progressive science; hence the absolute necessity of revising Text Books from time to time. Such revision it has been the editor's aim to give this book. As to those great principles of Therapeutics which constitute the distinctive merit of the work, they remain untouched. Time can only serve to confirm their truth and increase their value. MATERIA MEDICA AND THERAPEUTICS. INTRODUCTION. Br the Materia Medica is meant that branch of Medical Science which treats of the history, preparation, properties, and effects upon the living- system, in health and disease, of the various agents which are used for the prevention or cure of disease. It includes two distinct department —viz. First, Materia Medica proper, embracing simply an account of the history and properties —physical and chemical—of medicinal agents, and of their effects on the system in health. Second, Therapeutics, That which relates to the effects of these agents in their applications to the management of disease. It is in this extended sense that I propose to consider it in the following course of lectures; and I shall therefore, besides giving you a description of the various properties of medicines, endeavor to lay before you the general principles which arc to govern you in their use. There are several points of view in which medicines are generally considered in the books—viz. their natural history—their physical, their chemical, and finally, their therapeutical properties. "With regard to the natural history of medicines, it is not my intention to go into any minute botanical or mincralogical descriptions. I shall give only such general, concise notices as may be more immediately applicable to practical purposes; referring those who feel an interest in the subject to the Dispensatories for fuller information. Under the head of physical properties I shall call attention particularly to such circumstances as may assist in ascertaining the purity o 10 MATERIA MEDICA AND THERAPEUTICS. of the article as used in medicine. This is a subject of great importance, and one often neglected. To those who know to what au extent the adulteration of medicines is carried, and how often, from this cause, the expectations of the physician are frustrated, it will scarcely be necessary to say anything to show the importance of such knowledge as shall enable the practitioner to be certain that he is really giving the medicine which he has ordered. In the next place, of their chemical properties. A knowledge of the chemical properties of the medicines is no less necessary to the mere practitioner than it is to the scientific physician. By discovering the active principles of vegetables, it has enabled us to separate them from inert matter, and thus not merely to/ improve the mode of their administration, but to increase their activity. For a striking illustration we need go no further than Peruvian Bark. "Whoever compares the unwieldy and nauseous doses of this article as formerly given, with the elegant and condensed preparation made from it in the form of the sulphate of quinine, must at once admit the utility of chemical knowledge as applied to the Materia Medica. In addition to this, a knowledge of the chemical properties and relations of medicinal substances to each other, is the only thing which will enable the practitioner to avoid that very great though common error of giving articles w hich decompose each other, and cither neutralize the powers of each, or produce compounds whose effects are entirely different from those intended. With regard to the Therapeutical properties, these are the most important, and they shall claim the principal share of attention. To them a knowledge of all the other properties is only subscrvieut. This is a part of our subject of no small difficulty. The virtues ascribed to medicines arc so multifarious, and if we are to believe the reports of different writers, so positively contradictory, that it requires the soundest exercise of judgment, connected with no small share of experience, to decide what arc really the effects of medicines upon the living system, and how they may be rendered available in the cure of diseases. And as we cannot in all cases call in question the accuracy of the statements of distinguished men, however contradictory they may at first sight appear, it will frequently become a subject of philosophical and instructive inquiry to investigate the causes of this discrepancy. Such investigations are worthy of the highest efforts of intellect, as their object is to show that medicine is not an uncertain art, but a science, built upon fixed and rational principle. The principles upon which these investigations will be conducted are exceedingly simple. Without entering into any process of reasoning to establish it, the proposition may be assumed, that under similar circumstances the same medicines will produce similar effects. This is a self-evident proposition ; a nd by carefully applying it, \fc shall be able, in most cases, to arrive at a satisfactory solu- 11 INTRODUCTION. tion of the contradictory accounts which are upon record in relation to the effects of medicines. In all cases, therefore, in which the effects of the same medicine arc reported to be different, the first question to be determined is, ivas the medicine really the same ? From the ambiguity of nomenclature, and the fluctuations which it has undergone, it will not unfrcquently he found that the same term has been applied to substances totally different. Independently of this general error resulting from the confusion of terms, there are other circumstances which require investigation to ascertain the character of medicines. The virtues of medicinal vegetables especially, depend much upon the season of the year in which they are collected —upon the part of the plant used—upon the mode of preparation —upon the length of time they have been kept, Arc, eutical will properly come to be considered when we treat of the application of remedies to the management of disease. Physiological Effects. —These are divided into load and remote. By the first, we mean those impressions which the medicine makes upon the part with which it comes in immediate contact. By the second, those which are the consequence of the local ones, and which show themselves in distant parts of the system. Of the Local Effects. —In general, it may be said that there, are two ways in which medicines may act upon the part to which they are applied. In the first place, chemically, they then corrode and destroy it. Ordinary caustics applied to the surface of the body, furnish an illustration of this mode of action. Second, they may modify the vital properties of the part. The modes-in which the vital properties may thus be influenced, are various both in kind and degree. In some cases, the sensibility and irritability of the part are increased, and a stimulant or irritant effect is produced. Stimulants of various kinds, introduced into the stomach, produce on the mucous membrane of that organ such an effect. So, also, in a still more striking manner, do rubefacients and blisters applied to the surface. In these cases, the nerves and bloodvessels are both implicated. That the nerves arc affected, is evident from the heat and increased sensation, while the redness and distension show the effect on the blood-vessels. In other cases, the sensibility and irritability of the part, instead of being increased, are impaired, 13 IINTRODUCTION. and then a sedative effect is produced. Here the impression seems to be limited in a great measure to the nerves, without involving materially the blood-vessels. Of this mode of action, opium, aconite, and other narcotics furnish illustrations. In other cases, again, the local impression amounts to nothing more than exciting the absorbent vessels to which they are applied. This is the mode of action of many of those articles which are carried into the general circulation, and whose effects arc manifested only in the relief of morbid conditions of the system. The local effects of the same remedy will vary : 1st. According to the part of the system to which it is applied, e. g, when applied to the eye, brandy will produce a very different effect than when introduced into the stomach. 2d. According to the state of the part at the time— c. g. to the inflamed stomach, the effects of wine arc very different from those to the stomach in health. The remote effects, as already stated, are developed in different parts of the system. Like the local effects, they differ in character—some arc stimulating and others arc depressing —some alterative. Between the local and remote effects it is important to remark that there is no necessary similarity in the nature of their action. A medicine, for example, may be a stimulant to the part to which it is applied, and yet depressing to other parts of the system. An emetic, for example, is exciting to the stomach itself, but remotely depressing to the vascular system. Colchicum proves irritant to the stomach and bowels, while in its remote action it lowers, very strikingly, the circulation. Xo inference, therefore, can be drawn from the local action of a medicine, as to its remote effects. These differ, also, greatly in the parts of the system where they develope themselves. In some cases, the mucous tissue is the part remotely affected, as is shown in the increase or diminution of its secretions. In some cases the nervous system is the part remotely acted on. Thus opium acts locally on the stomach and remotely upon the brain and nerves of the system generally. Sometimes the vascular system is the part upon which the remote impression is chiefly developed. Digitalis, for example, a«ts thus in a remarkable manner upon the heart and blood-vessels. In other cases, again, the glandular system is chiefly affected. In this way mercury acts upon the salivary glands; iodine on the breast, thyroid, and othe glands of the system. In a great number of cases the remote effects of medicines, instead of being thus limited to particular parts, are developed in several conjointly. Thus mercury, in its remote agency, involves the mucous, the vascular, the nervous, and the whole glandular system. 14 MATERIA MEDICA AND THERAPEUTICS. Of the manner in which these Effects are Produced. —With regard to the local effects, our knowledge is confined within very naiTow limits. All that wc can say about it is, that the medicine, whatever it may be, comes in actual contact with a living surface, and produces upon it peculiar effects corresponding to the nature of the substance applied and the particular susceptibility of the part to which it is applied. In short, our knowledge docs not extend beyond the simple expression of the fact itself. How it is, or why it is, that such effects arc produced, are subjects entirely beyond our comprehension. With regard to the remote effects, the question which presents itself is of a different character —In what way is it that medicines, when locally applied, arc capable of producing effects on different parts of the system ? IIow r is it that agents taken into the stomach, or applied to the skin, can affect the brain, the lungs, the kidneys, the uterus, &c. This is a question by no means of easy solution, and has been greatly embarrassed by the theories and speculations of ingenious men. In discussing it, I shall endeavor to keep aloof from these theories, and confine myself to such views as may be sustained by fact as w 7 cll as argument. There are only two w r ays in which different parts of the system can hold intercourse or be acted upon by one another. The first of these is through the medium of the nerves y the second through the medium of the circulation. It is only in one or the other of these two ways, therefore, that the effects of medicinal agents can be produced in distant parts of the system. In other w r ords, the impression made by the medicine upon the part to which it is applied must be conveyed sympathetically, by reflex action, to other parts; or the medicine must be taken into the circulation and actually carried to different parts of the system, and thus produce its remote effects. A candid review of all the facts connected with the subject will lead us, I think, to the conclusion that in neither of these modes exclusively are the remote effects of medicines produced; but that, while in some cases they arc produced by sympathy, in others, and that the very great majority, they are the result of absorption into the circulation ; and these arc the points which I shall endeavor to establish. In the first place, of the production of the remote effects by sympathy. The human system is so constituted that no part of it is completely isolated from the rest. Impressions made upon one portion of it are extended with different degrees of force to others. An incessant intercourse is thus kept up throughout the complicated machinery of the animal economy, and the agents through which this is accomplished are the nerves. Now that some medicinal agents act through the nervous system is beyond doubt, and this is proved not so much by the rapidity with which these effects are evolved, though that was formerly 15 INTRODUCTION. much relied on, as by the character of the agents that produced them. Thus, for example, ammonia held to the nostrils almost immediately rouses from a fit of fainting; a feather applied to the same part causes sneezing ; the finger in the fauces causes vomiting, &c. Now in these cases, as well as many others which might be adduced, the effect is doubtless produced through nervous agency. Experiments made upon animals with certain poisonous agents were thought to show this in a still more conclusive manner, but more accurate investigation has robbed the argument from rapidity of action of all its force, by proving that absorption may take place in an astonishingly short time— a time quite within that in which the most violent poisons act. Blake says that the time in which a substance may be absorbed by the capillaries, and diffused throughout the body, may not exceed nine seconds. These experiments on the rapidity of absorption, and the exposition of the mode of operation of the reflex system of nerves, have thrown a flood of light on this formerly obscure subject. In the second place, of the production of the remote effects by the absorption of medicines into the circulation. In the investigation of this point two tilings require to be noticed. 1st, Are medicines actually absorbed ? and, 2d, Are the remote effects the result of this absorption ? Strange as it now appears to us it has been actually denied, and that by writers of authorit} 7 , that medicines are ever taken into the circulation. The proof, however, is jxu-fectly conclusive, and no one now thinks of denying that medicinal substances are taken into the circulation. This being so, another point remains to be settled, what is the precise mode in which their effects are finally produced ? The prevailing opinion is that the medicine, after being introduced into the circulation, is carried to different parts of the system and produces its effects by actual contact with the parts or organs in which its agency is developed. In concluding the whole subject of the modus operandi of medicines, the propositions which in the present state of our knowledge are entirely defensible, arc , 1st, That medicines differ in the manner in which their effects are produced. 2d, That some produce their effects through the nerves or by sympathy. 3d, That some are absorbed into the circulation and produce their effects in consequence of such absorption. As to the mode in which agents introduced into the general mass of the blood come to affect one organ rather than another, our knowledge is very limited ; we can hardly go beyond the expression of the fact, that certain substances have under such circumstances a tendency towards one organ rather than auother, or perhaps that one organ has, as a part of its peculiar 16 MATERIA MEDICA AND THERAPEUTICS. vitality, a special susceptibility to be affected by one agent when that is presented to it in the blood. The discussion of the modus operandi of medicines is not a mere subject of speculation ; on the contrary, it lias practical hearings of great importance, and it is on this account that I dwell upon it. 1. Medicines are modified in their effects by a great variety of circumstances, and in the treatment of many diseases it may he a matter of very great importance to determine whether the medicine which may be used produces its effects through the agency of the nerves, or by being absorbed into the circulation. In many diseases the fluids are manifestly changed in their condition, and these again react upon the solids. Is it unreasonable then to suppose that medicines, if absorbed into the circulation, must exert from this very circumstance some peculiarity in their operation ? 2. If medicinal substances be taken into the circulation, they must impregnate fluids secreted from the blood. Now milk is one of these ; and if this fluid can be thus impregnated, the sucking child must inevitably become affected. Besides if it can be proved that the articles taken into the stomach are introduced into the milk, it must necessarily modify the effect of it even as an article of diet, and may thus exert a most material influence over the whole constitution of the child. In addition to all this, if the milk can he thus charged with medicinal agents, it may be found exceedingly useful as a vehicle for administering certain medicines at an early period of life, by giving to the mother. It is important in its application to medical jurisprudence. It has been found that most poisons are absorbed, and that they are eliminated from the system mainly through the urine. If this be so, the urine ought to indicate their presence. Again, in the treatment of poisons, if they pass off by the urine, the more the quantity of urine is increased the more likely is the poison to be passed off also. Diuretics, therefore, are a class of remedies which may be made very useful here. You perceive, that this description of the modus operandi of medicines involves a great many points of great practical importance. Of the various parts of the Body to which Medicines are applied. — There are three different modes in which medicines may be brought to act on the system, viz., by applying them to some portion of the mucous membrane, by applying them to the skin, and lastly, by injecting them into the veins. Of the Application of Medicines to the Mucous Membrane. —Almost every part of this membrane may be made the seat of medical application, and in every case important effects may be produced. In the relative value and extent of these effects, however, there is a wide differ- 17 INTRODUCTION. encc, according to the part of the membrane to which the medicine is applied. The Mucous Membrane of the Stomach. —This is the surface to which medicines are usually applied, and from which effects are obtained, as a general rule, more prompt and important than when applied to any other part. The reason is obvious. Abundantly supplied with nerves, a primary impression may here be made with great effect. Placed, too, in the very centre of the system, and holding the most direct and constant intercourse with all the important organs of the body by means of its nervous communications, the stomach possesses a power of transmitting impressions unequalled by any other part. Besides this, it is supplied with a profusion of absorbing vessels, through whose agency substances may be introduced into the circulation, and thus carried to the remotest parts; over and above all this, it is the simplest and readiest mode of introducing medicines into the system. It is, therefore, generally resorted to, and in describing the effects of medicines, it is always to be understood that this is the mode unless the contrary be stated. The doses of medicines, too, are always stated in reference to this mode. The Mucous Membrane of the Large Intestines. —To this, medicines are also frequently applied, and with great effect. It possesses, however, less sensibility than the mucous membrane of the stomach, and therefore requires a larger dose of the medicine to produce the same amount of effect, as absorption is less active. Notwithstanding all this, medicines when applied here act with great efficiency, and not merely the local but the remote effects are obtained in the same way as when they are applied to the stomach. The Mucous Membrane of the Nostrils. —Medicines are sometimes applied to the surface and make a powerful impression, not merely upon the part itself, but extend their effects to other parts of the system. The vapor of ammonia, by the impression which it makes on the nerves of smell, produces a general effect upon the whole system. The Mucous Membrane of the Lungs. —The only way in which medicines can be applied here is by inhalation in the form of vapor, and as a general rule, the object had in view is to obtain their local effect upon the part itself, and they are employed for the correction of certain morbid conditions of this membrane. Notwithstanding, it is quite certain that impressions thus made, may be extended to other parts of the system. The attention of the profession has been very strongly directed to this mode of administering medicines by the general use of Anaesthetics, but of them hereafter. Besides the foregoing, there are other portions of the mucous membrane to which medicines are continually applied, such as the eye, the ear, the urethra and bladder, the vagina and uterus. In all these cases, 18 MATERIA MEDICA AND THERAPEUTICS. however, the only object is to obtain certain local effects from the remedies, though the remote or so called constitutional effects may follow, as for example, Belladonna has produced its constitutional effects when applied to the os uteri to favor dilatation. 2. The next Mode of bringing Medicines to act on the System, is by applying them to the Skin. —Blisters, rubefacients, frictions, cold and warm bathing, &c, all produce their effects in this way. Moreover, many medicines usually introduced into the stomach, may be made to produce all their ordinary effects, by applying them to the surface, and this is frequently a mode of great value. The skin is an extensive surface, plentifully supplied with nerves, and hence possessing great sensibility. It is capable, therefore, of receiving the primary impressions of medicines. An objection to the use of medicines in this way arises from the greater density of the epidermis as compared with the epithelium ; this modifies external impressions, and delays, though it does not prevent, absorption. To obviate this difficulty, two methods are resorted to —the one is to overcome it by frictions, so as to bring the medicine in contact with the sensitive portion of the skin; the other is to remove the cuticle altogether by means of a blister, so as to enable us to apply the medicine to the denuded surface. The first of these methods is called the latroleptic method, the other the Endermic method. latroleptic method. —This consists in the application of medicines by means of friction to the skin. That some medicines applied to the skin by friction are capable of producing the same effects as when taken into the stomach, is a fact well known. Thus, mercury rubbed in the form of ointment on the surface, produces salivation with as much, if not more certainty and rapidity, than the internal administration of the metal. Frictions with ointment of gold Avill produce all the specific effects of that metal on the system.* A strong decoction of tobacco rubbed on the epigastric region, or on the skin of the head, will cause nausea or * Castor oil, applied to the abdomen by friction, according to Sigmond, -will affect the bowels the same as if taken internally, especially if aided by the warm bath, lie states that " obstinate constipation has yielded to this remedy, and where such violent and constant sickness has been present as to preclude the possibility of the internal administration of the oil, it has produced all its good effects without adding to the distressing state in which the stomach is found. I have seen, by these means, an action produced upon the bowels within a quarter of an hour after the friction has been employed, immediately on the patient leaving a bath of the temperature of 98°, where calomel, jalap, neutral salts, and lavements had failed to relieve the intestinal canal, and when constant vomiting had commenced, and all idea of internal remedy had necessarily been abandoned."— Johnson's Journal, vol. xxvi. p. 493. Croton oil, it is also asserted, will produce its usual effects ou the bowels, particularly if combined with castor oil.—Ibid. 19 INTRODUCTION. vomiting. Belladonna or stramonium rubbed on tlie eyebrow will dilate the pupil as certainly as when taken inwardly. Tincture of cinchona rubbed on the spine has cured intermittent fever, when the internal exhibition of it has failed* Digitalis and squills too, rubbed on the skin, have excited the action of the urinary organs and cured dropsy. The foregoing facts arc sufficient to show that by friction on the surface, the effects of certain medicines may be fully obtained on the system. Endermic method. —This practice consists in first removing the cuticle from a portion of the skin, and then applying medicines to the denuded surface. This method is of recent origin, and we are indebted for it to M. Lambert, by whom it was first practised in one of the French hospitals, in 1828.f In this method, the first thing to be done is to separate the cuticle. The best mode of doing this is by the application of a common blister of moderate size, say about four inches square. The only objection to it is the length of time which it takes to blister. When it is desirable to apply the medicine as speedily as possible, the cuticle may be separated by the use of a pomade made of equal parts of lard and strong liquor ammonise.J By renewing this every five minutes, a blister will speedily be raised.§ The best part of the body for making the application is the epigastrium. Having separated the cuticle, the medicine is applied in the state of fine powder, or if it be too irritating, incorporated with cerate or lard. Applied in this way, a number of agents have been found to produce all their ordinary effects on the system. Among them are the sulphate of quinine, the acetate and sulphate of morphine, strychnine, belladonna, stramonium, hyosciamus, aconitine, aloes, gamboge and colocynth, squill and digitalis. From the experiments which have been made, it will appear that * Broussais cured intermittent fever in this way. Phlegmasia?, vol. ii. p. 242. See also on the effects of the external application of bark, Dr. II. Jackson in Caldwell's Theses for 1806, p. 113; also Dr. S. Pye, in Lond. Med. Obs. and Inq. vol. ii. p. 245. f Essay sur laMuthode Endermique par Ant. Lambert. Paris, 1828 \ Johnson's Journal, vol. xxii. p. 176. § Where an instantaneous blister is required, the following has been recommended : " Cut a piece of cotton, linen, or of paper, of the size and shape for which it may be required; immerse this in spirits of wine, in strong brandy, or in eau, de Cologne ; lay it on the surface to be blistered, wiping the edges, so that none of the fluid may moisten the surrounding parts; apply a lighted candle rapidly over the whole surface, that it may be burnt immediately. The ignition is exceedingly quick, and the cuticle will be found separated from the subjacent cutis."— Johnson's Journal, vol. xxvi. 494. On the endermic method, see also British and Foreign Review, vol. p. v. 343. Lon Med. Gazette, Nov. 1838, p. 233. Dunglison's Intelligencer, vol. iii. p. 50. Mad den on Cutaneous Absorption, p. 138. 20 MATERIA MEDICA AND THERAPEUTICS. medicines applied in this way act as promptly as, and sometimes more so than, when taken internally. Frequently, too, they do not require to be used in larger doses, though they generally require double the dose. A great objection to this mode is, that it sometimes produces a good deal of local irritation, causing painful and tedious sores. This I have witnessed myself in some of the first experiments which I made at the New York Hospital with the sulphate of quinine. [Many of the substances above noted produce, even when diluted, extreme pain, and they should be used in delicate, nervous subjects, with great caution; especially are they likely to do harm in children. I have known at least one case of fatal convulsions produced in this way. —Ed.] 3. Injecting into the Veins. —This is the last mode of introducing medicines into the system that requires notice. The first person who made any attempts at ascertaining the effects of medicines introduced into the veins appears to have been Dr. Wren, —then of Oxford. As early as the year 1G65, he made experiments upon dogs by injecting into the veins of the hind legs opium and the crocus metallorum. The dog in Avhom the opium was injected was stupified, but did not die. In the other, vomiting and death were the conseqiiences.* About two years afterwards experiments of a similar character were made at Pisa, by Frascati. Some of the mineral acids w 7 ere injected into the veins of dogs. These proved fatal. The first attempt made to inject medicines into the veins of the human subject appears to have been made about 1GG7 by Dr. Fabritius of Dantzick. The experiments were made upon three individuals —one male and two females—by injecting into the vein of the right arm a laxative solution. In all of them, a purgative effect "was produced on the bowels, besides which they vomited freely. Two did well; one of the females, on the day following the operation, took cold from exposure and dicd.f In the next year, 1GG8, Smith, a physician of Dantzick, experimented upon tw T o venereal patients, by introducing alterative medicines into the veins. One of these died, the other recovered. The same experiments were tried the same year upon three other patients— one laboring under the gout, another apoplexy, and a third plica polonica—all are said not only to have borne the operation well, but to have been cured of their respective complaints.^ These w T ere the earliest experiments of the kind made, and they certainly show that medicines may be injected into the veins both of man and of animals without proving fatal, and that their effects may be pro- * Hale's Boylston Prize Questions, p. 72. f Philosophical Trans, for 1067. Hale, p. 74. % Hale, p. 76. 21 INTRODUCTION. duced upon the system. Since then various other experiments have been made with the same view. In 1823, Magendie injected warm water into the veins of a patient at the Hotel Dicu, laboring under hydrophobia. It had the effect of quieting the spasms, but he nevertheless died at the end of some days. The same was tried in three other patients. In all it arrested the convulsions, without however saving the patients.* Still more reccntty, aqueous and saline fluids have been, in large quantities, injected into the veins, and in a few cases with apparent advantage, in Asiatic cholera. From all these experiments it^ appears that medicines may be introduced into the veins—and that they produce the same effects, and even more promptly, as when taken into the stomach. Nevertheless, the practice is attended with too much danger to be resorted to except in very extraordinary cases. Relative value of the different modes of introducing medicines into the system. —Having noticed the different modes in which medicines may be brought to bear upon the system, I shall make a remark or two upon their comparative value. As a general rule there can be no question that the ordinary mode of introducing medicines into the stomach is in every respect the best. Both the local and remote effects of medicines are produced more naturally and easily in this way than in any other. There is less trouble and inconvenience attending the administration, matters of no small importance. For ease and safety, then, this is to be preferred as a general practice. Cases and occasions, however, may occur in which some of the other modes are to be preferred. Such for instance as the following : —1. When the stomach will not retain medicines, and they are rejected by vomiting, or are passed by the bowels. A familiar instance of this is met with in using mercury as an alterative. It frequently, even when combined with opium, causes such a free action on the bowels as to interfere with its effects. In this case introducing it by friction on the surface is a most valuable and certain resource. 2. When some physical obstruction to swallowing occurs. 3. When some peculiar idiosyncrasy prevents the taking of medicines by the stomach. 4. In some cases in children from the difficulty of getting them to swallow medicines. In all these cases the external application may be suitable and preferable. Of the different modes of applying them externally, the latroleptic may be preferable in some cases, and the endermic in others. This must be determined by the nature of the case and the character of the remedy to be applied. With regard to injecting medicines into the veins, it is a practice attended with too much hazard to warrant its * Diet. Mat. Med., vol. iii. p. 610. f Diet. Mat. Med., vol. iii. p. 612. 22 MATERIA MEDICA AND THERAPEUTICS. adoption, except in cases of diseases intractable to the ordinary modes of treatment —such as hydrophobia, tetanus, and the like. Of the various circumstances modifying the effects of medicines. —The human system is not always the same. It differs at different periods of life, in different climates, and under various circumstances. It is very evident, therefore, that the impressions made upon it must also vary. In making out, therefore, a full and complete history of the effects of medicinal agents, it becomes necessary to analyse in detail all the circumstances which have an influence in modifying the condition of the system. 1. Age. —This modifies the condition of the human system, and, of course, the effects of medicinal agents. In infancy all the textures are exceedingly delicate, and much more easily affected by impressions made upon them than at any subsequent period. This is particularly the case with the mucous membrane and the skin, the two surfaces to which all medicinal agents are applied. The brain and nervous system, too, arc more delicate, and exercise a more predominating influence over every other part of the body. Hence it is that the brain is so easily excited by irritations, and that convulsions and organic diseases of this organ are so common at this early period. The vascular system, too, is now in a condition entirely different from what it afterwards comes. Not merely is the power of the heart and bloodvessels much less, but there exists a great difference in the relative size of the arteries and veins, as well as in the quantity of blood which they circulate. In advanced life, in all these respects, the system has undergone a complete revolution. The tissues, from being soft and delicate, become dense and firm—their sensibility and the activity of their functions are lessened. The brain and nerves, from being soft, become firm and solid—their functions are impaired, sensation is blunted, and all the motions impeded. Hence pain can bo much better borne in old age than in infancy. The blood-vessels, too, now become more solid, in many cases even ossified, and the venous blood in the system bears a much larger proportion to the arterial than it did at previous periods, and venous congestions are common. From all this it is very evident that the s}' , stem undergoes a great change, and it would seem as a matter of course that the effects of agents applied to it must be greatly modified by these changes, and such indeed is proved to be the case by observation and experience. Almost every medicinal agent is more or less modified in according to the period of life at which it is administered. For example : Emetics are given at all ages, and yet how different are their general effects. In infancy vomiting is excited with little or no difficulty, and so far as the mere mechanical process is concerned, attended with no danger. If, however, some active article be used, even in doses 23 INTRODUCTION. suitable to the age, the consequences may be fatal. Tartar emetic has thus been known to produce vomiting which ended in death. In advanced life, on the other hand, 'from the impaired sensibility of the organs concerned, vomiting is not so readily excited, while the mechanical process, which in children is attended with no danger, is now frequently destructive of life, owing to the tendency which there exists at this period to venous congestion of the brain. Cathartics afford a second illustration. In early life, as a general rule, this class of medicines operates much more readily than they do afterwards. As we advance in years, the intestines, in consequence of their repeated stimulation, have their sensibility impaired and their contractile power lessened, and cathartics make less impression; accordingly, they require to be used in much larger doses, and the more active articles selected. On the other hand, it is to be recollected that the intestines of children are more liable to he lined with collections of viscid mucus; and when this is the case, they can hear much larger proportional doses. Opium furnishes another illustration. While to adults this drugmay be given with perfect safety, in its effects upon children there is frequently nothing so uncertain. Not unfrequcntly the simplest preparations of it, administered, too, in reasonable doses, have been attended by alarming and even fatal symptoms. The syrup of poppies and Paregoric have both operated occasionally in this way. I shall notice only one other illustration, and that is Venesection. This is a remedy resorted to, and very properly, at all ages ; and yet in many cases it is to be feared without due regard to the difference of effect produced by it. As a general rule, children do not bear the loss of large quantities of blood so well as adults. One or two bleedings they may bear, if carried any further they sink under it. Nor do they recover from syncope, when induced by venesection, so readily as adults. On the contrary, such is the deficient reaction in them, that this state is always attended with more or less danger. In old age, the same general rule holds good. Moderate quantities of blood ¦ may be abstracted with beneficial effect, while the loss of large quantities is followed by great prostration of the powers of life. The foregoing illustrations, selected from a thousand others, which might be adduced, are abundant to show the importance of investigating the effects of remedies at different periods of life. Unless this be done, it is idle to suppose that they can be properly or even safely employed in the treatment of the various diseases to which the human frame, from infancy to old age, is liable. 2. Sex. —This modifies very greatly the condition of the human system, and it must therefore, also, as a matter of course modify the effects of medicinal agents. As a general rule, the constitution of 24 MATERIA MEDICA AND THERAPEUTICS. females is much more delicate than that of males. Their nervous system is also much more excitable. Hence impressions are more easily made upon them by medicinal agents. The more active articles accordingly require to be used with much greater caution in them. In venereal hospitals it has been observed that only half the quantity of mercury is necessary to produce precisely the same effect as in males. Independently of the general delicacy of constitution, there is another circumstance attending the female which greatly modifies the effect of remedies, and that is a state of pregnancy. During this state, women bear blood-letting much better than at any other period ; for the purpose of subduing disease, it is frequently necessaiy to carry it to a much greater extent than under the ordinary conditions of the system.'* Tonics, on the other hand, are not borne so well, and do not appear to produce precisely the same effects. The Peruvian hark, accordingly, very frequently fails under these circumstances to arrest the paroxysms of intermittent fever. In the advanced stages of pregnancy, the use of emetics is frequently followed by a premature expulsion of the foetus. 3. Peculiar Habit and Constitution of Body. —This modifies very greatly the effect of remedies. Ceteris paribus, fat persons arc vomited with more facility than lean ones. As a general rule, fat persons have less blood in proportion than lean ones, and on that account do not hear the loss of such large quantities. In delicate and irritable habits, blisters cause a great degree of nervous and vascular excitement, attended not unfrequently with the most distressing effects on the system at large. There is, perhaps, no medicine which shows in a more striking manner the modifying effects of temperament than mercury —an article which, in robust constitutions, may be given with impunity, in nervous and irritable habits, especially if carried to any extent, is followed by effects the most disastrous, augmenting general irritability, and predisposing the system to the invasion and development of various and even fatal diseases. 4. Climate and Season. —By the powerful effect which these exercise upon the human frame, they exert a modifying influence on the effects of remedies. So fully was the celebrated Baglivi impressed with the truth of this, that he frequently adds, in giving an account of his treatment, " Vivo et scribo in ./Ere Romano." Celsus has observed, that "medicines differ according to the nature of the climate; one kind being necessary in Rome, another in Egypt, and a third in France." To the same effect Baglivi says that, " The Spaniards, any more than the Italians, if their physicians may be credited, cannot well bear rough medicines of any kind." *By some it has been supposed that in hot climates, and in warm w r eather, venesection was a remedy which ought * Though this opinion was formerly almost universal, I doubt its correctness.—C. R. G. INTRODUCTION. 25 not to be resorted to for fear of the debility which it might induce. Erroneous as this opinion certainly is, there can be no doubt that under certain conditions of season and climate, this evacuation can be better sustained by the constitution than it can under others. As a general rule it is more indicated and better borne during the winter and spring than it is at other seasons. In dry weather, too, it is better supported than it is in moist weather. Yet, as a general fact, the natives of moist and foggy England bear bleeding better than Americans ; it depends probably on their mode of life. Hillary remarks, that in Barbadoes, under equal circumstances of pain, inflammation, and other symptoms, he always found the blood much less sizy and buffy than it was in England, and a consequent modification of the treatment was called for. Mr. Boyle says the same of the coast of Africa. During the prevalence of the sirocco, it has been observed in Egypt, as well as in Italy, that owing to the depression occasioned by it, sedatives cannot in any case be with safety administered. The effects of mercury, too, are modified very greatly by the nature of the season and the climate. In hot climates it is much more difficult to bring the patient under the influence of this remedy, than in more temperate regions. On this account it is, that such large quantities are required and used in tropical regions. Independently, however, of mere temperature, certain regions seem to be adverse to the kindly operation of this metal on the human system. In Egypt, according to Baron Larrey, the use of mercury, even in venereal disease, requires the greatest caution. If used with the same freedom as in Europe, it produces hepatic and various other affections. 5. Habit. —This greatly modifies the effects of many medicinal agents; but its influence is not the same in all cases : it diminishes the susceptibility of the system to the impression of some medicines—it greatly increases it to that of others. Opium furnishes a striking illustration of the first of these. The quantity of this drug that can eventually be borne, after the system has been habituated to it, is really astonishing. The Malays will swallow from 20 to 30 grains, daily, with perfect impunity; and in civilized society, persons have been known to take almost any quantity without suffering any inconvenience. Mercury, on the other hand, observes a different law, and the system, so far from becoming habituated to its use, becomes more and more sensible to its operation. When a person, for instance, has been salivated several times, the smallest quantities of mercury will sometimes produce the most violent effects. 6. The actual condition of the System at the time of taking the Medicine, with regard to health and disease. —Of all the circumstances which modify the effects of remedies, this is the most striking and important. 3 26 MATERIA MEDICA AND THERAPEUTICS. Medicines do not always produce the same effects in a state of disease which they do in perfect health. In different diseases, too, the effects of the same remedy differ entirely—almost every remedy and every disease furnishes an illustration of these facts. In apoplexy, for instance, the most active emetics fail to produce their ordinary effect. In certain diseased states of the intestinal canal, and of the system, the most drastic cathartics can be made to produce little or no effect. In delirium tremens, quantities of opium have been given with very little effect, which, in the ordinary conditions of the system, would inevitably have been followed by apoplexy and death. In tetanic and neuralgic affections, unaccompanied by inflammation, narcotics may be given to the greatest extent without producing any of their ordinary effects. In congestion of the brain, and inflammation of serous membranes, immense quantities of blood can be taken without producing syncope, while in other diseases, particularly of an irritative character, the system succumbs immediately to the loss of the vital fluid. I have thus, in a general way, noticed some of the circumstances modifying the effects of medicinal agents. When I come to treat of them in detail, all these circumstances wiU necessarily come again under review, for more special and particular consideration. Of the Classification of Medicinal Agents. —In every department of knowledge, a general classification of the various subjects embraced in it is of the greatest utility. It simplifies the science, and thus facilitates the acquisition of it. It is, in fact, nothing more than a generalization of otherwise individual and detached facts, by some principle of common relation. Any principle may be adopted as the basis of a classification, and almost every classification will be found to give rise to new combinations and interesting analogies. It is not to be inferred, however, that it is a matter of indifference what classification is adopted; on the contrary, not a little of the interest, as well as character of the science, may depend upon the selection which may be made. The principles which, it appears to me, ought to be chiefly held in view in the construction of a classification of the Materia Medica, are the following : —In the first place, the basis of it should not be theories, but well established facts. Unless it be so, it is evident that the classification must be fluctuating in its character, at the same time that it may lead to serious practical errors. In the second place, as the great object of this science is the investigation of the effects of medicinal substances upon the human system with a view to the cure of disease, such a classification should be preferred as is best suited to the attainment of this object. By keeping these principles in mind we shall be able to form a pretty correct estimate of the value of the classifications which at various periods have been offered. 27 INTRODUCTION. Among the earliest attempts at arranging the articles of the Materia Medica was that of classifying them according to their sensible properties, such as color, smell, taste, &c. Such a classification has the advantage of being founded on plain and obvious properties appertaining to medicinal substances, and this, so far as it goes, is much in its favor. It presents also a very interesting view of the analogies of these substances so far as their sensible properties are concerned. And if these properties furnished any true index of their medicinal effects, the classification would be unexceptionable. Such, however, is not the case, and it fails, therefore, in the principal object for which an artificial arrangement may be useful. The next attempt was founded on the botanical relations between plants. This of course can apply only to vegetable medicines, and on that account is defective on the basis of a classification which ought to embrace all medicinal agents, whether animal, mineral, or vegetable. So far, however, as it can be applied it has been attempted by Murray and De Candolle.* It is liable, however, to the same objection with that founded on the sensible qualities of substances, inasmuch as the natural affinities lead to no certain conclusions in relation to the medicinal properties of plants. By some the chemical properties of substances have been adopted as the basis of classification. This is evidently, however, the very worst that could be chosen, both for the uncertainty and imperfections, even at the present day, of the analysis of vegetable substances, and from its leading to no certain conclusions concerning the effects of medicines upon the living system. The last principle adopted as the basis of a classification is that of the medicinal properties, or, in other words, of the effects which they produce upon the living system. Of all the systems, this embraces the greatest number of advantages, and is the most decidedly practical and useful in its applications. Like the others, however, it is very far from being perfect. This arises from the limited extent of our knowledge in relation to the animal economy, as well as the effects of medicinal substances upon the system. It is in consequence of this that so many different classifications have been proposed, all based upon the same common principle, but varying in the application of that principle according to the particular view's which may be entertained in relation to the laws of the animal economy and the action of remedies. All this will be found abundantly illustrated by an analysis of the classifications of Cullen, Murray, Young, and indeed every other modern writer * Essai sur les proprietes medicales des plantes, comparees avee leurs formes exterieures et leur classification naturelle. Par M. Aug. Pyr. de Candolle, Prof. irits of turpentine. The pure oil is a thin, colorless liquid, having a peculiar odor. It is sparingly soluble in alcohol, and is so inflammable that it becomes dangerous when kept in large quantities. By contact with oil of vitriol it is changed into another liquid called terebine. With hydrochloric acid it forms a compound which has been called artificial camphor, from its resemblance in odor and appearance to that substance. Oil of Lemon. —This is obtained both by expression and distillation from the rind of the fruit. It has the same composition as the oil of turpentine, but differs from it in odor. The oils of orange peel, bergamot, pepper, juniper, savin, laurel oil, are also isomeric with the oils of turpentine and lemon. Oil of Aniseed. —The oil distilled from the seeds of the Pimpinella anisum, L., consists of two substances, one of which is a liquid oil, and 45 PROXIMATE PRINCIPLES. the other a solid crystalline substance so abundant as to cause the whole to solidify at the temperature of 50°. The solid essence may be separated by pressure. Camphor. —This is a concrete essential oil. It is obtained by distillation from the Laurus camphora, L., and several other plants. It is subsequently purified by sublimation, and is then a white, translucent, crystalline mass, which is difficult to powder, and having a powerful and very familiar odor. It is insoluble in water, but freely soluble in alcohol, from which it may be obtained in the form of brilliant crystals. Resins and Balsams. — Resins are the inspissated juices of plants, and commonly occur either pure or in combination with an essential oil. They are solid at common temperature, brittle, inodorous, and insipid ; generally of a yellow color ; some are transparent; soluble in alcohol, ether, and the essential oils ; from the former, they are precipitated by water, in which they are quite insoluble. The most important of these substances are common resin, or rosin, copal, lac, sandarach, mastich, and dragon's blood. In pharmacy, resins melted with oil and wax, are used to make plasters and ointments. Gum Resins.—These are the concrete juices of certain plants, and consist of resin, essential oil, gum, and extractive matter. The two former are soluble in alcohol, and the two latter in water. Their proper solvent, therefore, is proof spirit, or a mixture of alcohol and water. Under this class are included several valuable medicinal agents, such as aloes, ammoniacum, assafcetida, euphorbium, galbanum, gamboge, myrrh, scammony, and guaiacum. Balsam. —[By some chemists this term is applied exclusively to the compounds of benzoic or cynamic acid with resins. Others include among them some of what are more properly called oleo-resins, compounds of resin and volatile oils. The balsams of Peru and Tolu are types of the former class; Canada balsam and copaiva of the latter.] They are generally odorous and pungent. Some of them are liquid, as balsam copaiva and the balsam of Peru and Tolu ; others are solid, such as storax and benzoin. Caoutchouc, commonly called elastic gum, or India rubber, is the produce of the Siphonia clastica, Pers., a native of Brazil, and of several East India trees, which yield milky juice, hardening by exposure to the air. In a pure state, it is nearly white, the dark color of the common caoutchouc being caused by smoke and other impurities. The most remarkable property of this substance is its elasticity. It is inflammable, and burns with a bright flame. In water and alcohol it is per- 46 MATERIA MEDICA AND THERAPEUTICS. fectly insoluble. The best solvents are petroleum, purified naphtha, oil of turpentine, coal oil, and especially the thin oily liquid obtained from the distillation of the caoutchouc itself. In a state of solution it is employed for forming varnishes, for covering cloth so as to render it water proof, THERAPEUTICS. while it produces little or no local irritation. As an adjunct to calomel, castor oil is invaluable. It evacuates most thoroughly the contents of the bowels and has a tendency to allay irritation. In addition to these, the saline cathartics, jalap, rhubarb, and magnesia, may be used with safety and advantage. With regard to the condition of the mucous lining of the intestines, it is to be recollected that in fever it is frequently the seat of inflammation, and when this is the case, active purging ought to be avoided. Even this, however, should not preclude the occasional use of calomel, and the regular evacuation by mild means. As fevers differ in their phenomena, the use of cathartics as well as of all other agents must evidently be very much modified by this circumstance. For the purpose of illustrating this, let us notice briefly the more striking varieties of fever. (a.) Intermittent Fever. —The essential means of cure in this form of fever are tonics [anti-periodics] of various kinds, administered during the intermission, with the view of preventing the return of the paroxysms. For the safe and effective use of these agents, however, the system nmst be properly prepared, and among the agents used for this purpose, cathartics are the imost efficient. The reasons of this will be apparent from the following considerations. From the nature of the convulsion through which the system goes during a paroxysm of this form of fever, it is evident that a congestion of blood must take place in the abdominal viscera. The necessary consequence of such congestion is a derangement of function in the parts concerned, showing itself in disordered action of the stomach, liver, and bowels; the tongue is furred, the stomach is nauseated, and the bowels constipated. In the collapse of the system which takes place during the sweating stage, although the congestion is partially and sometimes entirely relieved, yet this disordered condition of the digestive organs remains behind to a greater or less degree. Now, if in this state of things tonics [anti-periodics] be at once resorted to, it will be found not merely that they are uncertain in their effects, but they frequently render permanent the periodical congestion which takes place during the paroxysms. To obviate all this, suitable preliminary evacuation is required. The best cathartics for this purpose, are such as will promote hepatic and intestinal secretion Avithout producing much irritation. The best articles to accomplish these objects are calomel followed by castor oil, or calomel and jalap in combination. In ordinary cases, and Avhen the disease is taken in its commencement, a single cathartic will answer every purpose. When, however, the paroxysms have been continued for some time, Avhero there is great bilious derangement, fulness of the abdomen, foul tongue, &c, repeated purgation may be necessary before tonics will produce their effects. In intermittent fever, then, cathartics are to be considered merely as CATHARTICS. 103 preliminary agents to bring the system, and especially the digestive organs, into a condition appropriate to the use of tonics [anti-periodics]. The best period for giving cathartics is during the intermission. (b.) Remittent Fever. —Here the use of cathartics is still more impe- ratively called for. In this form of fever the congestions of the abdominal viscera are of a more permanent character than the intermittent. In consequence of this the functional derangements of the liver, stomach, and intestines are more marked, and it is for the improvement and correction of these that cathartics are so essential, and they must be repeated according to circumstances until these objects are accomplished. The articles most useful here are calomel followed by castor oil, calomel and jalap, the saline cathartics, and magnesia. In this form of fever, inflammation of the stomach and bowels is not an uncommon occurrence, and when this is the case, all active cathartics should be avoided. Continued Fever. —Cathartics are no less important than in the preceding forms of fever, and they act by restoring intestinal and hepatic secretion, moderating general excitement, and where the head is much affected, exercising a salutary revulsion upon the bowels. As fevers of this kind differ materially, the kind of cathartics and the degree of purgation must be determined by existing circumstances. Where the liver is particularly implicated, calomel is an article never to be overlooked. Where the head is affected, such articles as are calculated to produce a decidedly revulsive effect may be used, such for example as jalap and cream of tartar. In these cases, too, more free purging will be required and prove beneficial. In the use of cathartics, the period ought to be specially considered. In the commencement, purges of an active nature may be required, while as it advances, and especially towards the latter period, such milder articles are only to be used as will evacuate the bowels without producing irritation on the one hand or debility on the other. From the foregoing, it must appear evident that cathartics are agents of great value in fever generally. At the same time, it is to be recollected that in their practical application great abuses have arisen and much injury is constantly done. This has probably arisen from attaching to them an importance somewhat exaggerated. They are accordingly, by many, relied upon almost exclusively in the cure of fever, and the most active purges are repeated from day to day throughout the disease, with the most unceasing and relentless assiduity. The considerations which have already been offered, must convince any reflecting person that such practice is irrational and attended with danger. Besides, it should be recollected, that fever is a disease affecting the wdiole system—all the functions are disordered and all the secretions are more or less prevented. Now, cathartics are only one of the means of cure, and, although some mild cases of fever may yield to them alone, yet more aggravated forms 104 MATERIA MEDICA AND THERAPEUTICS. of it are not to be managed by exclusive attention to the bowels. Important as this is, the other secretions, especially that of the skin, require equal attention. If this important fact was constantly borne in mind, it would tend to limit the use of cathartics within their proper bounds, and obviate much of the evil resulting from their use. [In the abdominal typhus, now so much more common than when Dr. Beck practised, too much caution cannot be used in prescribing cathartics, especially calomel.] The great objects then to be gained by the use of cathartics, in fever, are : — 1st, To relieve congestion of the abdominal organs. 2d, To restore secretion —in both these ways they prepare the system for the use of tonics. The evils they may, if injudiciously used, produce, are :— 1st, They may produce irritation or inflammation. 2d, They may produce too much debility. Inflammation. —I come next to consider the use of cathartics in the various forms of inflammation. The principles upon which they may be rendered available, are the following. 1. In all cases of inflammation, the functions of the system become more or less disturbed, and among these none more so than those of the intestinal canal. Hence, costiveness is a frequent attendant in these cases. The intestines being unnaturally overloaded, the general irritation of the system is increased, and as a consequence the local irritation is aggravated. Again, in all cases of inflammation, in consequence of the general disturbance of the system, the functions of the mucous lining of the intestines are deranged. The natural action of the secretory vessels of this tissue is impaired, the general excitement is increased, and the local inflammation aggravated. To obviate these conditions, cathartics of various kinds are used, and with the greatest advantage. By keeping the bowels continually in a free state they remove a constant source of irritation ; at the same time, by the impression which they make on the mucous membrane, they restore the natural secretions of the part. In this way, general excitement is directly lessened, and indirectly the local inflammation moderated. This is one mode in which cathartics are rendered beneficial in inflammation. 2. Cathartics, some more and some less, deplete all the organs and tissues upon which they operate, and in this way by the evacuations which they produce, lower excitement and thus prove useful. 3. Another mode in which cathartics prove beneficial in many cases of inflammation, is by the new action which they create in the intestinal canal, operating on the principle of revulsion. 105 CATHAETICS. For the purpose of illustrating the foregoing, let us notice briefly inflammation as it assails different parts of the body. (a.) Inflammation of the Brain. —In all inflammations affecting this organ, there can be no question as to the utility of cathartics. Theory sanctions, experience confirms it. In all cases of this kind, there is a general tendency to torpor of the bowels. In consequence of this, accumulations are apt to occur in them, and by their distension and pressure on the surrounding organs and large blood-vessels, they crowd the blood unnaturally towards the upper part of the body. By the judicious use of cathartics this is obviated. But they operate still further and more decidedly. They create a determination to the abdominal viscera, and they relieve the brain, upon the principle of revulsion. From the inactivity of the bowels generally attending these cases, such articles will be required as act efficiently and freely. Among these, calomel, jalap, senna, salts, and in some cases croton oil, are most to be relied on. To produce their full revulsive effect, it is necessary that their action should be kept up for a considerable length of time. For this purpose they should be repeated from day to day, according to circumstances. Trachitis. —In this disease, cathartics may be used with advantage as auxiliary to other remedies. In the selection of the cathartic, the preference should be given to calomel. Besides operating most efficiently on the liver and intestinal canal, this article possesses the additional advantage of extending its sympathetic action to the inflamed membrane —promoting the secretions of the part and lessening general excitement. To obtain the best effects of this article it should be given in full doses, and repeated at suitable intervals. As an adjunct, castor oil is the best article that can be used. Inflammation of the Lungs. —The propriety of having recourse to cathartics in this form of disease, has been made a question by some eminent authorities. Among the objections urged against their use, the most common and forcible is that they interfere with expectoration and perspiration, both of which are looked upon, and justly, as exceedingly important in the solution of thoracic inflammations. To a certain extent this objection is founded in truth. That active purging does have a tendency to check expectoration is certainly true; and if it be resorted to when this is freely going on, there is no doubt it may prove injurious. It is to be recollected, however, that expectoration only commences at a certain period of the inflammation, and the use of cathartics antecedently to this period can be no more objectionable than venesection or any other antiphlogistic remedy. With regard to perspiration, it is to be remarked, that in inflammation of the lungs, as in all other inflammations, this process never takes place, at least to any salutary extent, while the general excitement of the system is 8 106 MATERIA MEDICA AND THERAPEUTICS. above a certain standard. It is only -when this is properly subdued that the skin becomes free and perspirable. Purging, therefore, in the early periods of the disease, by lessening excitement, rather favors than otherwise the subsequent process of perspiration. In the early stages of thoracic inflammation, therefore, purgatives are not merely innocent, but may be made exceedingly valuable auxiliaries; and they operate both by lessening general excitement and producing a revulsive action upon the intestinal canal. When, however, the inflammation is coming to a regular crisis, when the skin is soft and moist, and the secretions from the mucous membranes of the lungs free, active purging should be avoided. This is the practical distinction to be observed in these cases. The cathartics best suited here are calomel, castor oil, and the neutral salts. Inflammation of the Abdomen. —In almost every case of this kind, cathartics may be used with advantage. In the selection of cathartics, however, and in the extent to which the purgation ought to be carried, there will be found a great difference, according to the particular tissue or organ which may be the seat of inflammation. This will be best illustrated by noticing in detail a few of the more important. Inflammation of the Mucous Membrane of the Stomach. —This may exist either in the acute or in the chronic form, and in both suitable evacuation of the bowels is a point of great importance. In relation to tin's practice, I am aware that a great difference of opinion exists. The propriety of it, however, appears to me to rest upon various considerations. In the first place, should the fasces be suffered to accumulate in the large intestines, the mere pressure upon the stomach which the distension w r ould occasion would increase the gastric irritation. In the second place, accumulations in the large intestines would have the effect of creating irritation in the mucous membrane of these organs, which might be extended, sympathetically, to the mucous membrane of the stomach. To remove, therefore, all cause of irritation from this source, it is essential that the large intestines should be kept freely evacuated. In the mode of doing this, however, certain precautions are to be attended to. As a general rule, it is not to bo accomplished by the introduction of cathartics into the stomach. In the irritable condition of the stomach in these cases, ordinary purgatives will be very apt to be rejected, and therefore will prove useless. In addition to this, if they are articles of an active character, even should they be retained, they will be apt to act as local irritants, and thus aggravate the inflammation. On these accounts, active enemata, repeated at suitable intervals, are to be preferred in these cases. To all this, however, there is an exception to be made in favor of one cathartic —and that is calomel. This article does not act as a local irritant. Even where it comes in contact with inflamed surfaces, so far from increasing inflammation, it frequently has 107 CATHARTICS. the effect of allaying it. From its small bulk, also, it can readily be taken, and is retained on the stomach when every other article is rejected. Calomel, therefore, is a remedy which may be used without any danger of increasing irritation; and, at the same time, by its antiphlogistic operation on the irritated surface, and its purgative action on the liver and bowels, may prove eminently beneficial. Inflammation of the Mucous Membrane of the Bowels. —Cathartics here may be used upon the same principles as in inflammation of the stomach. To keep the bowels properly evacuated is essential. This, however, is to be accomplished by the mildest means. All active, and especially drastic, cathartics prove injurious. The best articles to be used are calomel and castor oil. Inflammation of the Serous Membrane of the Abdomen. —In this form of inflammation, considerable difference of opinion exists with regard to the use of cathartics. By some they are considered as highly injurious. This opinion does not, however, appear to be well founded. In cases of peritonajal inflammation the bowels are generally costive ; and where this is the case, it must necessarily add to the existing inflammation. By the use of cathartics, this is obviated. Besides, where the mucous membrane is free of disease, copious secretion may be produced from this surface by the use of appropriate cathartics, and in this way may aid very powerfully in relieving the peritonaaal inflammation. Inflammation of the Liver. —With regard to the use of cathartics in this form of inflammation, there is in American and British practice very little difference of opinion. By the French, and especially the followers of Broussais, they are reprobated. Their objections go upon the supposition that purgatives are all irritating in their nature. That some purgatives are so is unquestionably true, and these ought certainly to be avoided. Every active cathartic, however, is not of this character. Calomel and castor oil are not so, and these may be used with perfect impunity so far as any irritation which they occasion is concerned—and so far from being injurious, their use is sanctioned both by theory and experience. After the free use of the lancet, there is no remedy so salutary as a largo dose of calomel, followed by castor oil and some of the saline cathartics. Should these act freely on the bowels, they relieve the oppression and fulness about the region of the liver, and at the same time aid in subduing inflammation; and they operate by the free secretion which they produce from the liver and the mucous membrane of the intestines, acting both as evacuants and revulsives. When tardy in their operation, they should be aided by enemata. Inflammation of the Kidneys and Bladder. —In both mild cathartics may be used with advantage. They relieve the inflamed organs from the pressure resulting from an overloaded state of the bowels, and at the same time act beneficially as evacuants. From the sympathies existing 108 MATERIA MEDICA AND THERAPEUTICS. between the kidneys and bladder and the rectum, all such cathartics as are apt to produce irritation in the latter organ should be avoided. Some cathartics, too, have a tendency to pass off by the urinary organs, and when this is the case they add to the existing inflammation. Upon this principle, the saline cathartics are objectionable. Rheumatism. —In the acute form of this disease, cathartics are of great value. They prove beneficial, as evacuants, by diminishing general excitement, and as revulsives, in keeping up a determination to the bowels. The best articles to be used are an occasional dose of calomel, followed by the saline cathartics. [Most of us now give the salines without calomel.] Gout. —Here, cathartics are no less needful. Everything connected with this disease shows how intimately it is associated with disorders of the digestive organs. From the slow and continued operation of various causes, the secretions of the liver and bowels become vitiated— there is costiveness and acidity —the bowels become loaded with mucus, and a general debility of the whole abdominal system ensues. In this condition of things free evacuation of the alimentary canal, and a constant action on it, cannot fail to do good. Dropsies. —There is perhaps no class of diseases in which the use of cathartics has been so generally concurred in as in dropsies, and there can be no question with regard to their general utility. They are not, however, to be given indiscriminately. For the purpose of understanding the principles upon which they are to be used, and the extent to which they may be carried, it is necessary to have correct notions of the disease for which they are prescribed. By dropsy, in the ordinary acceptation of the term, is meant nothing more than the accumulation of fluids in different parts of the body. This, however, conveys a very imperfect idea of the real nature of the affection. This accumulation of fluids is a mere effect or consequence of some deranged condition of the system at large, and more especially of the capillaries, the vessels concerned in excreting and absorbing the fluids. [Distension of the bloodvessels, either of the whole or part of the body, is the essential condition of the occurrence of dropsy. It is probable that the distended arteries, or the arterial capillaries, sometimes relieve themselves by pouring out the serum of the blood, but it is from the veins and venous capillaries that this exhalation takes place to the greatest extent; while at the same time, their distended state entirely prevents the taking up of effused fluids, a function, in the normal state of the system, performed by the veins. Now, this essential condition of dropsy, distension, may be the rapidly induced effect of some suddenly applied cause, or it may result gradually from some chronic condition. In the first case, the consequent dropsy will be active or acute ; in the latter, passive. Scarlatina dropsy, and the dropsy which suddenly follows exposure to cold 109 CATHARTICS. in persons previously in good health, are familiar examples of active dropsy; while the anasarca of pregnant women and cardiac dropsy belong to the passive variety. From this view of dropsy, it is obvious that our attention should be very mainly directed to the removal of the distended state of the vessels; and as, in very many cases, the direct diminution of the quantity of circulating blood is forbidden by the debilitated condition of the general system, we must resort to purgatives, diuretics, and diaphoretics, in order to eliminate from the vessels their more watery parts, being well assured that the partially emptied vessels will seize on watery fluid wherever they can find it. Cathartics are the most important of these evacuants, as more certain than diuretics, and more efficient than diaphoretics.] CLASSIFICATION OF CATHARTICS. Cathartics may be advantageously classified, according to their effectsinto three divisions. 1. Those which operate principally by increasing the natural peristaltic action of the intestines, causing little or no increase of secretion from the mucous lining of these organs. As a general rule, they act with great mildness, and their operation is limited in a great measure to evacuating the existing contents of the bowels. To this division belong the whole class of what are usually called Laxatives. Under this head may be ranged castor oil, magnesia, sulphur, manna, purging cassia, tamarinds, rhubarb and aloes, charcoal. 2. Those Avhich, in addition to increasing the natural peristaltic motion, stimulate the exhalant vessels of the intestines, and thus cause free secretion from them. Besides unloading the bowels, these produce watery evacuations. In the degree of activity in the articles of this class there is a good deal of difference, some operating very mildly, while others produce considerable irritation. To this division belong the whole class of hydragogue cathartics ; neutral salts, jalap, May apple, senna, scammony, gamboge, supertartrate of %>otass, colocynth, elaterium, croton oil. 3. Those which, in addition to increasing the natural peristaltic motion, excite the mucous follicles of the intestinal canal, and at the same time extend their influence to the liver. The evacuations produced by this class are mucous and bilious. To this belong calomel and blue pill. Other cathartics act also on the liver, especially the drastic ones, but not in the way calomel does ; calomel produces its effect mildly— the others by irritation. 110 MATERIA MEDICA AND THERAPEUTICS. INDIVIDUAL CATHARTICS. CASTOR OIL. The plant which yields this valuable article is the Bicinus communis, so called from the seeds resembling in shape and color the insect called the tick (ricinus). It grows in great abundance in the East Indies, where it is native. It is also a native of Africa. In the West Indies, in various parts of Europe, but more especially in the southern part of the United States, it is extensively cultivated. It is an annual plant of very speedy growth, from four to six feet high. In the warmer climates it sometimes attains the height of eight, ten, twenty, and even thirtyfeet —(Ray, Roxburg.) The oil used in medicine is obtained from tho seeds. These are inclosed in rough capsules, which are about the size of a large marble, of a pale green color, and covered with flexible prickles, Each of the capsules contains three seeds, which are expelled by the bursting of the capsules. The seeds are of an oval shape and of the size of a small bean, a quarter to one third of an inch long, of a pale greyish color, marbled with yellowish brown spots and veins. When the external coat is taken off, it leaves a kernel of a Avhite color, which has a sweetish, oily, and somewhat nauseous taste. In their action on the system, the seeds are acrid and irritating; three or four of them prove actively emetic and cathartic. Modes of preparing the oil. —These are different in different countries. In the United States, where the oil is manufactured very extensively, the process is the following : —The seeds, after being well cleansed, are put into a shallow iron receiver, where they are subjected to a very gentle heat, for the purpose of rendering the oil sufficiently liquid for easy expression. They are then put into a powerful screw press, by which a whitish oily liquid is obtained. This is then put into clean iron boilers, mixed with water, and boiled. During the boiling, the impurities which rise to the surface are skimmed off, until, at last, a pure oil is left on the surface of the water. The clear oil is now carefully separated, " and the process is completed by boiling it with a minute proportion of water, and continuing the application of heat, till aqueous vapor ceases to rise, and till a small portion of the liquid, taken out in a vial, preserves a perfect transparency when it cools. The effect of this last operation is to clarify the oil, and to render it less irritating by driving off the acrid volatile matter." If the heat employed be too great the oil becomes of a brownish color and of an acrid taste. Great care, therefore, is necessary in regulating the degree of heat. Good seeds, by this process, yield twenty-five per cent, of oil. By Alcohol. This is another mode recently suggested in France, CATHARTICS. 111 and is founded on the solubility of castor oil in alcohol. It consists in macerating the kernels, made into a paste, in cold alcohol. In this way § vi of oil are extracted from a pound of the seeds. The mode of preparing castor oil is a matter of much practical importance, inasmuch as it modifies its qualities and effects. It has already been stated that the seeds are exceedingly irritating, and the same is sometimes the case with the oil. What the cause of this may be, is a point which has given rise to a difference of opinion. By some it is supposed to be owing to an acrid principle residing in the seeds, while by others it has been attributed to the employment of heat in the preparation. With regard to the acrid principle, some suppose it to reside in the shells, while others locate it in the embryo. According to Guibourt, however, the shells contain none of it; and the only effect which they can have is to color the oil. Nor does it reside exclusively in the embryo. The truth is, the whole kernel appears to contain a volatile acrid principle. By boiling in water this principle is carried off, and a bland and almost colorless oil is obtained. With regard to the agency of heat, it appears that too great a degree of heat, or too long continued, changes the nature of the oily principle itself; in consequence of which it becomes deeper colored and acrid. From the foregoing it would seem : 1. That the removal of the shells is not necessary. 2. That the great point is the proper graduation of the heat. Properties. —Castor oil is a thick, viscid fluid; little or no smell; a mild and somewhat nauseous taste, leaving behind it a slight sensation of acrimony in the throat. When pure, it is colorless. Generally, however, of a light straw color. When prepared by decoction, or when the degree of heat has been too great, it is of a brownish color, and has a hot and acrid taste. When exposed to the air, it becomes thick and rancid, without becoming opaque. Composition. —When distilled, castor oil yields, besides a little gas, water, and acetic acid— A colorless, odorous, volatile oil. Two fatty acids—the Ricinic and Oleo-Ricinic, or Elaiodic ; both excessively acrid. A residual solid matter of a peculiar character. The volatile oil and the acids make up about one third, while the residual matter makes up the remaining two thirds. Castor oil possesses the general properties of the fixed oils, except that it is wholly soluble in alcohol and ether. Diluted alcohol dissolves about two thirds. Purity. —Sometimes adulterated with more common oils. This is tested by its solubility in alcohol. If castor oil be genuine, by adding 112 MATERIA MEDICA AND THERAPEUTICS. to it an equal quantity of alcohol of sp. gr. '820, a uniform solution will he made. On the contrary, if it form a milky mixture or any portion remain undissolved, an adulteration with some of the more common fixed oils may be suspected. Effects. —As a cathartic it possesses many valuable properties. It operates gently, yet efficaciously. While it thoroughly evacuates the intestines, it causes no griping or pain. The number of evacuations caused by a single dose seldom exceeds two or three. Besides operating mildly, it produces its effects with more rapidity than most other cathartics. It frequently acts in a couple of hours, and seldom takes longer than three or four. A peculiarity attending its operation was remarked by Dr. Cullen, viz. if it be frequently repeated, the same effect will be produced by diminished doses. Generally speaking, the oil may be recognised in the evacuations, sometimes appearing in masses, and in one case mentioned by Pereira in the form of nodules, like biliary concretions. From the peculiar operation of this article it is an exceedingly valuable cathartic, and well calculated to fulfil many indications which no other can accomplish. It is adapted to all cases, when the object is to evacuate the bowels freely, without causing any irritation, and without producing alvine secretion. It is admirably well adapted to follow the use of mercurial cathartics, of which it insures the operation without altering the effects. For this purpose it is superior to any other cathartic. For children it is a peculiarly safe and good laxative. In some cases, an objection to its use is that it leaves the bowels costive. In other cases this is an advantage. Mode of administration and dose. —For adult, § j ; child 3j to 3 ij. Simply thinned by heat, the best form of giving it, or mixed with syrup, sugar, hot coffee, or milk, or in emulsion with yolk of egg and sugar, or floating on spirit. MAGNESIA. Magnesia is used in medicine in three different forms— magnesia, carbonate of magnesia, and sulphate of magnesia. At present the two first are only to be considered. Magnesia.—From the manner in which it is prepared, commonly called magnesia usta or calcinata. It is prepared by subjecting the carbonate of magnesia in a crucible to a red heat for about two hours, or until no effervescence is produced on the addition of diluted acetic acid. During this process, the water and carbonic acid are driven off and the pure magnesia left. When cool, it is to be put into tightly stopped bottles. 113 CATITARTICS. Composition. —One eq. magnesium = 12, one eq. oxygen 8 = 20. Properties. —A white powder, without smell, and, if perfectly pure, without taste. It is very light, its specific gravity being 2*3. It is very sparingly soluble in water —more so in cold than in hot. According to Dr. Fyfe, it requires 5,142 parts of cold water and 36,000 parts of hot to dissolve it. With acids it does not effervesce. By exposure to the atmosphere, it slowdy attracts carbonic acid and is converted into the carbonate. Hence the necessity of keeping it in tight bottles. Purity. —The most common adulteration is the admixture of carbonate of magnesia. This is ascertained by adding to it a little diluted hydrochloric acid. The best way is to mix a little of the magnesia in water and then add a few drops of acid. If pure, it should not effervesce. Sometimes it contains lime, either added fraudulently, or obtained from the carbonate, from which it has been prepared. This may be ascertained by dissolving the magnesia in hydrochloric acid, neutralize the acid solution with ammonia, dilute it with water, and add to it a solution of oxalate of ammonia. If there is a white precipitate, it shows the presence of lime. Carbonate of Magnesia, commonly known by the names of magnesia alba and sub-carbonate of magnesia. In Hindostan and some parts of this country it is found native. What is used in medicine is prepared artificially. The mode of preparing this is to add together solutions of sulphate of magnesia and carbonate of potash or soda —boil the mixture for a short time, stirring it all the while. On standing, the carbonate of magnesia is precipitated, while the sulphate of potash or soda is held in solution. The liquor is then to be poured off, and the precipitated powder well washed with boiling distilled water and dried. The washing separates whatever of the sulphate of potash or soda may remain in combination w r ith it. Sometimes it is dried in wooden moulds, in consequence of which it has the square form in which it is found in the market. Another mode of preparing it is from the bittern, or liquor which remains after the crystallization of salt from sea water. The bittern consists chiefly of muriate and sulphate of magnesia. This is heated to 212° and a solution of carbonate of potash is added. The same process is then gone through as before. In the United States this article is extensively manufactured, particularly at Boston and Baltimore. Composition, —According to Berzelius, 100 parts consist of magnesia, 44-75; carbonic acid, 35-77; water, 19-48. Properties. —Carbonate of magnesia, as found in the shops, is either in powder or square masses. It is perfectly white, tasteless, and without smell; very light (48 grs. fill an ounce measure, Pereira). It is nearly insoluble in water, requiring 2,473 parts of cold, and 9,000 parts of 114 MATERIA MEDICA AND THERAPEUTICS. boiling water to dissolve it. In carbonic acid water, readily soluble— unaffected by exposure to the atmosphere —effervesces with acid, and is decomposed by a strong heat. Impurities and Adulterations. —Magnesia frequently contains carbonate of lime (chalk), sometimes added fraudulently, sometimes arising from the presence of calcareous salts in the compounds employed in the preparation of magnesia. Effects. —Magnesia, either in the state of calcination or of the carbonate, is a gentle laxative. From its great affinity for acids, it readily unites with these in the intestinal canal, and when it meets with enough of those existing there, it forms soluble salts, and thus its activity is increased. From the fact of its thus uniting with and neutralizino; acids, it acts powerfully in allaying gastric and intestinal irritation. Besides this, magnesia is supposed to act still further in allaying irritation, by being mechanically applied to the nervous extremities of the mucous membrane of the intestines. As a cathartic, this article is peculiar, and it is indicated where acidity and disordered secretion of the stomach and bowels are present. For children it is an invaluable agent. It corrects acidity, allays irritation, and operates with sufficient activity as a cathartic. It does not generally produce any serous evacuations, unless the quantity of acid with which it meets is very great. [In such cases it often operates very violently, causing pain and profuse serous discharges; this is a very great objection to magnesia. This article is, I believe, very much abused ; as a habitual or domestic remedy, its use ought to be proscribed.] It generally renders the evacuations of a lighter color. Calcined magnesia is preferable to the carbonate, because in the latter so much carbonic acid gas is extricated as frequently to cause painful distension of the intestines. Magnesia, when used for a long while, sometimes accumulates in the bowels in solid, hard masses, concreted by intestinal mucus, and they may cause mischievous irritation. A mass of this sort weighing from four to six pounds, was found in the colon.* Dose. —Of the carbonate for an adult, from 3i to 3 ij; a child from 2 to 10 grs. Calcined magnesia somewhat less. It may be given in milk or water intimately mixed. If a glass of lemonade be taken immediately after the magnesia is swallowed, its efficacy as a cathartic is increased. Of course its power as an antacid is diminished. Where flatulence is dreaded, give the alkali in mint or anise water. SULPHUR. This substance is extensively diffused throughout the mineral, the vegetable, and the animal kingdom. It is found native and in combi- * Pereira sub Voee. CATHARTICS. 115 nation either in the sulphurets or in the state of sulphuric acid. When native it is found cither in masses or crystallized. Native sulphur is found most abundantly in volcanic countries, and the great mass of what we use in the arts and in medicine comes from the south of Italy, where it abounds. The sulphur of commerce is procured chiefly by distillation from the native sulphur, though in some parts of Europe it is obtained from the sulphuret by strong heat. Sulphur is found in the shops in two states. In rolls, the roll brimstone of commerce, and in fine powder, the flowers of sulphur. Of each of these there are, or at least were, two varieties ; for roll brimstone was formerly prepared by simply melting the crude sulphur, when the impurity being allowed to subside, the pure sulphur was poured off and received into moulds. Now, however, the roll sulphur is usually prepared by distillation, the product being afterwards melted and run into moulds. If the product of distillation be received into a large sulphur chamber, it is deposited upon the walls in the form of fine powder. This is the common flowers of sulphur. And if this be afterwards carefully washed till the water no longer stains litmus, it is the sulphur lotum —the washed sulphur of the shops. Properties. —An elementary body of a pale yellow color, permanent in the air. When in rolls or masses it is crystalline or amorphous. It has little smell unless rubbed, and no taste ; is a bad conductor of electricity ; it is perfectly volatilizable —fuses at 400°. Effects. —In doses of from one to three drachms sulphur acts as a mild evacuant of the alimentary canal, causing little irritation, and having scarce any effect on the secretions. It is a good remedy where a purgative is wanted, and yet some diseases of the rectum, as stricture, prolapsus ani, or hemorrhoids, render the irritating effect of ordinary purgatives objectionable. To render it more prompt and certain it is often combined with cream of tartar, and less frequently with magnesia. [It is much to be regretted that sulphur is so little used as a laxative; we have few that are as good, especially for children.] Dose as a purgative, 3 i to 3 iij - MANNA. [A concrete juice obtained from several species of the genus Fraxinus, and also of genus Ornus (a genus detached from Fraxinus by Persoon). A substance resembling manna is obtained from trees of two or three species, as Hedysarum and Eucalyptus.] Manna is obtained by making slight incisions in the bark, though some of it flows spontaneously. The juice appears first as a clear viscid fluid, but soon concretes in the shape of ridges or stalactites. The 116 MATERIA MEDICA AND THERAPEUTICS. manna harvest begins in July and continues till October. There are many varieties, Avhich seem to depend on the season and mode of collection. Of these the flake manna is the best. It comes in pieces from one to six inches long, brittle, dry, white or yellowish white, hollowed in the side to which it has adhered to the tree. It has a faint odor, and a sweet, though somewhat sharp, peculiar taste. Manna in sorts. —This is a common kind, and seems to be a mixture of the flake with fatty manna. It is in smaller pieces, pale brown, not flaky or crystalline. Fatty Manna. —This is rarely met with. It is of a reddish brown, soft, viscid, having a strong honey smell, and a mawkish taste. It contains many impurities. Composition. —The principal ingredients in manna are a peculiar sweetish principle called mannite, 60; sugar and a bitter purgative matter, 5*5 ; and water, 32. Manna softens by the heat of the hand, and melts at 125°. It dissolves in three parts of water and in eight of alcohol. Effects. —Manna is nutritive and laxative. It operates mildly, but is apt to produce flatulence and griping. From its mildness it was formerly often given to women, especially when in the state of pregnancy. For the same reason, and for its sweetish taste, it was given to children. But it is now very rarely used alone, and not by any means as frequently in combination with senna, with which it w r as once the fashion in medicine to unite it. Dose. —One ounce for an adult, three drachms for a child. cassia fistula (purging cassia). The cassia fistula grow T s in the East Indies, Egypt, Arabia, and Persia, also in the West Indies and South America. It is a fine tree, thirty or forty feet high. The fruit is a cylindrical pod about an inch in diameter, and from one to two feet long. The outside is hard and dark brown; the inside divided into numerous cells, each of which contains one smooth, oval, shining seed, imbedded in a soft pulp. This pulp is the part used in medicine. Effects. —To produce any effect, it must be taken pretty freely, as a small quantity, being digested, fails altogether of any cathartic effect. An ounce will act as a mild laxative. Its coloring matter often blackens the stools. It is very little used. tamarindi fructus (tamarinds). This is the fruit of a large and very beautiful tree growing in India, Arabia, and Egypt, and also in the West Indies. The fruit is a pod the CATHARTICS. 117 size of that of the garden bean. It has a brittle woody husk, containing one or more seeds imbedded in a pulp. It is imported free from husk, and is preserved in raw sugar. Effects, —A very gentle cooling laxative, usually employed to make a pleasant drink in fever. It is very rarely used alone as a laxative. Tamarind whey, made by boiling an ounce of tamarinds in a pint of milk and straining, is a pleasant cooling drink, also slightly laxative. RHUBARB. This is the product of different species of Rheum, of which there are a number. This plant grows in Tartary and China, and is cultivated in different parts of Europe. Which of the species yield the rhubarb of commerce, is not precisely known. The species cultivated in England is the R. palmatum. In France, the R. undulatum, compactum, and Rhaponticum. The mode of preparing it in the East is the following: The root is dug up in the spring and autumn, and after removing the bark it is cut into pieces, through which holes are bored for the purpose of passingcords. By these they are hung up and dried. During this process the root loses much of its weight. General properties. —Rhubarb comes in solid pieces of considerable size, covered with dust of a yellow color. When this is rubbed off, the surface presents a reddish white tint, of a reticular appearance. When broken, the fracture is rough, presenting a variegated appearance, owing to the intermingling of white, red, and yellow parts. Here and there are found a star-like spot, and numerous streaks and veins of a red color; its odor is peculiar and aromatic—taste bitter and astringent. When chewed, stains the saliva yellow and feels gritty, owing to the oxalate of lime; yields a powder of a yellow color. The principal varieties of this article found in the market, are the Turkey, Chinese, and European. Turkey. —This is the same as the Russian rhubarb, and is the best kind. This rhubarb comes from Tartary, and is brought to a place called Kieatcha, a Russian town on the frontiers of China. Here the article is examined by an agent of the Russian government, and the bad pieces rejected. Thence it is sent to St. Petersburgh, from whence it is exported to different parts of Europe. Formerly it was sent from Tartary to Turkey through Natolia. Hence the name of Turkey rhubarb, which it more commonly bears even at present. Chinese. —Also called East India rhubarb. This comes from Canton, and is supposed to be obtained from a species of rheum, growing in China. Although resembling each other in their general properties, the 118 MATERIA MEDICA AND THERAPEUTICS. Russian and Chinese R. may be readily distinguished. This is important, as the first is much dearer than the second, and frauds are frequently practised in the sale. They differ —¦ 1. In the shape of the pieces. The Russian has a somewhat angular appearance, as if the bark had been shaved off, taking pieces of the root with it. The Chinese is rounder, as if the bark had been merely scraped off. 2. The perforations are different. In the Russian they are large, sometimes only partly through the pieces. They are evidently made for the purpose of examining the condition of the inner part of the root. In the Chinese the holes are small, and pieces of cord frequently found in them. The insides of the perforations, too, are dark colored, and frequently decayed. The holes here appear evidently made simply to pass cords through, and not with a view to examine the root. 3. The texture and weight are different. Russian rhubarb is not so compact and heavy as the Chinese—cuts with less facility, in consequence of giving way before the knife. 4. Color. —Russian rhubarb has a more lively fresh appearance. Powder, bright yellow; Chinese, orange. 5. Smell of Russian rhubarb more aromatic—taste, pleasant. European Rhubarb. —This is different both in appearance and in effect on the system, from the preceding varieties. It is in large pieces —more woody in its texture —scarcely gritty under the teeth —when chewed somewhat mucilaginous, and only slightly colors the saliva— pasty under the pestle, and its powder darker colored. In England, this is said to be extensively used to adulterate the foreign rhubarb. P urity. —In the state of powder it is hardly possible to judge well of the quality. The only properties by which any opinion can be formed, are the taste and color. The best plan is to buy it in the root and have it pulverized. In selecting the root, those pieces should be preferred which " are moderately heavy and compact —of a lively yellowish color—brittle— presenting, when broken, a fresh appearance, with reddish yellow veins intermingled with white ; odor decidedly aromatic, brittle, an astringent but not mucilaginous taste —gritty—staining saliva yellow —pow- bright yellow, or yellow mingled with orange," U. S. Disp. When very light, rhubarb is usually rotten or worm eaten. When very heavy and compact it is of inferior quality. Although Russian rhubarb is superior to the Chinese, yet the best kinds of this latter are very good and much cheaper. Real Russian rhubarb is very rarely seen here. Composition. —The principal constituents of rhubarb are :—1. Rhubarberic acid. This is the yellow, coloring matter of rhubarb. 2. Gallic and tannic acids. These constitute the astringent matter. The red veins are the seat of this astringent matter. 3. Oxalate of lime. This CATHARTICS. 119 gives the gritty taste to rhubarb. In the different varieties, the proportions of this differ. In European rhubarb there is scarcely any, while in Asiatic rhubarb, Brande found 14 per cent. 4. Starch. The proportion of this differs. The English contains a large quantity—14 per cent., the Asiatic very little. Besides these it contains gum, lignin, various salts, and water. Rhubarb yields all its virtues to alcohol and water. Effects. —As a cathartic this article is peculiar, in the fact of its combining a cathartic and an astringent In small doses, it acts as a tonic to the digestive organs, and proves astringent. In full doses it acts as a cathartic, and leaves behind it an astringent effect. In its general operation it is mild, the only unpleasant effect which it produces is griping. The evacuations which it causes are fsecal rather than Avatery. It promotes secretion moderately. It appears to act more on the muscular than on the mucous coat of the intestines. Although it gripes, it never produces inflammation of the bowels like some of the more active articles. During its use the coloring principle is absorbed and shows itself in the urine. Pereira says, the milk of nurses using it purges—differs from aloes, in not acting so much on large intestines. From the peculiarity of its action, it is suitable only in certain conditions of the system. When the boAvels are relaxed, and when a purgative and astringent tonic effect is required, it is exceedingly valuable. Hence it is so used in the summer complaints of children. When free secretion from the intestines is required, it is objectionable, and in general in febrile and inflammatory states of the system, it is improper. As a remedy in habitual costiveness, too, it is objectionable, although in some cases, where costiveness depends on laxity of intestines, it is good. As a purgative for children Avhose boAvels are apt to be debilitated by acid and flatulence, it is an excellent article. Dose. — Powder, 20 to 30 grs. Pill. —Simple and compound, vide Pharmacopoeia. Mixture. —Generally rubbed up with mint Avater. Aromatic Syrup. —This is an excellent laxative for children. Dose 3 i to 3 hj. ALOES. This drug is the inspissated juice of the leaves of different species of the aloe. The mode of obtaining it is very simple. The leaves are cut near their roots, and then placed with the cut ends downwards. The juice, of a greenish yelloAv color, readily exudes from the leaves, in which it is lodged in large longitudinal vessels. It is then collected and evaporated by exposure to the sun, or by boiling, until it becomes 120 MATERIA MEDICA AND THERAPEUTICS. about the consistency of honey, when it is poured into skins or calabashes. This forms the purest kind of aloes." In some places, the leaves are subjected to pressure for the purpose of increasing the quantity. In this way the real aloetic juice becomes mixed with the mucilaginous juice of the leaves, and the quality of the article is impaired. In other places, the leaves are boiled after the juice has exuded, and the decoction evaporated to a suitable consistence. In this way a still inferior kind of aloes is obtained. The principal varieties of aloes are the following : The Socotrine, pure Hepatic aloes, Cape aloes, and Barbadoes aloes. 1. Socotrine Aloes. —This is obtained from the Aloe socotrina, and comes from Socotra, an island near the Straits of Babelmandel. The greater part of it is carried to Egypt, and thence to Smyrna, from whence it is exported. A good deal of it, however, goes to Bombay, and thence to Europe. This comes in pieces of a reddish brown color, sometimes of a garnet red, sometimes of a golden red. The best pieces have a smooth, glassy, conchoidal fracture, edges translucent; very good pieces, however, break with a rough fracture. Its taste is bitter, odor aromatic, and by no means disagreeable, resembling that of myrrh. Heat readily melts it; and under the fingers, it softens like wax. Its powder is of a golden yellow color. 2. Cape Aloes. —This is the product of the Aloe spicata. It comes from the Cape of Good Hope. In mass it is of a deep brown color, with a greenish tinge ; in thin lamina), it is red and transparent. Fracture, glossy and resinous. Has a very strong and disagreeable odor, without any aroma. Powder greenish yellow. 3. Barbadoes Aloes. —Product of Aloe vulgaris. Comes from the West Indies in large gourds, weighing from 60 to 100 pounds. Generally known by the name of Hepatic aloes. Of a dark brown or liver color; its fracture generally dull, not so smooth, nor its edges so sharp or transparent as the first two kinds. Taste bitter and nauseous. Odor strong and nauseous, without any aroma. Powder dull olive yellow. Besides these there is another kind of aloes —the Caballine or Horse aloes, so called from its being used in veterinary practice. This is a very inferior kind, and is said to be prepared by boiling the leaves after the better kind of aloes has been obtained from them. It is opaque and almost black, and has an exceedingly offensive odor. Generally mixed with sand and other impurities. Composition. —Aloes contains a bitter principle called alorsin, probably a compound of several proximate principles, a resinous matter, a trace of albumen, and an acid, by some thought to be gallic. It yields its virtues to both water and alcohol. It is almost entirely CATHARTICS. 121 dissolved in boiling water, which, on cooling, deposits the substance called resin. Effects. —Aloes in small doses is stomachic, improving appetite and assisting digestion. Its action as a purgative is peculiar, and it fulfils certain indications better than any other drug. It is very slow ; eight, twelve, or even twenty-four hours elapse before it operates. It does not disorder the stomach, but on that organ is rather tonic. It acts on the liver, increasing its secretions. It acts especially on the lower intestines, and is very apt to produce irritation in the rectum and pelvic viscera. It affects mainly the muscular and very little the mucous coats of the intestines, producing large, thick, copious, and bilious stools. From these peculiarities of its operation, the class of cases to the treatment of which it is specially appropriate, is very obvious. When we desire to unload the bowels without disordering the stomach ; when the liver is torpid, and we wish to rouse it to action, without stimulating the mucous membrane; when we desire to remove costiveness, and yet avoid debilitating either the system at large or the intestinal canal in particular, no other remedy will meet our wishes with the certainty of aloes. 'Preparations and modes of administration. —Aloes in substance is only given in pill; if the full effect is desired, 10 grs. must be given; to remove the habit of costiveness, a much smaller quantity given in daily doses will answer. For this purpose we have no cathartic superior to the dinner pill, a combination of aloes, extr. wormwood, and gum mastic. Decoction of aloes is so very unpleasant, that though officinal it is not much used. [Except as enema.] Tinct. aloes cum myrrha, elixir proprietatis. —This is a most excellent purgative for children; both as a remedy for torpid liver, habitual constipation, or worms, it answers an admirable purpose. ¦ carbo ligni {vegetable charcoal). This is a well-known substance, with the sensible qualities of which you are all familiar, and of the chemical history of which it is not necessary I should speak. It has the property of absorbing different gases, and, though in a degree far inferior to animal charcoal, of destroying the taste and smell of a variety of animal and vegetable substances, especially when they are putrid. Its uses in medicine are various; but at present it is only to be noticed as a cathartic. It had at one time a very great reputation, 9 122 MATERIA MEDICA AND THERAPEUTICS. especially in obstinate constipation, in obviating which, Dr. Daniel says it will succeed when mercury, &c. &c, fail. Most late authorities deny altogether its powers; and as it is totally insoluble, it is difficult to imagine that it can produce any other than mechanical effects. Perhaps, as suggested by Dr. Chapman, it may produce an antiseptic effect on the excretions present in the bowels, and thus render them less irritating, while in its mechanical effect the mass is evacuated. It is now little used as a cathartic. It may be given in almost any quantit tea-spoonful is the usual dose. JALAP. For a long time the plant supposed to yield this substance was the Convolvulus jalapa. This is now ascertained not to be the case. The plant which yields it is Ipomcea jalapa, called also the Iponma purga, This is a climbing plant, growing native in Mexico. The jalap of medicine is the root, and derives its name from Jalapa, a place about which the plant grows abundantly, and from which it is sent to Vera Cruz and thence to other countries. It was first brought to Europe about A.D. 1610. The root is tuberose, and as found in the market, the tubers are either entire or cut into slices. They are of various sizes, sometimes as large as a man's fist, but generally much smaller. When entire, they are of an oval shape, with pointed extremities and marked Avith incisions on their surface, evidently made for the purpose of drying. They are solid and heavy, covered with a brown, wrinkled cuticle. When broken they present a surface of a deep yellow grey color, interspersed with deep browm concentric circles. The slices vary in size and shape. Its powder is of a pale brownish color, with a peculiar odor and a taste somewhat sweetish and] pungent. When swallowed it affects the throat with a sense of acrimony and causes a flow of saliva; when inhaled it causes sneezing and coughing. P urity. —The best pieces of jalap root arc those which are the hardest, most difficult to pulverize, and which have the greatest number of concentric circles in the interior. The inferior or spurious pieces are light—whitish internally, and spongy or friable. Jalap is apt to be worm-eaten. These animals, however, only devour the amylaceous and gummy parts, leaving the resinous part untouched. This renders it stronger, as the resin is the active part. Hence this should not be used for the powder. For obtaining the resin it is equally good. Jalap yields its virtues partly to alcohol, partly to water, wholly to dilute alcohol. Effects. —A very active, efficient, and safe cathartic. It quickens the peristaltic action and promotes intestinal secretion. Its operation is 123 CATHARTICS. generally attended with nausea and griping. The evacuations are watery. The general effect on the intestines is debilitating, and it does not heat or excite the system like some other cathartics. Uses. —In all cases where it is desirable to evacuate thoroughly the intestines, when torpid and loaded with mucus, and especially the large ones, and to make a decided impression on them in the way of intestinal secretion, jalap may be used with advantage. It is speedy in its operation. When the bowels are in a state of irritation, or when hemorrhoids, &c, are present, it is objectionable. Forms. Poivdcr. —Dose 10 to 30 grs. Generally given in combination with calomel. Pul. Jal. Comp. —Pulvis purgans; Jalap 1 part. Bi-tart. Pot. 2 parts. Dose. —40 to 60 grs. Much used in dropsy. Tinct. —Seldom used alone; sometimes added to purgative draughtsin doses of 3 i to 3 ij- Extract. —In this you have a combination of resin and gummy extractive. The resin, however, is the only active part. The advantage of the gummy part is, that it makes it operate more mildly. If water be not used you only get the resin. Of the resin the dose is from 3 to 6 grs.; of the extract 10 to 20 grs. The extract is a dark brown substance, not used by itself, but enters into the manufacture of pills. podophyllum peltatum—radix {May apple — the rhizome). This is a plant common in almost every part of the United States. The leaves are poisonous. The root, the part used in medicine, is smooth, dark brown color, white within, from three to six feet long, having an acrid, disagreeable taste. It gives up its active principles to water and alcohol. Effects. —As a cathartic it resembles jalap, producing the same watery stools, but by some it is said to gripe less though it nauseates more. Dose and mode of administration identical with those of jalap. Phytolacca decandria {the Poke weed — American nightshade). A common plant indigenous to this country, and growing in every part of it from New England to Florida. It is found in open woods and uncultivated fields. It grows to the height of six or eight feet, and 124 MATERIA MEDICA AND THERAPEUTICS. dividing into numerous spreading branches, with large rich leaves and purple berries. The root, which is perennial, is large, fleshy, and fibrous, dividing into two or three branches. The parts used in medicine are the root and the berries. ' The root is the most powerful and is generally used. When dried it is of a yellowish brown color, without smell, taste slightly sweetish, but followed by a sense of acrimony. Its virtues are extracted both by water and alcohol. Effects. —This article acts as an emetic, cathartic, and narcotic. As an emetic it has been said to resemble ipecac, and by some it has been recommended as a substitute for that article. It differs, however, very much from it. It is very slow in its action, taking at least an hour before it operates, and after it once begins it continues to vomit for three or four hours. At the same time it purges, and although the vomiting which it produces is mild, yet sometimes narcotic effects follow, such as vertigo, impaired vision, &c. It is therefore very different from ipecac. In small doses it appears to act as an alterative, promoting the secretion of the liver and acting moderately on the bowels. Form, Dose. —20 to 30 grs. in powder as emetic, 1 to 5 as alterative. As the latter it is used principally in chronic diseases. A saturated tincture of the berries is also used in the country in rheumatism—a teaspoonful three times a day. As a local application in the form of ointment it is also used in Tinea capitis and other cutaneous affections with great advantage. 3 i of powdered root or leaves to 3 i of lard. The proper period for gathering is in the autumn after the leaves have fallen. To be cut in thin transverse slices, dried, pulverized, and kept in tight bottles. Dr. Taswell, a country physician, who has used it a good deal, recommends it to me very highly. He says its action on the liver is very like calomel, and that it even salivates. In combination with aloes and gamboge he uses it as a cathartic. The pill is grs. ij aloes, h gr. of each of the others ; one pill is laxative, four a full dose. SALINE CATHARTICS. SULPHAS SODjE. This is the common Glauber's Salts, and is so called from Glauber, by whom it was first prepared. It exists in a native state and is also prepared artificially. Native State and Preparation. —In its native state this salt is found existing frequently in mineral waters, also in sea water. It sometimes CATHARTICS. 125 effloresces on the surface of the ground in the neighborhood of salt lakes. Captain Franklin states that to the north of Carlton House, on the river Skatchawan, lat. 53° 20', is a small lake, on the shore of which, in summer time, it effloresces in the form of a white powder to the depth of two or three inches.* According to Captain Hall, in his " Journey to South America," the valley of Copiapo, on the- coast of Chili, is covered with a layer of this salt several inches thick. It has the appearance of snow on the ground.f The salt used in medicine is artificially prepared. It is generally obtained during the processes for the manufacture of muriatic acid. The muriatic acid is obtained from the muriate of soda, which is decomposed by the action of sulphuric acid. After the muriatic acid is separated by distillation, a salt remains which is the sulphate of soda with excess of acid. For the purpose of neutralizing this excess of acid, the salt is dissolved in boiling water, and to this is added carbonate of lime. The solution is then evaporated, filtered, and crystallized. Chemical Composition. —Sulphate of soda consists of one equivalent of sulphuric acid, 40 ; one of soda, 32 ; and ten of water, 90:= 162. It contains, therefore, more than half its weight of water. Properties. —This salt, when first prepared, is in white, transparent crystals, and has a cool, bitter, and nauseous taste. When exposed to the air, it effloresces, and is converted into an opaque white powder. When subjected to the action of heat it undergoes watery It is soluble in three parts of cold water and in one part of boiling water. In alcohol it is insoluble. Physiological Effects. —This is a valuable cathartic, and was formerly much more extensively used than it is at present. It is speedy in its operation, and acts by promoting free secretions from the internal surface of the intestinal canal, and thus causing copious serous evacuations. It operates mildly, producing only a slight disagreeable sensation in the stomach, and afterwards transient uneasiness in the bowels. The great objection to it is its exceedingly nauseous taste and its consequent offensiveness to most stomachs. It is on this account, principally, that it has been so generally superseded by the sulphate of magnesia. Dose and Mode of Administration. —To an adult the dose is about one ounce, dissolved in water. To disguise the taste, a portion of lemon juice or cream of tartar may be added. Like some other salines (especially nitre) sulphate of soda hasa very notable effect on the plasma of the * Franklin's Journey to the Polar Sea, p. 506. f Vol. ii. p. 22. Quoted by Dr. Thomson in the London Dispensatory, p. 565. % Mr. Brande says, " it sometimes liquifies in very warm climates, and therefore should be previously dried if intended for equatorial consumption, it being only necessary to recollect that half an ounce of the dried sulphate is equivalent to about an ounce of crystals." Manual of Pharmacy, p. 164. 126 MATERIA MEDICA AND THERAPEUTICS. "blood, diminishing the quantity of fibrine. This is probably not a universal nor a very constant effect of the salines, still it is interesting as throwing light on the modus curandi of these articles in inflammation. SULPHAS MAGNESIA. This is called the bitter purging salt. It is also known by the name of Epsom salts, from its having been first artificially obtained from the evaporation of the water of the celebrated Epsom Springs in England. This was done by Dr. Grew, in 1675. Native State and Preparation. —This salt is found native in its pure state, cither in the forms of crystal or in the state of efflorescence. In the mercury mines of Idria, it is found crystallized. In Andalusia in Spain large tracts of land are covered with an efflorescence of it after floods. It also exists in certain caverns in some of our Western States. What is used in medicine is prepared artificially and chiefly from the liquor which remains after the crystallization of muriate of soda (common salt) from sea water, which holds sulphate of magnesia in solution along with muriate of magnesia. By boiling and evaporation, crystals of sulphate of magnesia are deposited. The salt thus found is not pui'e, inasmuch as it contains muriate of magnesia, in consequence of which it deliquesces. For the purpose of obtaining it in a state of greater purity another method of preparing it was adopted by Dr. Henry of Manchester, from magnesian limestone. According to this process the magnesian limestone, consisting of the carbonates of magnesia and lime, was first calcined for the purpose of driving off the carbonic acid gas. The magnesia and lime were then treated with muriatic acid with the view of taking up the lime. The muriate of lime is thus held in solution while the magnesia is precipitated. The two are then separated, and the magnesia is converted into the sulphate by the addition of sulphuric acid.* Prepared in this way, it contains no muriate of magnesia, and, therefore, does not deliquesce. At Baltimore it is prepared from the silicious hydrate of magnesia, marmolite. Chemical Composition. —This salt consists of one equivalent of sulphuric acid, 40 ; one of magnesia, 20 ; and |pven of water 63 = 123. Properties. —Sulphate of magnesia' usually forms small needle-like crystals —white and transparent. Its taste is bitter and saline. When exposed to the atmosphere, if pure, it slowly effloresces. When it deliquesces, it is owing to the presence of muriate of magnesia. It dis- * Thomson, vol. ii. p. 314. CATHARTICS. 127 solves in its own weight of water at 60°, and in three-fourths of its weight of boiling water. In alcohol, it is insoluble. Effects. —Like those of sulphate of soda, though it is less apt to offend the stomach or gripe, and operates rather less promptly. It is the best and far the most commonly used of the saline purgatives. The dose is from one to two ounces. The best way of disguising its taste is to add lemon juice to the solution. TARTRAS POTASSyE ET SOmE. This is commonly called Rochelle salts, from its having been first prepared and introduced into practice by an apothecary of Rochelle in France, by the name of Seignette. From him, too, it Avas called the salt of Seignette. The discovery of this salt was made in 1672, but its composition was kept a secret. From this circumstance, no doubt, it gained great celebrity, and from its being supposed useful in almost all complaints, it was called Sal polychrest, or the salt of many virtues. In 1731, the chemical constitution of it was ascertained by Bouldac and M. Geoffroy. Mode of Preparation. —This salt is prepared by simply adding bitartrate of potassa finely pulverized to a solution of carbonate of soda. Here the excess of acid in the bitartrate of potash combines with the soda, forming the tartrate of soda, while the carbonic acid escapes with effervescence. In this way a double tartrate of potash and soda is formed. Chemical Composition. —Rochelle salts consists of two equivalents of tartaric acid, 132 ; one of potassa, 48 ; one of soda, 32; and ten of water, 90 = 302. Properties. —It is in large, white, regular crystals ; taste, bitter and saline; slightly effloresces when exposed to the air; soluble in five parts of water at 60°, and in much less boiling water. Physiological Effects. —Similar in its operation as a purgative to those already noticed. It is less unpleasant than most of the saline cathartics, but it is also less active. Dose. —From one ounce to an ounce and a half is a dose for an adult. TARTRAS POTASS.E. Tartaric acid combines with potash in two proportions, the one forming an acidulous salt, bitartrate of potash ; the other a neutral salt, tartrate of potash. This last is commonly called soluble tartar, from its great solubility in water when compared with the bitartrate, which is very insoluble. Mode of Preparation. —Soluble tartar is prepared by taking a solu- 128 MATERIA MEDICA AXD THERAPEUTICS. tion of carbonate of potash, and adding to it bitartrate of potash reduced to a fine powder, and boiling. Here the excess of "acid with bitartrate is neutralized by the potash, while the carbonic acid escapes with effervescence. By a slow evaporation regular crystals form. Chemical Composition. —One equivalent of tartaric acid, 66 ; and one of potassa, 48 =: 114. Properties. —If properly prepared, soluble tartar forms in white crystals. As generally found in the shops, however, it is in a granular form. To obtain regular crystals the evaporation ought to be slow and nearly spontaneous. As commonly made, however, on a large scale, the evaporation is hastened by frequent stirring, which interferes with the crystallization. It has a cool, bitterish taste. In the form of crystal, it is soluble in its own weight of cold water; in the granular form, it requires four times its weight. In hot water its solubility is increased. In alcohol it is also soluble. When exposed to the atmosphere it deliquesces. Effects. —As a cathartic this salt acts mildly yet efficiently. It causes no griping, and possesses the properties of correcting the griping effects of senna and other cathartics. It operates quietly with them; and like the other saline cathartics, produces watery evacuations from the bowels. Dose. —From 3 ij to 3 j in any bland fluid. Not much used. SUPER-TARTRAS POTASSA CALLED ALSO M-TARTRATE ACID TARTRATE. This is called crystals of tartar or cream of tartar, and is a salt existing in the juice of the grape, and is deposited in the form of a crust on the sides of casks of wine, during the slow fermentation which Avine undergoes Avhen kept. This goes under the name of tartar, and is either red or white, according to the wine from Avhich it is deposited. By dissolving this substance in boiling water and filtering, broAvn crystals are deposited. The coloring matter is then separated by again boiling the crystals, and adding Avhite clay, Avhites of eggs, or Avoodashes, which attract the coloring matter. Properties. —Crystals of tartar consist of small, irregular, brittle, whitish crystals. They are easily reduced to powder, and in this state arc called cream of tartar. Its taste is sharp and very acid, very sparingly soluble in Avater, requiring 120 parts of cold and sixty parts of boiling Avater to dissolve it. It is insoluble in alcohol, which explains its deposit from grape juice Avhen the vinous fermentation begins and alcohol is found. Co?nposition. —Potash, 1 atom, 47 ; tartaric acid, 2 atoms, 132 ; Avater, 1 atom, 9. Total 188. CATHARTICS. 129 Effects on the System. —This is a pleasant, cooling laxative. It requires to he taken in doses from 3 iij to 3 j to produce its effect. It is taken in solution sweetened with sugar. [This solution should always be made with boiling water, and when cold, decanted from off the undissolved lime, . — Elixir salutis, senna, caraway seed, cardamom, raisins, proof spirit—a stimulating, cordial cathartic—good when the tone of the digestive organs is impaired, and when there is flatulency— good for intemperate, dose 3 ij to § h 4. Syrup. —Dose for children, 3 i to 3 ii. 5. Confection. Lenitive electuary. —This was formerly a good deal used, but has now gone out of fashion. CASSIA MARYLANDICA. Commonly known by the name of American Senna. It is a tall showy plant, growing in most of the States south and west of New York, commonly found in moist situations and the borders of streams—flowers from June to the latter part of August. Flowers, bright yellow. The leaves —the officinal part —are smooth, green above, yellowish green below, from one to two inches long, a quarter of an inch broad, having the odor and smell of foreign senna. Effects. —An active cathartic very like foreign senna; by some thought less active, though this is denied by others, who deem it fully equal in strength. The difference probably depends on the different modes of collecting and preserving the leaves. SCAMMONY. This substance is obtained from the root of the Convolvulus scammonia, a plant growing native in Syria. It consists of a number of slender twining stems, fifteen or twenty feet long, extending along the ground, or climbing upon neighboring plants. The root is perennial, from three to four feet in length, and from ten to twelve inches in circumference. The mode of obtaining Scammony is the following:—About the beginning of June, the ground is removed from the upper part of the root, the top of which is then cut off in an oblique direction, about two inches below the origin of the_stems. Small vessels or shells arc fixed under the root in such way as to receive the milky juice which oozes from the cut surface. Each root furnishes only a few drachms, and the whole of this flows out in about twelve hours. The juice thus collected 134 MATERIA MEDICA AND THERAPEUTICS. from different roots is put together, and'on standing concretes into solid masses. This is the pure scammony. Generally, however, while it is yet in the soft state, it is adulterated by mixing it with the expressed juice of the stalks and leaves, and not unfrequently with flour, ashes, fine sand, and chalk. As found in the market, scammony is of different qualities, depending upon the degree of adulteration. Formerly the best kind was called Aleppo scammony, and the inferior kind Smyrna scammony. These names are not used at present. The best kind is now called Virgin scammony, and the inferior kinds, seconds and thirds. Virgin scammony comes in amorphous pieces of a dark color, sometimes covered with a white powder. As this powder effervesces with hydrochloric acid, it is chalk in which the pieces have been rolled. They are friable and break readily under the pressure of the fingers, presenting a black and brilliant fracture. When rubbed with the finger, moistened with water or saliva, it forms a whitish liquid on its surface. Its smell is cheesy ; and its taste, at first slight, becomes afterwards acrid. The inferior kinds of scammony come in large flat masses or cakes. The better sort, however, sometimes amorphous. Not so friable, and its fracture generally dull. Tests. —Good scammony fractures readily under the fingers; the fracture is dark and brilliant. Its specific gravity, according to Pcrcira, is only P210 ; if much heavier, it is impure. If, on touching the fractured surface with hydrochloric acid, effervescence takes place, it is adulterated with chalk. If iodine strike a blue color in a decoction of scammony, Hour (starch) is present. When rubbed with the finger, moistened with water, a milky liquor is formed. Ether takes up 80 per cent, (the resin). Composition. —Principal ingredients, gum and resin. The proportions vary from 80 per cent., or even a little more, of resin, to so little as 29 per cent. That having the most resin is best. Being a gum resin, it is soluble partly in water and partly in alcohol. Diluted alcohol dissolves all but the impurities. Effects. —Scammony is one of the drastic hydragogue cathartics. It resembles jalap in its general action, being, however, more active and more liable to produce nausea. Generally operates speedily, and frequently gripes and causes a good deal of local irritation. Its action varies with the state of the bowels. If they are lined with mucus, it passes through without producing much effect. In combination its action is rendered much milder. Scammony is useful in all cases when it is desirable to make a strong impression on the bowels. In torpid states of these organs, it is a valuable article. Whenever active irritation or inflammation of the Dowels is present it is objectionable. CATHARTICS. 135 Mode of Administration. — Powder. —This is given intimately triturated with gum arable, starch, or sugar. This is supposed to render its action milder. Of this the dose must vary according to the purity of the article. Of Virgin scammony, six to ten grains for an adult; of the common, ten to twenty grains. For a child, from three to five grains. A good way of giving it is in the form of an emulsion with milk. Resin. —This operates like the scammony itself, only in smaller doses —eight to ten grains. Has no advantage over good scammony. GAMBOGE. This is the product of an unknown tree growing in Siam, and in the island of Ceylon. In Siam, it is procured by breaking the young shoots and leaves of the tree, and collecting in cocoa-nut shells the juice, which exudes in drops of a yellow color. It is then transferred into large earthen jars, where it remains until dried to a proper consistence, when it is formed into rolls and covered with leaves. Sometimes the juice is collected in the hollow joints of bamboo, and as it solidifies, the gamboge forms into pipes. As found in commerce, it is in three different forms; in solid rolls, in cylindrical pipes, and in irregular masses. The two first are known by the name of pipe gamboge, the last cake gamboge. The poorest pieces of all the varieties are called coarse gamboge. Pipe is the best. Good gamboge is an opaque substance of a uniform orange color, bitter, and breaking with a conchoidal fracture; when taken into the mouth it has no taste at first, but afterwards leaves an acrid sensation in the throat. It yields a powder of a bright yellow color. The inferior kinds are harder, the fracture is earthy, and of a brownish not uniform color; has dark spots in it from the presence of foreign bodies; generally adulterated with starch, fragments of wood, &c. Tests of its Purity. —1. The peculiar fracture. 2. If a decoction of its powder be tested with tinct. of iodine, if rendered green, starch is present. Composition. —The best analysis of this article is that of Professor Christison. According to him the purest kind consists of Resin. This he calls gambogin or gambogic acid, a brittle substance in thin laj'crs of a deep orange color insoluble in water, but soluble in alcohol and more so in ether. In doses of 5 grs. this acid produced free watery discharges, without griping or uneasiness. He infers from this that the activity of gamboge does not depend entirely on this acid, for if it did 5 grs. of it would be equal to 7 of gamboge, which is not the case. Soluble gum or arabin, analogous to gum arabic. Woody fibre, only a trace. Moisture. 136 MATERIA MEDICA AND THERAPEUTICS. The proportions of these ingredients in the different kinds of the article are found to vary very much. The inferior kinds contain large proportions of woody fibre and starch. Gamboge is dissolved partly by alcohol and partly by water. It is also dissolved bv the successive action of ether and water. Effects. —Gamboge is a powerfully hydragogue cathartic, promoting intestinal and urinary secretion, and producing liquid evacuations from the bowels. In larger doses it causes nausea, vomiting, griping, and copious Avatcry stools. Sometimes it causes great irritation of the mucous membrane of the intestines. In over doses it - acts as an acrid poison. The peculiarities of this article are, that it is very apt to affect the stomach. This is OAving to its easy solubility in the juices of that organ, and that it operates very rapidly. It may be used in all those cases where we want an active cathartic to produce copious watery evacuations. In cases where the boAvels are irritable, or where there is general debility, it is dangerous. This is one of the articles which entered into the composition of Morrison's pills, which have done so much mischief. Doses, d'c. —From the general propensity which gamboge has to affect the stomach from its ready solubility, the best form of giving it is that of pill, and in small doses, frequently repeated. Give a pill of 1, 2, or 3 grs. every three or four hours till it operates; a full dose is from 3 to 6 grs. Gamboge is generally given in combination to quicken the action of other articles. Pil. Camb. Comp., in which the gamboge is combined with aloes, carb. potass., and soap, is a good cathartic in dropsy and congestion of the brain. [helleborus niger (black hellebore — the root). Hellebore was well known to the ancients, and its use by Melampus (b.c. 1400) is the earliest instance on record of the giving of a purgative. Dr. Sibthorp, however, supposes that the ancients used the H. officinalis, not the H. niger. The root consists of rhizome and radicles; taste acrid and nauseous. Effects. —Hellebore is an acrid, narcotico-irritant purgative, useful only in torpid, phlegmatic habits, and where the pelvic circulation is languid. Though much lauded by the ancients, especially in mania, it is iioav little used. Forms. — Powder. —Dose, 10 grs. Tincture, U. S. —[Hellebore, § iv; dilute alcohol, Oij. Macerate seven days and strain.] Dose, 3 h] CATHARTICS. 137 COLOCYNTH. The plant yielding this is the Citrullus colocynthis, the Bitter Cucumber ; native in Japan, Turkey, Nubia, the Cape of Good Hope, and the Grecian islands. In Spain it is cultivated. It is an annual plant, resembling very much the common garden cucumber. The stems are trailing and beset with rough hairs. The fruit which it yields is a round berry, about the size of a common orange, with a smooth skin of a yellow color. Inside it has a white spongy pulp filled with seeds. It is this pulp which is used in medicine. The mode of preparing it is to peel the fruit when yellow and ripe, and dry it in stoves. In this state it is exported. As found in the shops, it is in the state of the dried round fruit, generally peeled. The pulp is light and spongy, of a white color, and filled with seeds. It is destitute of smell, but has an exceedingly bitter and nauseous taste. The only part of the fruit possessing active properties is the pulp. The powder is of a pale yellow color. Composition. —Colocynth contains a peculiar bitter principle, called colocyntin. This is a resinous substance of a yellowish color, extracted by alcohol. It is brittle and exceedingly bitter. In alcohol it is very soluble ; in water, sparingly so, imparting to that fluid, however, an intense bitterness. This substance possesses the active properties of the colocynth in a concentrated form. In doses of one or two grains, it is said to be a good substitute for croton oil. Besides this, colocynth contains a resinous matter, insoluble in ether; fixed oil, extractive matter, gum, and various salts. The virtues of colocynth are extracted by ether, alcohol, and water. Effects. —In small doses, colocynth acts as a safe and valuable cathartic, increasing the peristaltic action of the intestines, and promoting intestinal secretion. In full doses, it acts as a drastic and hydragogue, causing watery evacuations, severe irritation, griping, and sometimes bloody stools. It appears to pass rapidly over the small intestines, and to exert its principal effect on the large ones. If given in too large doses it has proved fatal, producing the effects of a narcotico-acrid poison. Analogous in its general operation to gamboge, except that gamboge operates more on the small intestines. Resembles aloes in acting on the large intestines, but differs from it in producing more secretion, and being less tonic. Dose. —2 to 8 grains in powder, mixed with gum or starch. Seldom, however, given in this way. Generally in form of extract, and in combination. Ext. Colocynthidis Comp. —Is a very popular and a very active cathartic, much used in obstinate constipation. 10 138 MATERIA MEDICA AND THERAPEUTICS. ELATERIUM. The plant which yields this article is the Mormodica elaterium. It was known to and used by Hippocrates. The common name is the wild or squirting cucumber. It is an annual, growing native in the south of Europe, especially in Sicily, Italy, and the south of France, in uncultivated and stony situations. In England, it is cultivated exclusively for medicinal purposes. In that climate, however, it does not survive the winter. The root of the plant is thick and fleshy, sending out trailing stems spreading in different directions, resembling those of the common cucumber. Its fruit, also, resembles that of the common cucumber, only being much smaller. It is about two inches long and one inch thick, of a greenish grey color, and covered with prickles, "When perfectly ripe, the fruit separates from the stalk, and scatters its seeds and juice to a considerable distance. It is from this peculiarity that it derives the name of the squirting cucumber. The elaterium of medicine is the substance spontaneously deposited by the juice of the fruit when allowed to stand. The quality of the elaterium depends in a great measure upon the manner in which it is prepared. From a series of experiments made by Dr. Clutterbuck of London, it appears that the active principle of the cucumber resides only in the juice which surrounds the seeds. The fruit itself, the seeds, as well as the stalks, leaves, &c n contain little or none of it. It is from this, therefore,, that the pure elaterium is obtained. The best kind of English elaterium consists of thin, slightly curled flakes, marked with the impression of the linen on which it has been dried; of a pale, greyish green color, becoming yellow by exposure ; very light and friable ; taste acrid and bitter, with very little odor. It is readily reduced to powder. This is called E. album. The inferior kinds (E. nigrum) are hard, breaking with difficulty; more curled, gummy, and dark colored. Purity. —Elaterium differs greatly in its shape owing to the mode of preparation and actual adulteration. 1. From the Mode of Prcj)aration.— -That obtained according to Dr. Clutterbuck's method, from the juice which has been allowed to flow spontaneously from the sliced fruit, is the strongest, but is obtained in very small quantity. Where the juice is forced out by strong pressure, more elaterium is made, but it is of inferior quality. By evaporating the juice a still inferior quality is produced. Then again, if the juice from which the elaterium is deposited be suffered to stand too long before it is separated, a mucilaginous matter subsides, which greatly impairs its strength. This renders the elaterium dark and gummy. CATHARTICS. 139 The adulterations are with chalk and lime, generally of the Maltese kind. Tests. —It should be friable, of a pale green greyish color, floating on water, not effervescing on the addition of diluted hydrochloric acid. If it does, it shows the presence of chalk. If the acid solution be neutralized by ammonia, gives no precipitate on the addition of oxalate of ammonia. If chalk be present, throws down a copious precipitate (oxalate of lime). Touched with the tincture of iodine gives no evidence of presence of starch. If this be present turns it blue. Chemical Composition. —According to analysis of Mr. Hennel of London, elaterium contains in 100 parts, 40 parts of a peculiar crystallizable substance which he called elaterin, 17 parts of green resin, starch 6 parts, woocly fibre 27 parts, saline matters 6 parts. Effects, —Elaterium is among the most active of the hydragogue cathartics, causing free secretion and copious watery evacuations. If the dose be somewhat large it acts with great violence, causing sickness and vomiting, together with irritation, and in some cases actual inflammation of the mucous membrane of the bowels. From the local irritation which it produces, general febrile excitement is apt to occur during its action ; the pulse becomes excited, the tongue and skin dry, together with great thirst. As this article operates so powerfully, its use 'must be limited to those cases [in which the bowels are torpid, and where it is desirable to excite a powerfully revulsive action in the intestines and to cause free intestinal secretion. On the other hand, whencverany local irritation of the intestines exists, it ought not to be used. In delicate habits, too, and in young subjects it is improper. This article is uncertain and variable in its operation, large doses at one time produce little effect, while small ones are sometimes followed by violent effects, owing either to difference in the strength of the article or in the state of the intestines. Mode of Administration. —The best form is that of pill, made with extract of gentian. The dose must vary with the strength; of the best kind one sixteenth to one eighth gr. is sufficient; of the ordinary kind one half a grain; of the black kind 2 or 3 grs. are sometimes used. The dose to be repeated every two or three hours until the desired effect is produced. Elaterin is crystalline, very bitter, no smell, neither acid nor alkaline ; insoluble in water and soluble in hot alcohol. One sixteenth of a grain operates like a dose of elaterium. 140 MATERIA MEBICA AND THERAPEUTICS. CROTON OIL. The plant which yields this is the Croton tiglium, a tree growing ten or fifteen feet high in China, Cochin China, Ceylon, the Molucca islands, and the greater part of the East Indies. The fruit is a capsule about the size of a filbert, with three cells divided by membranous partitions, each containing one seed. It is from the seeds that the oil is obtained. They are about the size of the castor oil seeds; viewed laterally they have an oblong shape, but from either extremity their shape is four-sided, having two of the sides convex and the other two somewhat flattened. The shell of the seed is black, but is covered with a soft yellowish brown epidermis. The kernel is of a yellowish brown color. The seeds have no smell; taste at first mild but soon becomes hot and burning, this continues for some time. The seeds are imported from the East Indies in cases, and from the friction which they undergo during their transportation the epidermis is generally rubbed off. On their first introduction into Europe they were known by the name of Molucca grains. The croton seeds are actively cathartic, producing the effects of a hydragogue. This is the form in which this article is frequently used in the East Indies. The seeds are first well dried by a fire and the shells carefully removed. This is supposed to correct the acrimony of the seeds. They are then pulverized and made up into pills with honey, each pill containing grs. of the powder. Two of these pills are an ordinary dose for an adult. Mr. Marshall says this dose is about equal to 3 ss of jalap or to grs. vi of calomel. The stools are invariably watery and copious. It operates without nausea and griping, except in occasional instances. In Europe and in this country the only preparation that is used is the oil. Croton Oil. —This is obtained by first roasting the seeds and then separating the shells; after this subjecting them to strong pressure. In this way 50 per cent, of their weight of oil may be procured. The oil is of a reddish yellow color, with a faint odor and of an unctuous thickness, like castor oil. Its taste is hot and acrid, leaving an uneasy feeling in the mouth and throat, which continues for some hours. Chemical Composition. —Dr. Nimmo, who early investigated the subject, states the composition thus: —acrid purgative matter 45, bland fixed oil 55 = 100. This acrid matter was supposed to be of a resinous nature, but the subsequent analysis of Brande established the existence of a peculiar principle, crotonin, and an acid, crotonic. 141 CATHARTICS. Croton oil is soluble in ether, the fixed and volatile oils. In absolute alcohol cold it is insoluble but soluble in hot, from which it is again deposited on cooling. Effects. —Croton oil is an active hydragogue cathartic and operates with great rapidity, producing copious watery evacuations. In moderate doses, although it operates actively, it does not produce much nausea or griping. If the dose be somewhat large, it occasions considerable intestinal as well as general irritation. As a cathartic it is suited to those cases in which there is great torpor of the bowels and where an active revulsion upon those organs is desirable. In children and feeble habits, or where inflammation of the intestines is present, it ought not to be used. What is peculiar to this article is that the simple application of it to the tongue, without swallowing, will cause purging. One or two drops applied in this way will operate, and may be resorted to in cases where the patient has lost the power of deglutition, as in apoplexy, tetanus, &c. This oil is variable in its action. Mode of Administration. —The ordinary mode is that of pill, made up with crumbs of bread, each pill containing a drop of the oil. To an adult, one or two of these is an average dose. A better way is to take a pill every hour or two until the desired effect is produced. MERCURIAL PURGATIVES. CALOMEL. Of the history and properties of this most important article I shall speak at large under the head of sialagogues; I now refer to it only as a cathartic. In this respect, it is peculiar and produces effects widely different from those of other medicines of this class. The peculiar effects of calomel depend not upon its mere cathartic power, but on its action upon the liver and the mucous membrane of the bowels. The chief of these peculiarities are : — 1st. Its action on the mucous membrane is peculiar and often very salutary—increasing the secretion, and seeming to enable the membrane to throw off any viscid mucus with which it may be coated. 2d. Its influence on the liver is marked, and its cathartic operation has been by some attributed to its increasing the flow of bile. 3d. It is slow, often taking from 8 to 12 hours to produce any effect —the motions are few and commonly large. 4th. The operation of calomel is rarely attended by much griping, but often by nausea and prostration even to the extent of fainting. 5th. The action of calomel is permanent, and it does not leave behind it that tendency to constipation which follows the use of many cathartics. 142 MATERIA MEDICA AND THERAPEUTICS. 6th. There is yet another peculiarity in the operation of calomel to which I wish to call your especial attention, and that is that when given in large doses, it does not produce any corresponding irritation. On the contrary, it seems to act as a sedative to the intestinal canal. On this principle, scruple doses of calomel have been given in dysentery and other intestinal disorders. The purgative effect is not increased, and the irritation is lessened by thus doubling the dose. Its depressing effect on the whole system is very markedly increased. From a scruple of calomel, the alvine evacuations will be neither more numerous nor more copious than from six or eight grains, but the prostration will be far greater. Cases are recorded where by mistake very large doses of calomel have been taken, £ i or more. The purgation was generally very moderate. Of late years immense doses of calomel have been given in Asiatic cholera and some other diseases. [Pereira gives some cases from the records of a London cholera hospital, in which calomel was given in frightful doses. Three drachms on the entrance of the patient into the hospital, and one drachm every hour till in some cases 20, 25, and 30 drachms were given. In none of these cases did violent irritation or profuse salivation occur. Seventeen out of eighteen cases recovered. The patient who died took 53 drachms in 42 hours, without sensible effects. The best that can be said of this practice is, that it did not kill.— Ed.~\ For the purpose of testing the effects of calomel upon the stomach and intestines, Mr. Annesley instituted some experiments upon dogs which are very curious and interesting. Ho took three healthy dogs, and gave to one 3 i of calomel; to a second, 3 ij ; to a third, 3 iij. After this they were tied up in a room. Twenty-four hours after they had taken the calomel, the dogs were all killed; and five minutes after they were dead, they were examined, and the vascularity of the stomach was found to be in the inverse ratio of the calomel which they had taken, i. e. in the clog who had taken 3 iij, the vascularity was the least, and so on. For the purpose of comparing this with the condition of the stomach of a clog which had taken no calomel at all, an examination of another dog was made, and here the stomach was more vascular than in any of the others. From these experiments, Mr. Annesley draws the conclusion, " that the natural and healthy state of the stomach and intestinal canal is high vascularity, and that the operation of calomel in large doses is directly the reverse of inflammatory." Therapeutical Effects of Calomel. —Upon the use of calomel as a purgative in different diseases, so much was said in my general remarks on purgatives, that I will not now go into the subject in detail. Suffice it to say chiefly by way of recapitulation, that in fevers and inflamma- CATHARTICS. 143 tions, whatever be the type of the former, oV the location of the latter, calomel may, with the precautions and restrictions which were detailed when I spoke of purgatives generally, be used with excellent effect. In jaundice, too, it will often produce the happiest results. For obstinate constipation depending on torpor of the bowels it may be also given with advantage. PILULA HYDRARGYRI (blllC pill). This is a mercurial purgative, not so much used as a cathartic, yet capable, when given in adequate doses, of producing free purging, with most of the advantages which attend the operation of calomel. Of its pharmaceutic history I mall speak under the head of sialogogues. Its dose as a purgath J should be from 15 to 20 grs. The practice of giving five grs. of blue pill at bedtime, and a senna draught in the morning, so highly recommended by the late Dr. Abernethy, has lost some of its favor with the profession; yet for a very large class of cases of constipation it is of great value. Blue pill is an excellent purgative for children ; five grs. given at night will commonly operate in the morning; and its influence, if given early in the febrile and inflammatory affections of children, is usually most salutary. COMBINATION OF CATHARTICS. In what has been said of individual cathartics I have confined myself to a notice of the effects which they produce when given separately, and I have done this with the tw T ofold design of showing that all cathartics do not act precisely alike, and to enable you to understand the principles upon which they are combined in our ordinary prescriptions. On this account I have omitted saying anything in relation to these combinations until the present time. After stating briefly the object to be attained by uniting different cathartics in one prescription, I shall analyse the whole of them with the view of illustrating the principles upon which these combinations should be made. 1. The first object to be attained by combining cathartic medicines is to increase their activity. This may be done either by increasing the rapidity with which they operate or by increasing the actual effect produced. 2. The second object is to make them act more mildly. A number of valuable cathartics, you now know, act with such intensity and produce effects so unpleasant, in the Avay of nausea and griping, when given alone, that their use in this way is exceedingly objectionable. By judicious combination this may, to a very great extent, be obviated. 3. The third object is to obtain in one combination the effect of differ- 144 MATERIA MEDICA AND THERAPEUTICS. ent cathartics. As I have already stated, these articles act in various ways—some increase the peristaltic motion—others cause copious secretions from the inner surface of the intestines—while others again act by promoting the biliary secretions. Now by uniting different cathartics all the effects may be produced by one prescription. These are the principal objects to be gained by combining these articles, illustrations of which you will find in the notice which I shall now take of the different substances belonging to this class. Laxatives, generally speaking, do not admit of combinations. Being used for their mildness and simplicity, they do not require anything to modify their operation. In fact as a general rule, the best form in which they can be given is alone. They are sometimes, however, combined, and then their effects are very much modified. Castor oil is best administered alone. Manna and cassia, from the quantity in which they are obliged to be taken, are apt to sit heavy on the stomach and frequently to cause griping and uneasiness. On this account they are generally combined with the more active purgatives, of which I shall speak hereafter. Sulphur and cream of tartar are frequently combined, and the compound is more active than either separately. Sulphur and magnesia combined frequently answer an excellent purpose. You have a gentle laxative suited to acid states of the digestive organs. As magnesia only operates as a cathartic when it meets with an acid in the alimentary canal, its activity is promoted by following it with cream of tartar. Of Purgatives. —It is in these especially that the advantages of combination are shown. Senna. —This substance, as already stated, when given alone is apt to produce a great deal of griping. . By combining it with manna this is corrected. It is rendered milder in its operation, though not less effectua —at the same time all the unpleasant effects of the manna when given alone are obviated by the senna. By combining senna with some of the neutral salts its griping effects are also corrected, while the compound is more active in clearing out the bowels than either separately. A very good combination consists of senna, manna, and epsom salts. It acts thoroughly yet pleasantly. Rhubarb. —This is a cathartic which is given very conveniently and advantageously alone. It is mild in its operation and sits easily on the stomach. It is frequently, however, combined with advantage. With magnesia it forms a very valuable compound, in all cases where you wish an antacid effect together with a tonic purgative. This is peculiarly useful in cases of enfeebled and deranged stomach from over feeding or over drinking. The most common combination of it, however, is with calomel. Here you combine the peculiar operation of both— that of the rhubarb on the stomach and intestines, and that of calomel 145 CATHARTICS. on the liver. With aloes, which is laxative and tonic, it forms a useful tonic. It combines the united operation of rhubarb on stomach and small intestines and aloes on large. Jalap. —This is a very active cathartic and operates well when given alone. Generally, however, it is combined. With equal parts of cream of tartar, it makes the pulvis purgans so commonly used. By this union the jalap is rendered milder and the whole effect is increased. United with calomel the double effect is obtained upon the liver and upon the intestinal canal. Scammony. —This is an active article and liable to gripe when given alone. This is corrected by combination with other cathartics, and what is singular those of a very active character. By a union of Aloes, Scammony, and Colocynth, in the form of the compound colocynth pill, you get a preparation more permanent in its operation than aloes alone, and yet without the irritation and unpleasant effects either of scammony or colocynth. Gamboge. —This is a very active griping cathartic, operating with uncommon celerity, and usually when given alone commencing its action in the stomach and causing nausea and vomiting. On these accounts it cannot well be given alone. By combination, however, it is rendered a manageable and valuable cathartic. With aloes, which is very slow in its operation, and does not affect the stomach, it forms a purgative in which the effect of gamboge on the stomach and bowels is corrected, and yet more active than aloes alone. Generally speaking, gamboge is used only in small quantities, say gr. j., to increase the activity of other articles when you want to produce a strong hydragogue effect. Elaterium. —This is generally given alone. Croton Oil. —Generally speaking, this article has been used in its uncoinbined state, and principally with the view of getting the very active hydragogue effects which it produces. By combination, however, it may be made much more available as a general cathartic. In combination with Calomel or Blue pill, in the dose of half a drop to six or eight grains of the latter, its general efficacy has been increased, while the nausea and griping which it is apt to produce have been obviated. With the compound pill of rhubarb, too, it forms a good combination. Neutral Salts. —Very commonly these are given by themselves, and this is a very good way when the object is merely to wash out the existing contents of the intestines. Their activity is considerably increased by mixing them together. This curious fact is illustrated in some mineral waters (such as Cheltenham salts). Another instance is in the sulphate of magnesia, which acts with great effect if the muriate of magnesia be present. 146 MATERIA MEDICA AND THERAPEUTICS. Of the combination of the neutral salts with senna and manna I have already spoken. Calomel. —This article enters into a great number of combinations, which it is unnecessary to enumerate. In all cases where the object is to promote the secretion from the liver, it forms a useful addition to cathartics. It may be given either alone, and then followed in five or six hours by some quick cathartic to carry it through the bowels, such as neutral salts; or it may be given in combination with other articles, such as powder of jalap, rhubarb, extract of butternut, may apple, croton oil, dr. d'c. In this way you get the combined operation of calomel on the liver, and the other articles on the intestines. ENEMATA (clysters). From the great susceptibility of the mucous surface of the lower bowels, it is evident that medicinal substances may be applied to it to produce impressions not merely on the intestine itself, but on the system at large. Hence enemata arc used for a great variety of purposes. At present I shall only speak of them as agents intended to evacuate the bowels, either by their own powers, or by promoting the operation of cathartics. Used for this purpose, they are of very great value. Cathartic enemata operate in two different ways; first, by the mere stimulus of distension causing contraction of the gut; second, by an irritation of the mucous membrane of the rectum, they stimulate the muscular coat, and in that way provoke contraction. This impression is frequently conveyed to the upper portion of the large intestines. Enemata are capable of fulfilling three indications : 1. They evacuate the lower portion of the alimentary canal. 2. They assist and expedite the operation of cathartics. 3. By the irritation on the intestine they act as revulsives, and thus relieve distant parts. They are made more or less stimulating according as they are intended for one or other of these purposes. To evacuate the lower bowels we use either those which act by mere distension, or those which are only moderately stimulating. 1. Warm water, warm gruel, molasses and water. These operate by distension only. The quantity to be given is from a pint to a quart. Bereira objects very strongly to the large enemata recommended by late authors, insisting that " it is rarely proper to use more than a pint." That " large quantities destroy the tonicity of the gut," &c. I think experience has shown the entire safety and manifest utility of large enemata. Injections may be made slightly more stimulating by adding to the warm water, salt, oil, or soap. These are of course more efficient and better calculated to aid the operation of a cathartic. 147 CATHARTICS. If a still more active enema is desired, decoctions or infusions of the various purgatives may he used, as dec. aloes, inf. senna;, solutions of the purgative salts, &c. If a strong revulsive action is required, doc. colocynth, or the spirits of turpentine (made into emulsion with gum arabic or eggs), may bo tried. The instrument used, and the manner of using it, are by no means indifferent matters. The best instrument is the valve syringe, but the ordinary enema syringe, if good, will answer very well with care. The tube or bag to which a pipe is attached, and from which, the pipe being introduced into the rectum, the fluid is allowed to run by its own gravity, has the great advantage that it is impossible to do any harm with it. The common pipe and bladder are unhandy, but safe. The fluid should be injected very gradually, and the greatest care taken to avoid injuring the parts with the pipe. [Moving the bowels every day with a largo enema of cold water has cured very many cases of chronic piles. It should be continued for a 3'ear, and resumed on any return of the difficulty. Even where cure is not effected the comfort of the patient is much increased.] ANTHELMINTICS. Anthelmintics are those medicinal substances which possess the power of destroying and expelling worms from the human system. I shall first give you a brief account of some of the different kinds of worms which are found infesting the human bod}-. They may be divided into two general classes, viz. those which infest the intestinal canal, and those which are found in other parts of the body. I shall treat of the first of these only. Of those Worms which infest the Intestinal Canal. —These are of five species, three possessing an alimentary canal, hence called hollow worms, Coclelmintha —two having no abdominal cavity, called solid worms, or Sterelmintha. The hollow worms— nematoid worms —are ascaris lumbricoides, ascaris vermicularis, and tricocephalus dispar —called respectively the large round worm, the small thread worm, and the long thread worm. The solid worms are : Taenia solium, the common tape-worm, and Bothriocephalus latus, the broad tape-worm, formerly called Tsenia lata. The Tape-worm, Taenia. —This is a very long worm, made up of flat articulations, united by means of a border or edge varying in breadth and thickness. It is of a whitish color, and varies in length usually from twenty to thirty feet. It generally occupies the small intestines. The head is turned upwards and firmly insinuated in the mucous membrane, while the bod}'' extends floating down the intestinal canal. There are two species which have been found in the human subject. Tcenia lata, or, as it is now called, Bothriocephalus latus —the broad tape-worm. This species has been found chiefly in the inhabitants of Poland, Switzerland, Russia, and some parts of France. In other parts of Europe it is not found. In this species the articulations arc broader than they are long, and the whole worm is broader and thicker than the other species—the tamia solium. The breadth varies from one eighth to one quarter or more of an inch. Its general length is from fifteen to twenty feet. Its color is dusky and not so white as the tenia solium. Tcenia Solium. —The solitary worm—so called from its being sup- ANTHELMINTICS. 149 posed that never more than a single one was found in the intestinal canal at the same time. Satisfactory observations have, however, proved this to be incorrect. This species is found in the inhabitants of Europe generally, with the exception of those nations in whom the taenia lata is met with, in whom it is not often found, though occasionally the two species of worm are found in the same individual at the same time. Among the Egyptians it is also common. It is not so broad or so thick as the other species. Its length however is greater, averaging from twenty-five to thirty feet. Its color is commonly a pale white. This species of taenia is never passed entire, and it possesses the curious property of parting with a number of joints and reproducing others to supply their place. This worm is Hermaphrodite, having a double sexual apparatus in each joint. Ascaris Lumbricoides. The long round worm. This animal is about the thickness of a common quill and from six to ten fingers' breadth long. When first passed it has a transparent appearance, but it soon acquires an opaque yellow tinge. The general shape of the body is cylindrical, but tapering towards the extremities. It is found both in children and adults ; in the former, however, it is most common. Its natural abode is in the small intestines, more especially the jejunum and ilium. Occasionally it passes into the stomach and makes its way out by the mouth. Unlike the tajnia it exists in great numbers—fifty, a hundred, and even a greater quantity having been discharged, in a few clays, from the same person. Occasionally it is found with other worms. Ascaris Vermiciilaris, also known by the name of Oxyuris vcrmicularis —the maw or thread worm. The common name by which they are known is ascarides. This is a small worm with an obtuse head, and varying in length from one line to five and six lines. The part of the intestines in which this worm is generally found is the rectum, sometimes also in the colon, and occasionally in the coecum. In children and young subjects they are more common than in adults. In females they are sometimes found in the vagina, from whence they have been known to pass up into the urinary organs. In some very rare cases, they have been detected in the stomach and oesophagus. The worm is never found alone, but always in conglobate masses. According to Bura, the ascarides live longer in the human body than any other worm. Tricocephalus Dispar —thread worm —the long thread worm, or capillary headed worm. This is a slender worm from one and a quarter to two inches in length, and in breadth not more than about half a line. Its color is usually white. This worm is not of a uniform size throughout its whole length. The extremity where the head is situated, is very slender and resembling a thread, and from this it derives its name. For about two thirds of its length it continues of this size. The remaining one third 150 MATERIA MEDICA AND THERAPEUTICS. towards the tail is much larger. Pereira says " it does not appear that the long thread worm ever excites any symptoms." Evidences of the Existence of Worms. —It is by no means easy to decide in all cases whether worms are actually present. This arises mainly from two causes. In the first place, they most commonly occur in very young subjects, who, of course, can give no accurate account of their symptoms or sensations; and in the second place, the sympathetic irritations occasioned by worms in the intestines, are so diffused over the whole system, so remote frequently from the intestines, and so varied in their character, that it is not always easy to trace them up to their original source. The symptoms may be divided into two classes, viz. primary and secondary. 1. Primary Symptoms. —By these I mean the immediate symptoms of local irritation in the intestinal canal. The first of these is pain in the abdomen. As may naturally be inferred, from the moving nature of the irritating cause, these pains are not fixed in any particular spot, but wandering over the whole abdomen. They differ, too, in intensity, varying from a mere sense of uneasiness to pains of a more sharp and pricking character. Whenever the stomach and intestines are empt3 T , these pains are aggravated, and on taking food they are usually relieved. The abdomen becomes tumid and tender. The second symptom is derangement of the functions of the stomach and bowels. This exhibits itself in nausea, eructations, and sometimes vomiting. The appetite is variable —at one time entirely gone, and at another voracious. The bowels arc irregular—sometimes costive, sometimes relaxed. Not unfrcquently tenesmus is present. Such are the primary and local effects of worms, viz. irritation in the intestinal canal and a consequent derangement of the function of digestion. 2. Secondary Symptoms. —These are various, and show themselves in almost every part of the system. The countenance is generally changed in its appearance. Usually it is of a pale or leaden color, with a red spot on the cheek. The eye becomes dull and frequently fixed; the pupil is dilated, and the under cyelid;s become tumid and have a bluish streak upon them. The nose is tumid, and itches incessantly. Children are constantly picking their noses. The mouth is full of saliva; the upper lip swollen ; the tongue foul, and the breath offensive. The brain and nervous system are also greatly affected. There is headache, especially after taking food —singing in the ears. Disturbed sleep, and vertigo. Delirium and fainting have all been known to occur. Amaurosis, deafness, apoplexy, and epilepsy have resulted from the presence of worms. 151 ANTHELMINTICS. The foregoing is account of the symptoms indicating the presence of worms. You are not to expect to meet the whole of them in any particular case. After all, however, the only certain sign is the actual evacuation of worms from the intestinal canal. [And then we are not sure that the previous symptoms have resulted from worms.] Symptoms produced by the different species of worms. —1. Ascarides. —As these reside chiefly in the rectum, they cause an excessive irritation about the anus, sometimes extending to the neck of the bladder. 2. Taenia.—As may naturally be supposed, the sensation occasioned by this worm is peculiar. Occasionally pricking or biting is felt; most commonly, however, it is that of something alive and moving. The abdomen swells at intervals, and then subsides, as it were, by undulation. From time to time, also, a sense of coldness pervades the abdominal viscera; the appetite is voracious, while the more the person eats, the thinner he becomes. The complexion is livid, the eye is dilated ; confusion of the head and vertigo. There is sickness at stomach, and sometimes vomiting, with general weakness in all the limbs, and frequent trembling of the whole body. [These violent symptoms are by no means universal. I have known a man in the most florid health pass joints of taenia.] 3. Lumbricoides.—The sensation caused by these animals is much more severe generally than that of the taenia. This arises from the greater number of these generally present, and from their insinuating their sharp points into the mucous lining of the intestines. About the umbilicus, accordingly, severe colicky pains are frequently felt, together with rumbling of the abdomen. Origin of Worms. —The advocates for spontaneous generation have made the existence and multiplication of intestinal worms and other parasites the great foundation of their theory. Their whole argument amounts, when stripped of its verbiage, to this. We do not well see how a worm can have got into the intestines of a man, still less of a foetus in utero (where they have been found), or into the liver or the eye ; and therefore we will insist that it not, but has been generated in the spot where we find it. This is an argument not from our knowledge, but from our ignorance, and is entirely unphilosophical. I need not tell you after this, that I do not believe at all in the spontaneous origin of these animals. However they may originally get into the human body, they are propagated in the ordinary way, though only under certain circumstances of the human body are their germs developed. Circumstances favoring the development of ivorms. —These are various, and in a practical point of view are worthy of investigation. A knowledge of them is the only thing which can lead to a correct and philosophical use of the various remedies proposed for their extermination. 152 MATERIA MEDICA AND THERAPEUTICS. 1. A peculiar condition of the intestinal canal. —The precise condition of the intestines favorable to the development of worms is that in which large accumulations of mucous and other secretions have taken place, and are found lining the inner surface. 2. Age. —It is a well known fact that children are more liable to worms than adults, and the reason is that there is a greater tendency in them to mucous and crude accumulations in the intestines. There are only two species of worms that children are liable to, viz. ascarides and lumbrici. 3. Sex. —As a general rule females are more liable than males. 4. Diet. —It is a fact well ascertained that certain kinds of diet are more favorable to the production of worms than others. This must necessarily be the case. The too frequent use of crude and raw vegetables and fruits has this effect. The excessive use of sugar, milk, butter, and cheese, and abstinence fvom animal food, have the same tendency. In a still more striking manner does the abstinence from the use of salt produce this effect. 5. Climate. —Independently of mode of living, the climate seems to exercise a certain influence in developing worms. They are especially common in India and the western coast of Africa. I have already stated that the taenia lata is only found in the natives of the north of Europe. Taenia solium is very common in Switzerland. Blacks are more obnoxious to worms than whites. (Pereira.) 5. Disease. —In fevers worms are sometimes discharged. Now, in many cases of this kind, practitioners have been in the habit of ascribing the fever to the presence of these animals. This has been carried too far. Although there can be no question that the irritation of these animals is capable of producing febrile excitement in the system, yet in a great majority of these cases their presence is a mere coincidence, and so far from having been the primary cause of the fever, it is merely the condition of the system and of the intestinal canal occasioned by the fever which has favored their development. In debilitating diseases they are very common. Dr. Isaac Wood of this city says that when the cancrum oris prevailed endemically at the Alms House, the intestines of such children as died of it were found " stuffed full of I believe with Pereira, that we know very little of the circumstances which favor or check the production of intestinal worms, and that referring their formation to a debilitated state of the alimentary canal is a mere hypothetical assumption. PRACTICAL RULES TO BE OBSERVED IN THE USE OF ANTHELMINTICS. These are few and simple, and directly deducible from what has already been stated. 153 ANTHELMINTICS. As worms are always associated with certain conditions of the system, and more particularly of the intestinal canal, you are carefully to analyse these. It is only by so doing that you will be enabled to make a proper selection of the articles appropriate to any particular case; and as in almost all cases the intestinal canal is in a deranged state, a general rule is to begin with those articles which shall correct this condition of it. Of course the first remedies are active cathartics, and especially those that possess the power of separating mucus from the inner surface of the intestines, such as aloes, senna, and the like. By these means alone you frequently not merely get rid of the worms, but you correct that condition of the intestines which favors their propagation. In cases where this condition of the intestines is accompanied with great laxity and debility, tonics are essential, and it is here that iron proves so valuable. If after the use of these remedies the worms still remain, recourse may be had to those articles which act more specially upon these animals. After the worms are expelled, endeavor to fortify the constitution against their return by the use of such means as the nature of the case may render appropriate. In cases of fever supposed to be owing to worms, do not be led astray by importunities of friends to treat it exclusively for these animals. CALOMEL. Calomel is certainly among the very best anthelmintics that we possess. It acts, probably, simply by clearing away more effectually than any other medicine the mucus and other viscid materials generally found lining the intestinal canal in cases of worms, and in which these animals arc always found imbedded. [All this about worms imbedded in the mucus of the stomach and bowels is mere hypothesis—there is no proof of its truth.] It should be given in such quantities, and so often repeated, as to produce its full effect upon the whole secretory apparatus of the intestinal canal, and this object should be accomplished with as much rapidity as possible. The best plan, therefore, is to give it in large doses, with the view of making a decided impression at once upon the intestinal canal, and then following up its use by some active cathartic, for the purpose of carrying off quickly the matters which may have been separated by the action of the calomel. In this way the worm is first removed from its bed of mucus, and then hurried out before it has had time to make any new attachments. It should never be carried to the extent of producing salivation. This can do no good as a mere anthel. mintic, and may do much injury to the constitution. Mode of Administration, —To adults, from ten to twenty grains, and 11 154 MATERIA MEDICA AND THERAPEUTICS. to children, from three to five grains, may he given at night on going to bed; to be followed early in the morning by some active and quick purge, such as castor oil, salts and senna, &c. In many cases a single dose will in this way prove effectual. If it should not, however, it may be repeated again after an interval of two or three nights. [To these repetitions I should strongly object.] Other Cathartics. —All cathartics, to a certain extent, have the power of expelling worms. Bitter, nauseous, and drastic purgatives have been chiefly resorted to for this purpose. Among these, senna, aloes, gamboge, jalap, without either sickness or purging. This, too, indicates that its use ought to be stopped, for the patient may sink in this state of collapse. Armstrong alludes to a case where death resulted in consequence of continuing the use of it after the purging and sickness had commenced. (Lectures, p. 354.)* In all cases, therefore, when a patient is under the use of this article he ought to be carefully watched. Forms of Administration. Substance. —The powder of the bulb in doses of from grs. iij. to grs. v repeated about three times a day. Dr. Armstrong recommends that in this form it should never be used except * See also Beardsley, p. 118. SEDATIVES. 323 in combination with an aperient. If sickness should occur, so much of the powder may be absorbed as to prove dangerous. He states that he saw one patient's life nearly sacrificed by inattention to this circumstance. Acetum Colckici. —The vinegar of colchicum is prepared by macerating two ounces of the dried bulb sliced in two pints of vinegar, and then adding a fluid ounce of alcohol to preserve the preparation from decomposition. Dose from half a drachm to a drachm. Tincture and Wine. —From the variable strength of the bulb the only way is to prepare a saturated tincture or wine. Of these the dose is from half a drachm to a drachm repeated three or four times a day. As the bulb is uncertain in its strength, the seeds have been lately used as a substitute. A tincture or wine is prepared by macerating an ounce of the seeds in a pint of Teneriffe wine. As the active properties reside in the husk, the seeds should not be bruised. The dose is from half to one drachm. With regard to all the preparations of colchicum, Dr. Armstrong remarks, that by long keeping or exposure to the light they become more or less impaired in their virtues. Hence he advises them to be kept in a dark place, wrapped in paper, or in opaque vessels. (Lectures, p. 353.) Colchicum is not a remedy used in a great number of diseases. It is particularly celebrated in the treatment of gout and rheumatism, and in these it sometimes proves exceedingly valuable. It is supposed to be the active ingredient in the celebrated remedy for the gout, the Eau Medicinale d'Husson. In gout it sometimes produces relief without any sensible evacuation, acting simply as a sedative. Generally, however, you will find that the patient is not relieved until it acts on the bowels. In acute rheumatism it is advisable to bleed before prescribing the colchicum, although by some it is considered to be a substitute for the lancet. You will not find, however, this to be the case any more than with digitalis. Both are good adjuvants to bloodletting, but not substitutes for it. Colchicum has also been used, and with some success, in [dropsy and in] inflammatory affections of the chest. ACONITUM NAPELLUS. This is commonly known by the name of monkshood or wolfs-bane. It is a perennial herbaceous plant, growing from two to six feet in height, and found abundantly on the mountains of Germany, France, and Switzerland. Until recently the part used officinally was the leaves. At present, however, the root is preferred as containing more 324 MATERIA MEDICA AND THERAPEUTICS. of the active principle of the plant, and as more uniform in its strength. The root at the thickest part is about the size of the finger, and from four to five inches long, with numerous fleshy fibres arising from it. When fresh its color is brownish externally and white internally. Its smell is earth}-, its taste bitter. After being chewed, it leaves a peculiar tingling and numbness on the tongue, lips, and fauces. The same effects on the mouth are produced by chewing the leaves. The root becomes of a darker color when dried. Composition. —No very satisfactory analysis of the root or leaves has yet been made. They contain, however, a vegetable alkali, aconitina, a peculiar acid, aconitic acid, and a volatile acid principle. The alkali exists in the state of a salt, aconitate of aconitina. Effects. —The effects of aconite are curious and peculiar. If a small quantity of the soft alcoholic extract be introduced into the cavity of the peritoneum of a dog, it usually causes vomiting, lessens the force of the circulation, impairs the muscular power so as to cause the animal to stagger, and destroys sensibility without causing stupor. The animal will sometimes follow its owner around the room, recognise him by wagging his tail, and yet be totally insensible to pinching, pricking with needles, &c. Before death slight tremors, but no regular convulsions, generally take place. (Pereira.) On the human subject the effects are the following. If the leaf or root be chewed, or a few drops of the alcoholic tincture applied to the lips, in a few minutes a sensation of numbness and tingling is produced in the part, which lasts for several hours. If the quantity taken into the mouth be somewhat large, the throat and palate become affected. Pereira describes the sensation " as if the velum and soft palate were elongated, and resting on the dorsum of the tongue. To relieve this, frequent attempts are made to swallow." When small and repeated doses of the alcoholic tincture of the root are swallowed, they cause a sensation of heat and tingling in the extremities, and occasionally slight diuresis. In poisonous doses, the characteristic symptoms are, numbness and tingling of the jiarts about the mouth and throat, and of the extremities, vomiting, contracted pupil, and failure of the circulation. Neither convulsion nor stupor, as a general rule, precedes death. It lessens directly the sensibility of the nerves and impairs the action of the heart. It is perhaps, therefore, the purest sedative that we possess. The principal use to which the agent has been applied is that of lessening morbid sensibility of the nerves, and as such it frequently proves very efficacious. In neuralgic affections, it is sometimes wonderful in its effects —a single local application effecting a cure. In rheumatic affections too, unattended by inflammation, it frequently proves very useful. The best form of it in these cases is the tincture, locally applied. 325 SEDATIVES. ' About a century ago, this remedy was in great repute in a number of diseases, such as scrofula, phthisis, cancer, dropsy, . Aconitine gr. ij. Alcohol gtt. vi tere optime. Et adde Axung. 3 i ut fit ung. If necessary, it may be increased to the strength of four or five grains to the drachm. This is to be rubbed on the part until the pain is relieved, and may be repeated three or four times a day, according to the effect produced. With regard to the aconitine, the same rule holds good as with the veratrine. Unless it produces the peculiar effects of the article on the skin, no good need be expected from it. SEDATIVES. 327 Solution. —One or two grains dissolved in a drachm of alcohol. This may be applied by means of a small sponge brush. Care should be taken in making these applications that the skin is not abraded. [Veratrum Album, U. S. White Hellebore. —Native of Central Europe. Stem of long leaf-stalks, sheathing each other. Root, the part used in medicine, composed of root-stalk, two inches long, and radicles. Taste at first sweetish, then acrid, bitter, and permanent. Its medicinal properties depend on the presence of the alkaloid veratrine. Effects. —A violent irritant poison, causing at first vomiting and purging, then stupor and convulsions. Little employed. Preparation. —The best is the wine. U. S. P. Dose, gtt. xxx to gtt. xl. Veratrum Viride. American Hellebore. —Said to have been long known to the Aborigines, first introduced into practice by Dr. Osgood; much praised by Ware, Tully, and others. It resembles white hellebore, and like it contains veratrine. Effects. —Resembling hellebore, the less apt to purge.] Veratrine.—This vegetable alkali was first discovered in 1819, by Pelletier and Caventou, in the seeds of the Veratrum sabadilla, or the Helonias officinalis, a plant growing in Mexico. It was afterwards detected by them in the roots of the Veratrum album and the Colchicum autumnale. What is used in medicine, however, is obtained entirely from the sabadilla seeds. Mode of obtaining it. —The seeds of the sabadilla bruised are first boiled in alcohol, and this is repeated three times. The alcohol here dissolves out all the Veratrine, along with veratric acid, coloring and other compounds. The alcoholic solution is then evaporated to the consistency of an extract. This is then boiled three or four times in water, to which a little sulphuric acid has been added. Here the veratrate of veratrine is decomposed, and converted into the sulphate of veratrine. The solution is then evaporated to the consistence of a syrup. This is then saturated with magnesia, and afterwards digested with a gentle heat in alcohol. Here the magnesia decomposes the sulphate of veratrine, and sets free the veratrine, which is taken up by the alcohol. The alcohol is then distilled off. The extract which remains is then boiled in water, to'which sulphuric acid and animal charcoal are added. To the strained solution ammonia is added, which throws down a precipitate, which is to be separated and dried. In the latter part of this process, the sulphuric acid unites with the veratrine, while the charcoal abstracts the coloring matter; the am- 328 MATERIA MEDICA AND THERAPEUTICS. monia then again decomposes the sulphate, and throws down the veratrine. The article thus prepared is the one used in medicine. It is not, however, considered as the pure alkali. It is a compound consisting of pure veratrine, sabadilla, resin of veratrine, and gum resin of veratrine. (Pereira.) Properties. —Veratrine is obtained in the form of a light brown or white powder, without smell; taste acrid and burning, and producing a feeling of numbness and tingling, when applied to the tongue. In water, it is very sparingly soluble, but sufficiently so to render the fluid acrid ; in alcohol and ether, very soluble. It restores the blue color of litmus, reddened by an acid, and unites readily with acids, forming uncrystallizable salts. When heated, it melts, and has the appearance of wax, and on cooling presents a mass of a brownish transparent appearance ; when ignited in the air, it is decomposed and totally dissipated. Effects. —By Magendie, the following results were obtained by experiments made upon animals. A very small quantity injected into the nostrils of a dog caused instantly a violent sneezing, which lasted near half an hour. One or two grains thrown into the throat caused a free salivation, which continued for some time. The same quantity injected into any part of the intestinal canal produced inflammation of the part with which it came in contact, succeeded by vomiting and purging." In large doses, it caused great acceleration of the circulation and respiration, quickly followed by tetanus and death. One or two grains injected under the pleura or tunica vaginalis produced tetanus and death in ten minutes. The same quantity injected into the jugular vein caused similar effects in a few seconds. On dissection, the mucous membrane of the intestines was found inflamed, and the lungs engorged and inflamed. In the human subject, the smallest quantity taken into the mouth causes free salivation, and if applied to the nostrils, produces violent sneezing. When given internally in medicinal doses, a sensation of warmth is produced.in the stomach, which gradually extends itself over the abdomen and lower parts of the chest, and afterwards to the head and extremities. If the medicine be continued, a sense of tingling is felt in different parts of the body, and sometimes over the whole surface, accompanied frequently by perspiration and a sense of oppression. To this succeeds a sensation of coldness, and if the medicine be still continued, nausea and vomiting take place; sometimes looseness and only occasionally purging are produced. Generally the force and frequency of the pulse are diminished under its use, but no narcotic effects take place. When applied externally, in the form of ointment rubbed on the skin, as a general rule, no local irritation is caused. In some cases a slight blister, and in others an eruption appear on the part. The first effect experienced is a sense of warmth and tingling in the part, and, according SEDATIVES. 329 to Turnbull, until this is produced, no effect is experienced from the medicine. This is a good criterion to judge of the purity of the article. After the ointment has been applied a sufficient length of time to influence the system, the heat and tingling extend over the whole surface, and the same sensations are produced as those accompanying its internal use. The pulse is also affected as by the internal use. Applied endermically the effects are still more decided, but the local irritation is so great as to preclude its use. Form of Administration. —In consequence of its acrid taste, the best form of giving it is that of pill. The formula recommended by Turnbull is the following: R Veratrine grs. ij. Ext. hyoscam. grs. vi. Pulv. rad. glycyr. grs. xii. M. Divide into twelve pills —one three times a day. Tincture. —Magendie directs four grs. to be dissolved in one ounce of alcohol. Of this he advises from ten to twenty-five drops to be given in a cup of broth as a substitute for the tincture of colchicum. As external applications, it may be used either in the form of ointment or tincture. The ointment is the best. This is made by rubbing up from fifteen grs. to 3 ss veratrine, with 3 i of olive oil and § i of lard. Of this a piece as big as a nut is to be rubbed with the hand for ten or fifteen minutes on the part affected. In doing this, care should be taken that the skin be not broken or denuded, otherwise great irritation will be produced. Where the ointment cannot be used, a tincture made of 3 i veratrine to 5 ij of alcohol may be applied in the same way. Besides the alkali itself, the tartrate, acetate, and sulphate, have been used. They produce the same effects, and are given in the same doses. Diseases in which Veratrine has been used. —The diseases in which it has been used by Dr. Turnbull, and as he says with advantage, are : 1. Affections of the heart, unattended by organic disease; 2. Neuralgic affections. In these it seems to exert its power in the most strikingmanner. In some cases a single friction gives entire relief. 3. In chronic rheumatism; 4. Gout; 5. Dropsy. In this case it operates by promoting the flow of urine. In all of the foregoing cases, the remedy was applied externally. Delphine.—This was first discovered in 1819, by MM. Lassaigne and Fenuelle. It exists in the seeds of the stavesacre (Delphinum staphisagria) in combination with delphinic acid. .The mode of obtaining it, recommended by M. Coucrbe, is the following :—a saturated tincture of the seeds is to be evaporated to the consistence of a thin extract, and heated with water acidulated by sulphuric 22 330 Materia medica and therapeutics. acid. This solution, when filtered, is to be precipitated by ammonia. The precipitate, after being freed from its water, is to be taken up with alcohol, and again reduced to the consistence of extract, which is likewise to be dissolved in acidulated water. To this solution, when filtered, a small quantity of nitric acid is to be added, as long as any precipitate falls. The liquid freed from this precipitate is again to be thrown down by ammonia and the powder dried. (Turnbull, p. 49.) This is the delphine of commerce. Like veratrine, however, this is a compound substance, consisting of delphine, resinous matter, and staphisacre (an acrid resin). To obtain the delphine separately, dissolve in ether. This takes up the delphine, but leaves the others. Properties. —When pure, delphine is in a state of white powder, without smell, but has a bitter and acrid taste. It is very sparingly soluble in water, whether hot or cold. It nevertheless imparts its bitter taste to the water. In ether it is soluble, and still more so in alcohol. Its solutions in these fluids have the property of rendering syrup of violets green, and of restoring the blue color of litmus when reddened by acid. It unites with the acids, forming salts which are bitter and acrid, and crystallizes with great difficulty. When heated, it melts and resembles wax in its appearance. On cooling it is brittle like resin. Effects. —In doses of half a grain, repeated three or four times a day, delphine may be given without producing any irritation of the stomach. In some cases it operates on the bowels, and most usually causes an increased flow of urine. When taken to the extent of a few grains, it gives rise to sensations of heat and tingling in various parts of the body, analogous to those produced by veratrine. In large doses, it is a narcotico-acrid poison. The salts of delphine act in the same manner as the pure alkali. When applied externally, in the shape of ointment or solution, it causes a sensation of burning, resembling very much the effect produced by a blister a short time after it has been applied. In almost every case it causes a blush of redness on the surface to which it is applied. In this respect it differs from veratrine, which causes no redness. Besides this, the local effect of delphine is more permanent than that of veratrine. Test of the goodness of Delphine. —Turnbull lays down the rule that unless a solution of it in alcohol, in the proportion of four grs. to the drachm, produce a sense of heat and pricking, after being rubbed on the forehead for three orfour minutes, it is not good and ought not to be used. Form of Administration. —Internally, it may be given in pill. R; Delphine, gr. i. Extract hyoscyamus, Extract glycyrrhizse, aa grs. 12.—12 pills. One to be taken every three or four hours. 331 SEDATIVES. It is generally, however, used as an external application either as ointment or solution, in the proportion of from 10 to 30 grs. to the ounce of lard or alcohol. These are to be rubbed on in the same way as the veratrine,.fromi 10 to 20 minutes, or until the peculiar tingling sensation is caused in the part, and this is to be repeated three or four times a day.. Diseases in which Delphine is used. —In its general effects, delphine resembles veratrine, and has been used in the same affections. Chiefly used in neuralgic affections, paralysis, and rheumatism. ACT03A RACEMOSA. Known by various other names, as Cimifuga racemosa, Cimifugaserpentaria, Macrotys racemosa, and by the common names of black snake root, cohosh, squaw root. This plant grows from four to six or eight feet high. It is found native in many parts of the United States, from Canada to Florida. It flowers in June and July. The part used is the root, which is perennial. As found in the shops it consists of a rough, tuberculated head, with numerous radicles, sometimes several inches long. These radicles are brittle, and easily separated. The color of the root is blackish externally, and white internally. It has little smell, its taste is bitter and somewhat astringent, leaving a sense of acrimony on the palate. The proper time for gathering the root is late in the summer or in the autumn. Its sensible properties are said to depend a good deal upon the time of gathering, mode of drying, etc. According to the analysis of Mr. Tilghman, it contains fatty matter, gum, starch, resin, green coloring matter, tannin, wax, gallic acid, sugar, oil, lignin, with salts of lime, iron, magnesia, and potassa. The virtues are yielded to water and alcohol. Effects. —In its general action on the system, this article appears to resemble very much the colchicum. It promotes the secretions of the mucous membrane, and at the same time produces an impression on the nervous system, and lowers the action of the heart and arteries. It is very much used by many American practitioners in rheumatism, and is said very often to produce excellent effects. It has also been used in some nervous affections, as chorea. It had at one time great reputation in affections of the lungs, as humoral asthma, chronic bronchitis ; it was even said to have cured phthisis. That it may do good' in the former cases is probable; in the latter, certainly not. 332 MATERIA MEDICA AND THERAPEUTICS. Cold. Cold is used in medicine to produce two very different effects, which may be called its immediate and its secondary effects. The immediate effects of cold are to depress vital action; it is one of the purest and most indisputable of sedatives ; but cold is much more frequently used in the treatment of disease with a view to its secondary effect, or to the reaction which, when not too intense nor too long continued, it provokes. It is with the former of these uses of cold that we are now to deal. Cold as a sedative is used either— 1. To reduce the temperature of the part to which it is applied, or of the whole system. 2. To repress vital action, especially the action of the heart and arteries. The first of these uses of cold will be considered when I speak of reifrigerants, and the use and value of the remedy appreciated; it is with the latter or the proper sedative effects of cold that we have now to do. Cold, then, is used to repress vital action in internal inflammations, especially of the brain; the mode of applying it is either by cloths wet with cold water, by ice applied to the head, or by freezing mixtures. As to the use of cold cloths, I remark that their value, indeed their safety, depends altogether on the manner in which they are used. If the water used is quite cold, and the cloths are changed often enough to keep the heat of the part down, nothing but good can result; but if, on the contrary, the water be only moderately cold, and the cloths be allowed to remain on long enough to become warm, reaction takes place . after each application, and the art of man could scarce contrive a more mischievous agent. This is a very great objection to the use of this agent in this way. Everything depends on the nurse, and she is not always a safe dependence. Ice to the head. —This is generally applied in a bladder; it is free from the objection which I have stated against cold cloths, and if decent care be taken it will always do good, and never harm. The only way, indeed, in which it can do harm, is by depressing the vital powers below the standard of life, and causing either fatal prostration of the whole or gangrene of the part to which it is immediately applied. To guard against this remember— 1. The class of patients most obnoxious to this kind of mischief are those whose powers are reduced, and whose capacity of generating heat is small. The two extremes of life present us with illustrations of these states. The old man's powers are worn out, he resists cold badly, his circulation is languid, his extremities are more likely to give way under the local effects of cold. On the other hand, the young child, SEDATIVES. 333 especially the infant, has hut a moderate power of producing animal, heat, and besides his vital powers are weak. He, too, resists cold badly But, aside from age, constitutions differ, and of course the feeble, the ill-nourished, the depressed, and those whose vital powers are failing under the influence of severe disease, will suffer most from intense cold. The rule to be observed for all these facts is simply to moderate the degree of cold which you use to persons who from age or constitution are ill able to bear up against it, and to watch the effect of cold applications in such patients, and indeed in all patients. With these guards the application of the ice poultice (so called) may be resorted to in inflammation of the brain with the best effects. The freezing mixtures arc only to be used as substitutes for the ice bag. If it is desirable early in an attack to make a very strong impression on the cerebral circulation, this can be done by pouring from a height ice-cold water on the head. This is a remedy of great power, and should be used with caution. It is not proper where serious organic mischief is suspected. It must not be long continued (three to five minutes is enough). 2. Great care should be taken to prevent excessive reaction after the cold dash by immediately applying to the head either cold cloths or the ice bag, and keeping it there for some time, watching always its effects, and removing the ice if it seem likely to endanger the vitality of the scalp, or the vigor of the general system. To Local Inflammations, the results of injury, cold water is an admirable remedy. Here the great art is to apply the cold in a moderate degree, but continue it for a very long time. This, however, belongs rather to surgery than to medicine. Internal use of Cold as a Sedative. —This is resorted to in fevers, and especially in gastric inflammations. In fevers, cold water taken very freely is the form in which cold is best administered, because here you have with the sedative the action of that best of diuretics, water. In Gastric Inflammations. —Here ice may be given, and with the very best effects; the feelings of the patient are the best guide as to the quantity, and it is very rarely necessary to put any restraint upon him in respect to what the Germans call ice pills. The most admirable effects often follow the very free use of ice and iced water. In Puerperal Peritonitis. —When thirst is urgent, the use of ice will do more than any other agent to quiet the distressing nausea and allay the burning thirst which add so much to the sufferings of the patient. Michaelis of Kiel has recommended the free application of ice in bladders to the abdomen, while ice was taken by the mouth. In his hands the practice was very successful. EEEEIGEEANTS. Refrigerants are those agents which possess the property of lessening animal heat when preternaturally increased. They are sometimes called Temperants, from their lessening excitement. From the fact of their being used in inflammatory affections, they are sometimes also called Antiphlogisties. The term refrigerant is, however, perhaps the best. It is not my intention to go into any account of the various theories which have been offered in relation to the modus operandi of this class of agents. Ingenious as many of these are, they are nevertheless unsatisfactory. The effects of refrigerants are simple and obvious. They lessen animal heat and moderate the action of the heart and arteries. It is to be observed, however, that they do this, if in any marked extent, only when the heat and circulation are above the natural standard. In the ordinary condition of the system they produce no very sensible effects. The individual articles of this class are not numerous, and they may be divided into three classes —1. Acids; 2. Salts; 3. Cold. Vegetable Acids—Possess refrigerant properties in a considerable degree. Those most used are the citric, acetic, tartaric, and malic. Most commonly these are not used, except as they exist in certain vegetable productions in which they abound. These, therefore, will be briefly noticed. Lemon. —This is the product of the Citrus linionum or lemon tree, a native of Asia, and from thence introduced into Europe. It is now cultivated extensively in the south of Europe and in the East and West Indies. The Spanish lemon is considered the best. The juice of the lemon consists of, in 100 parts, citric acid 1.77, malic acid, gum and bitter extractive 0.72, water 97.51. The form in which this article is used is that of ordinary lemonade, and in that state it affords not only one of the most agreeable but valuable refrigerant drinks. In combination with the bicarbonate of soda it is used for the purpose of making the effervescing draught. A simple way of preparing this is to take § ss of lemon juice, diluted with an equal quantity of •water, and add to this a solution of 15 or 20 grs. of bicarbonate of soda 335 REFRIGERANTS. in | ss of water. To be taken in the act of effervescence. Besides being refrigerant, this is a grateful stimulant to the stomach in cases of nausea and vomiting. It is also diaphoretic and diuretic. Here a citrate of soda is formed, while the carbonic acid is diffused through the water. Orange.—This is the product of the Citrus aurantium, a native of Asia, but cultivated in the south of Europe, in the West Indies, and in Florida. The juice consists of citric acid, malic acid, mucilage, albumen, sugar, citrate of lime, and water. This is a most grateful refrigerant, allaying thirst and lessening heat. Citric Acid. —This acid is peculiar to the vegetable kingdom, and was first obtained in the solid state by Scheele in 1781. It is found in the juice of many acid fruits, generally in a free state, but sometimes in combination with potash and lime. It is found in the fruits of the genus citrus, in the cranberry, whortleberry, gooseberry, red currant, strawberry, raspberry, cherry, mixed with equal quantities of malic acid. In the tamarind it exists both with malic and tartaric acids. It is always obtained from the juice of the lemon and lime. It crystallizes in colorless rhomboidal prisms which are slightly affected by exposure to a moist air. It is exceedingly acid, but destitute of smell. It is soluble both in hot and cold water, and, in small proportions, in alcohol. Citric acid answers as a substitute for lime juice when that article cannot be procured. Nine drachms and a half of the acid dissolved in a pint of distilled water form a solution equal in strength to recent lime juice. Of this solution or of lemon juice 3j of bicarbonate of potassa saturates 3 iijss, 3j of carbonate of potassa 3 iv, and 3j of carbonate of ammonia 3 vi. A scruple of the acid dissolved in a pint of water, and sweetened with sugar which has been rubbed on fresh lemon peel, makes a good substitute for lemonade. —TJ. S. Disp. Tamarinds. —This is the product of the Tamarindus Indicus, a large tree growing native in the East Indies, Egypt, and Arabia, and from thence transplanted in the West Indies. In every part of India this tree is common, and in all the Eastern islands it grows luxuriantly. According to Ainslee, it is in Java that it attains the greatest perfection, and is an exceedingly beautiful tree. The fruit is a broad ash-colored pod, from two to six inches long, containing numerous seeds, surrounded by a viscid pulpy matter. Tamarinds are chiefly brought here from the West Indies, where they are prepared by placing the pods, previously deprived of their shells, in 336 MATERIA MEDICA AND THERAPEUTICS. layers in a suitable vessel, and then pouring boiling syrup over them. This congeals on becoming cool. Fresh tamarinds have a pleasant acid taste, without any sweetness. As brought to this country they are in the form of a dark-colored mass, with a sweet acidulous taste. According to the analysis of Vauquelin, the pulp of the prepared tamarind contains in 100 parts (besides the sugar which is added), citric acid, 9.40 ; tartaric acid, 1.55 ; malic acid, 0.45 ; super-tar tr ate of potassa, 3.25 ; gum, 4.70 ; gelatine or jelly, 6.25 ; parenchymatous matter, 34.35 ; water, 27.55. Sometimes copper is also detected in them. This is supposed to be owing to the vessels in which they are frequently prepared. This may easily be ascertained by inserting a smooth iron blade in them. If copper be present a reddish crust will form on the blade. Effects. —Tamarinds are agreeably acid and refrigerant. If taken in sufficient quantities they also prove laxative. The common form of using them is that of tamarind water, made by infusing boiling water on the prepared pulp. VINEGAR. This is called Acetum, or the Acidum aceticum impurum, a peculiar fluid obtained from certain liquors undergoing the acetous fermentation. In wine countries it is obtained from vinous liquors, but in this country it is usually obtained from beer and cider. In its color, vinegar varies from a yellow to a deep red, according as it is prepared from white or red wine. According to analysis, vinegar consists chiefly of acetic acid and water, in the proportion of five parts of the first to ninety-five of tho second. Besides these, it contains various impurities derived from the liquors from which it is prepared, such as gum, starch, malic and tartaric acids, coloring matter, a little alcohol, and small proportions of alkaline and earthy salts. Properly diluted, vinegar forms an excellent refrigerant drink, although not so agreeable as the other vegetable acids, and on that account not so much used. As an addition to gargles, it is frequently very useful as an astringent; as an external application, largely diluted with water, it is very valuable for sponging the surface, for the purpose of lessening morbid heat. Cold.—This is the most decided refrigerant that Ave know of; and in many cases is most advantageously applied in the management of disease. It may be applied in various ways. 1. In the shape of Cold air; 2. Cold water taken internally and externally; 3. Ice applied externally and taken internally. 337 REFRIGERANTS. PRACTICAL APPLICATION IN THE TREATMENT OF DISEASES. 1. Fevers.—Whatever difference of opinion may have existed at one time in relation to the use of refrigerants in febrile affections, scarcely any exists at present. That there ever should have been any doubt on the subject seems strange enough. If refrigerant agents possess the power of lessening morbid heat, moderating the action of the heart and arteries, and allaying thirst, one would suppose that common sense as well as reason would have sanctioned, if not suggested, the propriety of their use in fever. In the practice of the present clay they are generally resorted to, and may be used with great advantage in all fevers, where the object is to diminish morbid heat and moderate the circulation. In many cases, too, they are the best remedies which can be used for the purpose of quieting irritability of the stomach. In some of the forms of fever in which this is a prominent symptom, besides the ordinary effervescing draughts, cold water and ice in small pieces are among our most efficient agents. The history of the use of cold water in fever is very interesting. Among the ancients it was a practice by no means uncommon. It was used by Hippocrates ; and Galen, who wrote extensively on the use of water, recommends in the highest terms the administration of cold drinks, and even immersion in the cold bath, in cases of ardent fever. The form of affusion, however, as practised in modern times, does not appear to have been known to them, and their practice, such as it was, seems never to have been established upon any scientific or philosophical principles. Accordingly, like all other remedies used empirically, it sank before the wave of varying opinions and successive theories, and eventually was completely lost in the medical practice of the civilized world. Among some of the ruder nations of Asia and Africa traces of it were, however, to be met with. Lavary, who travelled in Egypt, says it is customary for the inhabitants, when attacked by fever, to bathe in the Nile; and Bruce, the celebrated traveller, states it to have been common among the Abyssinians. The first regular and systematic notice that we have of the practice, however, was in the early part of the last century, by De Hahn, by whom it was extensively used in an epidemic fever of a typhoid character, which prevailed in Breslau, in Silesia, in the year 1737. The manner in which the water was applied was by means of " sponges soaked in cold water to every part of the surface in succession." In general, it was not resorted to until the eighth or ninth day of the disease, or when the case was becoming desperate from the failure of other remedies. Applied in this way, it must have frequently done more harm than good; at any rate, the practice made no progress. 338 MATERIA MEDICA AND THERAPEUTICS. It was reserved for Dr. William Wright, a British physician, who had resided previously in the West Indies, to revive the practice. In the year 1777, while on his passage from the West Indies to Liverpool, he was seized with a fever which prevailed on board the vessel. Having tried various remedies, but without effect, and finding, too, that whenever he got upon deck he felt better, and that just in proportion to the coldness of the air, he determined, as he says, " to put in practice on himself what he had often wished to try on others in fevers similar to his own." Accordingly, on the fifth day of the disease, he pursued the following treatment, which I shall give in his own words : " Sept. 9. Having given the necessary directions, about three o'clock in the afternoon I stripped off all my clothes, and threw a sea cloak loosely about me till I got upon deck, when the cloak was also laid aside ; three bucketfuls of salt water were then thrown at once upon me ; the shock w r as very great, but I felt immediate relief. The headache and other pains instantly abated, and a fine glow and diaphoresis succeeded. Towards evening, however, the same febrile symptoms threatened a return, and I had again recourse to the same method as before, with the same good effect. I now took food with an appetite, and for the first time had a good night's rest. "Sept. 10. No fever, but a little uneasiness in the hams and thighs — used the cold bath twice. "Sept. 11. Every symptom vanished; but to prevent a relapse, I used the cold bath twice." Another person seized on board with the fever was treated in the same way, and with like success. The account from which the foregoing is drawn was published by Dr. Wright in 1787 in the London Medical Journal; and it was this simple narrative which struck the eye of Dr. Currie, and suggested the hints which afterwards led to the ingenious and beautiful investigations of this subject by that elegant scholar and accomplished physician. Thus it is that men of genius, seizing the rude ideas of inferior minds, have constructed theories and perfected discoveries, which have rendered their names immortal. Having received the commendation of such high authority, as might naturally be expected, the remedy became exceedingly popular, and was extensively used, more especially in hospital practice, by Drs. McLean, Jackson, and others. Undergoing the same vicissitudes which have so strikingly marked the history of our art, it has again fallen into disrepute. Believing it, nevertheless, to be a remedy of value, it may not be useless to designate the leading principles which should govern its use in fever. 1. It ought not to be used in the cold stage of fever. The internal organs are already in a state of oppression, and unable to react upon the REFRIGERANTS. 339 blood thrown into them. In this condition of things the application of cold to the surface will still further increase the oppression, and the consequence may even be fatal to the patient. 2. It should never be used when the heat of the system is not greater than natural. In judging of the degree of heat, it should not be determined merely by the feelings of the patient, but by actual measurement with a thermometer. For this purpose the bulb of a small thermometer should be placed under the tongue, or in the axilla. The heat in these two places corresponds exactly, and will indicate the heat of the surface of the body, where covered from the contact of the external air. 3. It should never be used when the patient is in a state of perspiration. The reason must be obvious. It interferes with a process which is most effectually lessening febrile heat and excitement, at the same time that it would drive the fluids upon the internal organs when they are not in a suitable condition for reaction. 4. It should never be used when local inflammation or congestion of some internal organ is present. Both would inevitably be aggravated by it. 5. It should never be used in the advanced stages of fever, where there is great debility, and where the heat of the system is already much reduced. Under these restrictions this remedy may be used with great advantage in fevers, and the suitable period for it is when the exacerbation is at its height. In continued fever this generally takes place towards evening. Generally speaking, it will prove most efficacious if used in the earlier stages of the disease. In applying this remedy certain precautions are necessary. Salt water is preferable to fresh, as it produces greater reaction, and the temperature of it should be about 40°. The patient is to be placed on a stool in a large tub, and a bucketful of water is to be poured over his head and shoulders. He is then to be rubbed dry and put into bed. If the remedy agrees with him, it will be found in a short time afterwards that the heat is diminished, the pulse lessened in frequency, and indeed all the febrile symptoms are annihilated. If these effects should be produced, it may with safety be repeated whenever the febrile exacerbation comes on. Such was the practice of cold affusions as recommended by Dr. Curric. At present it is but little used, and in place of it the safer and more convenient mode of applying cold in the form of cold sponging has been adopted. Used in this way, it proves exceedingly salutary in allaying morbid heat, lowering the circulation, and soothing the patient. Inflammations. —As a general rule, as has been already stated, the use of cold in cases of internal inflammations is objectionable. There are, however, two exceptions which require especial notice. 340 MATERIA MEDICA AND THERAPEUTICS. Phrenitis. —In cases of this kind, in addition to venesection, there is no remedy which exercises so powerful an influence as the application of cold to the head. It may be used in various ways—either by applying cloths dipped in cold water to the head, or by a common bladder filled with ice, or what is still more efficient, pouring cold water on it from a vessel. In using this the patient is to be raised in bed, and the body to be protected from being made wet. A large empty basin is to be held under the chin, and the cold water is then to be poured from a pitcher on the crown of the head, the stream to be raised gradually as the patient can bear it. This is to be continued until the desired effect is produced. This mode of applying cold originated, I believe, with Dr. Abercrombie, of Edinburgh. " Applied in this manner," he says, " it is a remedy of such power that it requires to be used with much discretion. Under the operation of it I have seen a strong man thrown, in a very few minutes, into a state approaching asphyxia, who immediately before had been in the highest state of maniacal excitement, with morbid increase of strength, defeating every attempt of four or five men to restrain him.* The same remedy is recommended by Dr. Abercrombie in the convulsive diseases of children, in preference to the warm bath so commonly used.f Gastritis.—This is another form of inflammation in which cold may be used with great advantage, taken internally. Small pieces of ice swallowed have frequently an admirable effect in allaying the gastric irritation. [Intoxication and Narcotic Poisons. —To remove the effects of intoxicating drinks no agent can compare with cold affusion. I have tried this very frequently on men who were " dead drunk" unable to move; in ten minutes they walk about. It is, however, a remedy of very great power, and only to be used where there is vigor of constitution. In poisoning by opium, &c, it may be relied on with great confidence. I have again and again seen persons profoundly narcotized restored to sense and life by the continued use of cold affusion. It is, I am sure, not as frequently used, nor as confidently relied upon as it should be.—Ed.] * Abercrombie on Brain, p. 174. f P. 175, also Tweedie, p. 146. DEMULCENTS. This class of remedies was by many supposed to act only mechanically, by involving acrid matters in a mild and viscid coating, or by sheathing the surfaces to which they were applied, and thus protecting them from the action of irritants. This is an imperfect view of them. They do in fact act on the vital properties of the system, diminishing tone, relaxing and softening the tissues, and rendering them more flexible. [This effect is probably owing to a dilution of the blood by the absorption of the watery part of the demulcent.] Effects. — On the Mucous System. —When taken by the mouth, emollients, by their bland influence on the nerves of the mouth, pharynx, oesophagus, and stomach, produce a direct soothing influence on those parts, and a like effect on the bronchial mucous membrane. Hence their use in irritations and inflammations of any portion of the gastric and pulmonary membrane. [Is it not possible that demulcents may in the same way affect the vagino-uterine mucous membrane, relaxing its tissue and promoting secretion from it? If so, the popular notion, that these articles taken during the latter months of gestation facilitate parturition, may be easily explained. I have generally attributed their effect (in the reality of which I fully believe) to their operation as laxatives.—Ed.] On the Blood and the Heart's Action. —The effect of demulcents must of course depend here, if not always, on the water in which they are taken : this would impoverish the blood and thus lower the heart's action, and diminish generally the tone of the system. On the Urinary Organs. —Here again these agents act purely as diluents. They increase the amount and diminish the acridity of the urine. Oil and water are the only essential emollients. For though gum, starch, sugar, and gelatine are so termed, they do not act unless water be present. —Pereira. 342 MATERIA MEDICA AND THERAPEUTICS. INDIVIDUAL DEMULCENTS. GUM ARABIC. This is the product of the Acacia vera and Acacia nilotica, native trees of Africa, and found growing in almost every part of that continent. It is a spontaneous exudation from the bark of the trunk and branches. Sometimes the exudation is promoted by artificial incisions. When it first begins to flow it is soft and almost liquid, but by exposure to the air it hardens into tears. In this form it is imported from Barbary and Morocco. The sensible properties of gum arabic are by no means striking. When perfectly pure it is almost entirely destitute of color, or it has a pale yellowish hue. It has no smell, but a slightly sweetish taste, and is more or less transparent. It is hard, brittle, and easily pulverized, yielding a white powder. It has all the properties of pure gum, is completely soluble both in cold and hot water, and in this state it forms what is called mucilage —when this is evaporated it yields the gum unchanged. It is insoluble in alcohol, ether, and the oils. By trituration with the oils, volatile and fixed, it renders them miscible in water. As sold in the shops, gum arabic is frequentty mixed with gum Senegal, the product of the Acacia Senegal, a tree growing in the forests of Africa, in the neighborhood of the Senegal. In its general properties this gum does not differ materially from the gum arabic. It comes in larger pieces and is of a reddish color. It is, however, nearly as pure as the gum arabic, and in its medicinal properties is little if at all inferior. Purity. —Gum Senegal is frequently substituted for gum arabic. This may be distinguished by the gum Senegal being clammy and tenacious, while the gum arabic is dry and brittle. This is a fraud, however, of no importance in a medical point of view. Sometimes it is mixed with the gum which exudes from the plum and cherry tree. This is much inferior to the gum arabic and gum Senegal. It is distinguished from gum arabic by being, like tragacanth, insoluble in water, whereas gum arabic and gum Senegal arc completely soluble. In the form of powder as sold in the shops, gum arabic is generally adulterated. The articles used for this purpose are starch, wheat flour, and sulphate of lime. Tests. —1. Take a little of the suspected article and shake it in a vial, with the addition of cold water. The gum will dissolve in the water, and if there be any of the preceding articles present, they will fall to the bottom. 2. Boil the gum in water —add a little nitric acid and then a few drops 343 DEMTJLCENTS. of a solution of iodide of potassium. If starch be present it will strike a blue color. 3. Mix a little of the article with water into a dough. Fix this to the end of a platinum wire and subject it to the flame of a blow-pipe. If it does not burn away, but leaves anything behind, it is adulterated. 4. If the suspected article be mixed with the powder of plum and cherry tree gum, it makes a ropy solution. Gum arabic makes a clear pellucid solution. Effects. —Gum arabic is one of the most common and best of the demulcents. By some it is supposed to be positively sedative in its action upon irritated and inflamed surfaces. It is also nutritive, although this is positively denied by some. Experiments to ascertain this were made by Magendie upon dogs, who were confined to the use of this article. In the second week they became emaciated and debilitated, and finally died of marasmus. In opposition to this, however, there are other facts which show that it cannot be so entirely destitute of nutritive properties. Haselquist, in his " Voyages in the Levant," gives an interesting account of a caravan travelling from Ethiopia to Egypt in the year 1750, which, during their long journey across the deserts, fell short of provisions. In searching among the merchandise which they were carrying to Cairo, they fortunately found a quantity of gum arabic, and upon this alone more than a thousand persons subsisted for the space of two whole months. Lind also states that the gum Senegal or arabic serves as a sustenance for whole negro towns during the scarcity of other provisions occasioned by a failure of the crops of millet and rice; and the Arabs who twice a year collect this gum in the inland forests on the north side of the river Niger, have no other provisions to live upon for some months. Gum arabic, therefore, may be considered nutritive as well as demulcent. Mode of Administration. —Generally used in the form of solution ; one ounce of the gum to a pint of boiling water and suffered to cool. Also in the form of syrup, by taking of gum arabic § iv, sugar fb i, boiling water a pint. Dissolve the gum in the water; add the sugar and boil to the consistence of a syrup. Also in the form of lozenges. TRAGACANTH. This substance is obtained from different species of Astragalus, but chiefly from the Astragalus verus. This is a shrub growing two or three feet high, and is a native of the north of Persia. The gum exudes spontaneously from the stem and branches in the heat of summer, and is suffered to dry on the plant before it is collected. It comes in small wrinkled pieces of a whitish color, without smell, and has a slightly 344 MATERIA MEDICA AND THERAPEUTICS. viscid taste. Although considered as a gum, it differs from this class of substances in the degree of its solubility in water. When put into water, it imbibes a large quantity of that fluid and swells, but does not dissolve nor form a fluid homogeneous mixture. It is turbid, and on standing separates from the water and settles down. In alcohol, it is, like gum, insoluble. The principal peculiarity of this substance is the power which it possesses of giving viscidity to water, this being much greater than that of the gums. It possesses this in a degree twenty-four times greater than gum arabic. It is on this account that it is so much used in pharmacy to give consistency to the manufacture of pills and troches. " It appears to be composed of two different parts, one soluble in water and resembling, though not identical with gum arabic ; the other swelling in water but not dissolving." (IT. S. Disp.) Effects. —Demulcent and nutritive, though difficult of digestion. In consequence of its great insolubility not much used internally. Principally used in pharmacy. LIQUORICE. The plant which yields this is the Glycyrrhiza glabra, a native of Syria, Barbary, and the south of Europe. It is cultivated, also, in all parts of Europe. In the north of Spain it is raised to a great extent as an article of commerce. That which grows in Spain is considered the best, containing a larger proportion of saccharine matter. The plant grows about four or five feet high. The part used is the root, which is dug up Avhen the plant is about three years old. It is long and flexible, and about the size of the little finger; externally of a brownish color, and yellow internally. It is without smell, and has a sweet, mucilaginous taste. If chewed with the bark on, it leaves a slight degree of bitterness in the mouth. Composition. —According to analysis, liquorice contains glycyrrhizine, starch, asparagin, resinous oil, albumen, lignin, and salts. The glycyrrhizine is a modification of saccharine matter, scarcely soluble in cold water, but readily so in boiling water, and differing also from common sugar in not being capable of undergoing fermentation. The resinous oil is bitter, and it is to this the slight degree of acridity which the root possesses is owing. The extract is prepared from the root in the following way. The roots, dried and cleaned, are cut into small pieces and then boiled in water until the liquid is saturated. After the dregs have subsided it is poured off and evaporated to a proper consistence, when it is formed into rolls about five or six inches long and an inch in thickness. These are then dried and covered with leaves. In this state it is imported from Spain and Italy. When pure it is very black, dry, and brittle, DEMULCENTS. 345 with, a glossy fracture and sweetish taste. In water it is completely soluble. Purity. —The roots are frequently worm-eaten and decayed. Those are the best which have the brightest yellow color internally and when the layers are distinct. The extract is very apt to be adulterated with various articles, such as starch and sand. It sometimes also contains a little copper. When pure the extract ought not to become moist when exposed to the air in a dry place, and it should dissolve in water without leaving any residue. What is called refined liquorice is nothing more than the foreign extract dissolved in water and the solution filtered and inspissated; this is then usually made up into little sticks called the pipe liquorice t When this is adulterated with starch it dissolves only partially in cold water, and immediately deposits a dirty white powder possessing the properties of starch. When mixed with carpenter's glue it gives out ammonia, when heated in a glass tube or before the blowpipe. Effects. —Liquorice is an excellent demulcent article, admirably adapt- 1 ed to allaying irritations of the mucous membrane in various parts of the body. Hence it has been used with great advantage in catarrhal affections, and irritations of the urinary organs. Of the root the best preparation is the decoction, made by boiling § i of the root in a pint of water for about ten minutes. As the bark is acrid, this should be taken off before it is boiled. The extract may be taken cither in the solid form or in solution, or in the form of lozenges,, marsh mallows (Althaa officinalis)* This is a plant growing in Europe, on banks of rivers, and in marshy places, from which circumstance it derives its name. It grows to the height of four or five feet, and the part used is the root. When prepared for the market the epidermis is taken off. It is of a whitish destitute of smell, and has a viscous mucilaginous taste. Every part of the plant abounds in mucilage and starch, besides sugar. It also contains a peculiar principle which has been called but which is identical with asparagin. Effects. —An excellent emollient and demulcent, and in general use as such in France and in Europe generally. It is used in the form of decoction and syrup. In this country it its not much used, being considered inferior to gum arabic, 23 346 MATERIA MEDICA AND THERAPEUTICS. jujube (Rhamnus zizyphus). The tree yielding the jujuhe is cultivated in the south of France, in Spain, and in Italy. The part used is the fruit. This is of an oval shape, about the size of an olive, and of a reddish color. Internally it contains a yellowish mucilaginous pulp, with a sweetish and acidulous taste. It is demulcent and nutritive. If taken to any extent it proves laxative. It is used in the form of decoction. The jujube paste, which is so commonly sold in the shops, should consist of gum arabic and sugar, dissolved in a decoction of this fruit and evaporated to a proper consistence. The preparation, however, very seldom contains any of the jujube. [Would probably be no better if it did.] slippery elm bark (Ulmus fulva, the red elm or slippery elm). It is a lofty tree, growing to the height of 50 or 60 feet, and is indigenous in this country, more particularly in the Northern and Western States. The part used in medicine is the inner bark, from which the epidermis has been removed. It comes in long flat pieces of a fibrous texture, with a sweetish and mucilaginous taste when chewed. It contains fecula, gum, and ulmin. It abounds in mucilaginous matter, and by infusion or gentle boiling in water it is readily dissolved and forms an insipid mucilaginous fluid. Effects. —This substance is highly demulcent and nutritive. In times of scarcity the Indians are said to live upon it. Another use made by them of it is to facilitate labor. According to Mr. Rafinesque, it is " a specific to procure easy labor to pregnant women by using the tea for two months previous* well known to Indian women, whose easy parturition has often been noticed." Med. Flor. vol. ii. p. 271. It is also somewhat diuretic. Mode of Administration. —The common form is that of infusion made by macerating an ounce of the bark in a pint of cold water. When ground into powder it, makes a kind of flour, which mixed with boiling water makes a mucilage. [The cold infusion of the unground bark is much more palatable.] It makes an agreeable demulcent drink. The powder made into a poultice is an admirable local application. benne. The Sesamum orientale, a native of the East Indies and Africa. From the latter region it was introduced by the negroes into the West DEMULCENTS. 347 Indies and the Southern States, especially Georgia and South Carolina, where it succeeds very well. In this latitude it grows very well, but never comes to seed. It is an annual plant, about three or four feet high, and yields a small, yellowish seed, which is particularly valuable for the quantity and quality of the oil which is obtained from it. It is said that by expression ninety per cent, of this oil is obtained from the seeds, a larger proportion than that yielded by any other known vegetable, and of a quality fully equal to the common olive oil. By the negroes the seeds arc used as an article of food, boiling them with Indian corn, aralysis its use has been universally reprobated, and as a general rule, unquestionably it ought to be resorted' to with caution. Even here, however, it may be used under suitable conditions of the system. Where the paralysis is not associated with a plethoric or congested 372 MATERIA MEDICA AND THERAPEUTICS. state, it is frequently very useful to quiet irritability and produce sleep. On this subject the opinion of Ileberden is valuable. " When 1 knew no more of physic," says he, " than what I had learned from books, I was very apprehensive, as I was taught to be, and by plausible reasoning, that opium was hurtful in palsies and apoplexies ; for it is supposed to have the effect of deadening the powers of the nerves, and, therefore, must be improper where we want to enliven them. This hypothesis, however specious, wants the attestation of experience. I have met with some, who, while they were recovering from a palsy, used opium plentifully, and afterwards never passed a night without taking twenty or thirty drops of tinct. opii for many years, which practice did nothinder them from living very well, and was supposed to assist them in doing so. In consequence of these examples I have frequently given it in paralytic cases, when the restlessness seemed to require it, and with as much advantage as in any other disease." (Commentaries, p. 290.) In Mania.—Opium has been highly commended by some and denounced by others. Whether it proves serviceable or not depends entirely upon circumstances. If it be used while there is great fulness of habit, or where there is active determination to the brain, and where the bowels are costive, it will be sure to aggravate all the symptoms. As a general rule, therefore, in the early stage of the disease, it will surely prove injurious. In the more advanced periods, where the system has been properly evacuated and reduced, it sometimes proves exceedingly salutary in quieting irritability and causing sleep. The dose to produce these* effects ought to be large, otherwise more harm than good results from its use. Burrows recommends a large dose at first, to be followed by smaller ones until the desired effect is produced. Where an anodyne is admissible, he begins with three grains of opium, and repeats a grain every two or three hours. He has never in this way exceeded twelve grains, and if sleep did not follow from this he has desisted.* By others much larger quantities have been given.f It is an interesting fact connected with the operation of opium, that the insane are comparatively insensible to its effects, as they are to many other remedial agents. After the operation of an emetic, it has been found that smaller closes will affect the system. (See Crump on Opium, p. 288. Cox on Insanity.) There arc two forms of maniacal disorder in which opium is a remedv of great value. The mania of puerperal women and the mania resulting from the too free ute of liquor. In puerperal mania, opium operates more kindly and beneficially than it does in the ordinary forms of mania, and the reason no doubt is * Commentaries, p. 613. \ Ibid. p. 612. NARCOTICS. 373 the peculiar condition of the system under .which it occurs, being more favorable for obtaining the soothing and sedative effects of this drug. The patient is debilitated by the various evacuations attending delivery. The mania is frequently dependent merely upon nervous irritation and debility, and in this condition of the system opiates may be given with great prospect of success. Even here, however, they should not be given indiscriminately. If there should be fulness of the head, as indicated by heat of the head, flushed face, &c, opium should not be given until this is relieved by local bleeding, purgatives, cold to the head, &c. After these are removed, it may then be given in a full dose. Dr. Gooch recommends twenty minims of the sedative solution of Battley, repeated once or twice at intervals of two hours unless sleep be induced. When sleep has once been procured, small doses, such as five or ten minims, should be given at intervals of six hours. If these do not produce sleep at night the larger doses maybe occasionally resorted to. Constipation should be obviated all this time by suitable cathartics. When opiates have produced the desired effect in this complaint, they should be withdrawn gradually, diminishing the dose and lengthening the interval.* In Delirium Tremens. —In this disease most enormous doses of opium have been given, and as a general result, if profound and long continued sleep follows their use, the patient will recover. But here the same Cautions as to the exact condition of the system at the time when the drug is administered, that have been so often insisted on, are to be regarded. If plethora and determination to the brain exist, if the bowels are loaded, the tongue foul, the skin dry and hot, opium will do no good ; and in delirium tremens, it may be laid down as an almost universal rule that where opium docs no good it is certain to do harm. In multitudes of these cases life has been sacrificed in the vain, irrational attempt to overwhelm the system by opium. When the skin is cool and moist, the bowels free, the pulse soft, and the prostration not extreme, opium will often produce sleep and cure the disease. Where prostration is extreme, a large dose of opium may overwhelm the system and induce fatal consequences. [Peritonitis, —The use of opium in peritonitis, commended by Armstrong, has been much extended, and with the happiest effects, by Prof. Clark. He gives, immediately on diagnosticating the disease, from half a grain to one grain of morphine, or an equivalent dose of opium, two grains to five grains, and repeats it every hour or two till the patient is profoundly narcotised. The opium is then continued in such doses as to keep up decided narcotism, as marked by contracted pupil, respiration not over twelve in the minute, deep sleep, from which the patient is roused * Gooch's Essays, p. 152 ; also Burrow*, p. 400. 374 MATERIA MEDICA AND THERAPEUTICS. with some difficulty; in this condition he is kept, occasionally allowing a slight let up, till the pulse falls, then the opium must be gradually diminished in dose and frequency, the practitioner being ready at the slightest hurrying of the pulse to plunge his patient again into the deepest narcotism. I have tried this mode of treatment both in puerperal and idiopathic peritonitis with most encouraging results. In puerperal peritonitis especially my experience warrants me in preferring it to any other practice. It must be carefully watched, the patient seen every two to four hours. The bowels often remain unmoved for ten days —purges are utterly incompatible with this treatment.] Preparations.—The decoction of poppy heads is a good fomentation. Poppy heads scalded are sometimes added to bran, hops, and the like when used as a poultice, to make it more decidedly anodyne. Pulvis Opii et Ipecacuanha; Compositus. —This is commonly known by the name of Dover's powder, and is prepared by taking one part of opium and ipecac, each, and of sulphate of potassa eight parts, and triturating to a fine powder. Ten grains of this contain one grain of opium. This is an excellent preparation, and furnishes a striking illustration of the advantages of combining medicines. The ipecac, renders the opium more certain in its action as a sudorific, and at the same time corrects to a great extent the evil effects which opium alone is apt to produce on the head. The sulphate is added for the purpose of triturating more freely and mixing the ingredients more intimately. By some it is supposed that the general efficacy of the compound is thus increased, inasmuch as the opium and ipecac, alone will not act precisely in the same way as when the potassa is combined. Dover's powder may be used in all cases where a sudorific anodyne is required. The average dose for an adult is 10 grs. Tinctura Opii, Tinctura Thebaica, commonly called Laudanum or Liquid Laudanum. —This is prepared according to the IT. S. P., by macerating for fourteen days 5 iiss of opium in powder in two pints of diluted alcohol, and then straining. This tincture is of a deep brownish red color, having the peculiar smell and taste of opium. In this preparation about two thirds of the opium are dissolved by the alcohol (water dissolves less than threesevenths). The residuum consists of impurities, containing still, however, a small proportion of morphine. Pereira says he has repeatedly prepared morphine from the insoluble residue thus left. Twenty-five drops (or thirteen minims) are about equivalent to one grain of opium. The tincture of opium has some important advantages over the solid opium. It is more speedy in its action. It can be given more conveniently in minute doses. *This is a great advantage when an opiate it 375 NARCOTICS. required for children. Lastly, it can be combined more readily with other medicines. Incompatibles. —Care should be taken not to give laudanum in combination with ammonia, soda, and potash, or their carbonates, as they precipitate the morphine. Most metallic salts and tincture of galls also decompose it. In the use of this article it is important to know that if it be kept for any length of time, and occasionally exposed to the air, it becomes thick. This .is owing to the evaporation of a portion of the alcohol, and the deposition of the opium. In this state its strength is greatly increased, and infants have frequently been destroyed by giving this even in moderate and ordinary doses.* In all cases the tincture should be transparent. 2. Tinctura Opii Camphorata. —This is the common paregoric elixir. This consists of opium, Benzoic acid, oil of anise, liquorice, clarified honey, camphor, and diluted alcohol. Half an ounce of this contains about one grain of opium. This is a mild and valuable preparation of opium, and unites the properties of a narcotic with those of an antispasmodic. The principal use of it is to allay troublesome cough. It diminishes the sensibility of the bronchial membrane to the influence of cold air, checks profuse secretion, and allays spasmodic cough. Besides this it is used to relieve nausea and slight pains in the stomach and bowels, and in infants to procure sleep. The dose for an adult is from 3 i to 3 iv ; for a child, from five to twenty drops, according to the age. Acetated Tincture of Opium. —This is prepared by rubbing up 1 ij of opium with 5 xii of vinegar, and then adding half a pint of alcohol, and macerating for fourteen days and filtering. In this preparation, it is supposed that a portion at least of the meconate of morphine is decomposed, and acetate of morphine is formed. Pereira, however, says this is not fully established. This is a very mild and valuable preparation of opium. It has all the narcotic effects without producing the nausea, headache, and nervous disorders, which frequently result from the ordinary preparations of this article. Ten minims or twenty drops are equivalent to gr. i of opium. This preparation has been introduced into the U. S. Pharmacopoeia, as a substitute for the ordinary black drop, and has the great advantages of uniformity and certainty in its strength. 4. Vinum Opii. —This is prepared by taking of opium 5 ij, cinnamon and cloves bruised each 3 i, and macerating in a pint of Teneriffe wine * Ellis's Formulary. IT. S. Disp. 376 MATERIA MEDICA AND THERAPEUTICS. for fourteen clays and filtering. This is nearly the same as the liquid laudanum of Sydenham. It is about the same strength as common laudanum, and may be given in the same doses. From the aromatics ¦with which it is combined, it sits better on the stomach. As a local application, the wine of opium is recommended in cases of chronic ophthalmia, two or three drops being introduced under the eyelids daily. Morphine— Modes of obtaining it. —There are various modes of obtaining morphine from opium. The process recommended in the U. S. Pharmacopoeia is the following: Sliced opium is first macerated and worked up with water for a suitable length of time, then filtered, and to this added a mixture of alcohol and water of ammonia, when the morphia is deposited in crystals. To purify these, they are boiled in alcohol, and filtered through animal charcoal. In this process the water extracts the meconatc of morphine. This is decomposed by the ammonia, while the alcohol seems to suspend the coloring matter and render the crystals purer. Quantity of Morphine in Opium. —This has already been alluded to. As then stated, it varies not merely in the different kinds of opium, but in different samples of the same kind. The Smyrna opium contains the most, varying from nine per cent, or less to fourteen, the Constantinople only one half, and the Egyptian five sevenths of the quantity obtained from the Smyrna opium. Dr. Christison obtained from half a pound of the best Turkey opium 3£ drachms of morphine, and two drachms of narcotine. M. Dublanc procured as the mean of six trials eight per cent, of morphine and three per cent, of narcotine. Properties. —When pure, morphine is in small, beautifully white crystals. The primary form of the crystal is a right rhombic prism. It has a bitter taste, but is destitute of smell. In cold water it is insoluble — boiling water dissolves about one part in one hundred. It is soluble in forty parts of cold anhydrous alcohol, and thirty parts when boiling. In ether, it is nearly insoluble. It turns vegetable blues to green, and combines with the acids forming crystallizable salts—nitric acid turns it red. It consists of oxygen, hydrogen, carbon, and nitrogen. Effects. —Although the most powerful principle of opium, morphine is not used in medicine in its simple alkaline state. Owing to its great insolubility, it is by no means certain and constant in its effects, depending for its activity, no doubt, upon the degree and kinds of acid it meets with in the stomach. In combination with acids it is, however, very soluble, and it is only in the form of salts, therefore, that it is used. Of these, the ones used are the acetate, sulphate, and hydrochlorate. Acetate of Morphine.—This is prepared by dissolving morphine in NARCOTICS. 377 dilute acetic acid, and then evaporating the solution to dryness. Acetate of morphine crystallizes in slender needles, but from its deliquescent nature is seldom obtained in a crystalline form. It is generally in the form of a powder. It is readily dissolved in water, especially where there is an excess of acid. In alcohol it is less soluble than in water. It may be given in pill or solution. One sixth of a grain is about equivalent to a grain of opium. Sulphate of Morphine.—This is prepared by dissolving morphine in diluted sulphuric acid. By evaporating the solution, crystals are formed. These are small, white, and feathery, resembling very much in appearance the sulphate of quinine. They can easily be however, by adding concentrated nitric acid. This turns the sulphate of morphine red, but not the sulphate of quinine. Sulphate of morphine is soluble in twice its weight of boiling water, and if pure, is easily and readily soluble in cold water. As found in the shops, and especially if obtained from France, it is not always entirely soluble in water. This is owing sometimes to adulterations, but oftener to its containing some uncombined morphine, owing to the mode of preparation. This is corrected by the addition of a little acid. The sulphate may be given in pill and solution. One sixth of a grain is equal to a grain of opium. Solution of Sulphate of Morphine. —It is important to know that there are two solutions of this salt of very different strength—that of Magendie, and that of the United States Pharmacopoeia. Magendie's contains sixteen grains to § j of water. Of this, five drops are equivalent to one sixth of a grain of the salt. U. S. Pharmacopeia contains one grain to § j of water —of this, eighty drops are equal to one sixth of a grain. Hydrochlorate of Morphine.—This is prepared by saturating the pure base with hydrochloric acid, and crystallizing. This is a colorless, inodorous, bitter salt, crystallizing in plumose acicular crystals; it is soluble in sixteen to twenty times its weight of water. It is also soluble in alcohol. The strength of this is the same as the two preceding. This is considered by many as the best salt of morphine for medicinal purposes. To the acetate it is preferable, as it is more easily obtained in crystals, and is not subject to decomposition during its preparation. Effects of the Salts of Morphine.—In their action on the system they do not differ. They produce the same effects, and may be given in the same doses. Compared with opium and its ordinary preparations, 25 378 MATERIA MEDICA AND THERAPEUTICS. they differ in many important particulars. While they produce the anodyne and narcotic effects of opium, they are less stimulating —they are less sudorific —they do not have the same tendency to produce constipation, and they are less apt to leave headache, nausea, dryness of the tongue, and other unpleasant effects. In all cases, therefore, where the object is to allay pain and nervous irritation, and to produce sleep, they are preferable to opium. Where the object is to get an astringent effect on the mucous membrane, or a stimulant effect on the system, opium is to be preferred. In cases of chronic irritation, where the daily repetition of an anodyne is called for, the morphic salts are invaluable. Another advantage attending them is, that they may be applied endermically. HENBANE. The Hyoscyamus Niger, growing two or three feet high, with large sea-green leaves, and straw-colored flowers. The whole plant has a dark, lurid appearance. It is found in every part of Europe, and extends to Asia. In this country it is supposed to have been naturalized, from the fact of its being found only in the vicinity of houses, road sides, in old fields, gardens, &c. It is only met with in the Northern and Eastern States, from Nova Scotia to Rhode Island, and extending back to New York and Canada. In Ohio and Pennsylvania it is very rare, and at the South quite unknown. (Rafinesque's Flora.) Every part of this plant is possessed of activity. The only part, however, that is used officinally in this country is the leaves. When fresh, these have a mucilaginous and slightly acrid taste, and Avhen bruised emit a strong, foetid, and narcotic odor. Thrown on the fire they burn with a noise as if they contained nitre, and give out a strong smell. By drying the leaves lose both their taste and smell. Diluted alcohol extracts all their virtues. The active principle of the henbane is Hyoscyamine, a vegetable alkali, obtained by Brande from the seeds and the herb—resembles in its properties very much atropine. Besides this an empyreumatic oil has been obtained from it by destructive distillation, its chemical properties identical with those of the empyreumatic oil of digitalis, and is a powerful narcotic poison. Effects. —In some respects henbane resembles opium in its action on the system. In moderate doses, it first slightly quickens the pulse ; after this, diminishes sensibility, calms the system, and eventually produces sleep. In larger doses, general insensibility speedily comes on, there is profound sleep, dilatation of the pupil, and in some cases delirium accompanied with a full pulse, indicating great cerebral congestion. Opium and henbane resemble each other in the power of diminishing NARCOTICS. 379 sensibility and calming the system, inducing sleep and acting on the skin. In some important respects, however, they differ. 1. In its primary operation and in small doses, henbane is not so stimulating as opium. 2. It does not constipate the bowels, but rather relaxes them. 3. Opium lessens the urinary secretion, while henbane increases it. 4. On the organ of vision the effect of the two differs—opium contracts, henbane dilates the pupil. The same effect is produced by the local application of henbane to the conjunctiva. As a remedial agent henbane has many advantages over opium, and may be used as a substitute for that article where it does not agree with the patient. It calms the system, allays pain, and produces sleep, at the same time it docs not shut up the secretions. It may be given in all irritable states of the nervous system with advantage. It is commonly, too, combined with cathartics to obviate their irritating effects without lessening their cathartic power. Mode of Administration. —Two extracts, a watery and an alcoholic, are officinal, as is the tincture. Dose of the extracts grs. i to ij. Of the tincture 3 i to 3 ij- [One grain of extract hyoscyamus combined with one of camphor makes the best anodyne pill for the use of females subsequent to confinement with which I am acquainted. I direct a pill at bedtime, and another every hour till sleep is obtained. Rarely are more than three required.—Ed.] LACTUCARIUM. This is a peculiar substance obtained from the Lactuca sativa, or garden lettuce, a plant extensively cultivated both in this country and in Europe. The leaves and stem of the plant abound in a juice which has a milky appearance, but on exposure to the atmosphere it concretes, and becomes of a brownish color, resembling opium. This is the lactucarium, by the French called theridace. Preparation. —The mode originally suggested by Mr. Young, of Edinburgh, for obtaining it, is the following. The top of the stem is cut off when the plant is in flower about a foot above the ground, and the juice which exudes from the cut surface is absorbed by means of a moist sponge, from which it is again squeezed into a proper vessel and inspissated. As soon as the cut surface ceases to yield the juice, another slice is to be taken off, and this to be continued as long as juice continues to be poured out. On standing, it concretes and changes to a brown color. Properties. —In its taste and smell, lactucarium bears a strong resemblance to opium. It is soluble both in water and in alcohol. At one time it was supposed to contain morphine. Caventou, Dublanc, and Ganzel, in their analysis of it, could discover no trace of this principle. 380 MATERIA MEDICA AND THERAPEUTICS. Physiological Effects. —In its action on the animal economy, lactucarium resembles opium, impairing the sensibility of the system and inducing sleep. It is more mild, however, in its operation, and does not leave behind it any of the unpleasant effects which so frequently follow the use of opium, such as stupor, headache, and nausea. Unlike opium it does not constipate the bowels, and according to the experiments of Dr. Francois, it acts on the circulation as a direct sedative. In a number of cases in which he gave it the pulse was reduced from seven to twelve beats in the minute. Mode of Administration. —Given in pill, dose grs. x to 3i. Tincture, 3 i to 3 iij. It is very little used. HUMULUS LUPULUS. This is the common hop, a plant growing native both in Europe and America. In both also it is extensively cultivated. In different parts of the United States it is found growing spontaneously. The part of the plant used are the strobiles. These are picked when the plant is scarcely ripe, and gradually and carefully dried. Five pounds of fresh hops make about one pound dried. Properties. —The strobiles of the hop consist of thin scales of a greenish yellow color; they have a strong, fragrant, and somewhat narcotic odor, and a bitter, aromatic taste. The surface of these scales is covered with a yellow powdery substance, which is easily separated by sifting the hops through a common sieve. It is supposed to be peculiar to the female plant, and to be secreted by the nectaria. To this powder the name of Lupulin has been given. It is in the Lupulin that the active principles of the hop chiefly reside. The strobiles yield their virtues to boiling water, alcohol, and ether. By long boiling, they lose their aromatic flavor. Physiological Effects. —As a narcotic the powers of the hop are feeble, and it is not to be compared with opium and other articles of this class. Nevertheless, it is capable of lessening sensibility, assuaging pain, and inducing sleep. It differs from opium in being tonic to the digestive organs and laxative to the bowels, hence it js not so apt to produce headache as opium. In its general properties it resembles more nearly hyoscyamus, and may frequently be used with great advantage as a substitute for more potent narcotics. Mode of Administration.—!. Substance. —In the form of powder, twenty grains may be given to an adult. In the experiments made by Bryaily, this caused nausea and catharsis without affecting the pulse. 2. Infusion. —Half an ounce of the hops in a pint of boiling water. Of this two or three ounces may be taken three or four times a day. 381 NARCOTICS. 3. Tincture. —This is the most common form of using it. The dose is from 3 i to 3 ij. Lupulin.—This, as already stated, is a peculiar substance obtained from the hop. It is in the form of small, shiny, yellowish grains, having an aromatic smell and bitter taste. Chemical Properties. —According to the analysis of Chevalier and Payen, lupulin contains resin, volatile oil, and a peculiar bitter principle. It is to this bitter principle that it has been proposed to restrict the name of lupulin. Lupulin is soluble in water, alcohol, and ether, and to all these substances imparts its bitterness. Physiological Effects. —In its general operation, lupulin resembles the hop itself, acting as a tonic and narcotic. Mode of Administration. —1. Substance. —In doses of from six to twelve grains made into pills. 2. Tincture. —Made by digesting f ij of lupulin in a pint of alcohol. Of this the dose is from one to two drachms. 3. Hop Pillow. —This is frequently resorted to as a soporific, and has undoubtedly some force in controlling restlessness. It was rendered fashionable in England towards the close of the last century, from the circumstance that it was prescribed by Willis with great apparent benefit to George III. CONIUM MACULATUM. This is the hemlock, and was formerly known by the name of cicuta. It is a large umbelliferous plant, indigenous in Europe, but now naturalized and growing in great abundance in this country. It has a striated stalk from three to five feet high, with purple spots upon it. These characters of the stem distinguish it from other plants resembling it. In this country it is found in old fields, near roads and fences, and flowers from June to August. The whole plant has a disagreeable smell, generally compared to the urine of the cat. The part used in medicine is the leaves. Properties. —The leaves are of a beautiful green color. When dried they lose somewhat of their disagreeable smell, though they still retain a strong narcotic odor, and have a slightly bitter and nauseous taste. The fresh leaves are supposed to contain both a narcotic and an acrid principle. P>y drying, the latter is dissipated, while the former undergoes no change. This process, therefore, improves their medicinal virtues. When pulverized, which is readily done, the powder should retain the beautiful green color of the leases, and with this the peculiar odor of the plant. It is important to recollect that exposure to light 382 MATERIA MEDICA AND THERAPEUTICS. dissipates the color, and with it the virtues of the article. It should, therefore, always he kept in a dark situation. Chemical Composition and Properties. —According to the analysis of Brande, conium contains resin, albumen, coloring matter, an odorant volatile oil, salts, and a peculiar alkaline principle, to which the name of coneine has been given. By others it is called cicutine. The most appropriate, however, is conine. Effects. —These differ with the dose. In very small closes, it may be continued for a long time without producing any effect either upon the digestive organs or upon the constitution at large. When a full dose is given, the following effects show themselves : giddiness, a sense of fulness in the eyes, feeling as if they were pushed from their sockets, slight sickness at the stomach, dryness of the throat and fauces, together with a trembling agitation of the whole body and impaired muscular power. Along with these there are generally one or two loose evacuations. If given in doses a little smaller, its most obvious and striking operation on the system is that of lessening sensibility, allaying pain, and promoting rest. On the circulation, conium produces no marked effect. It differs from opium in not constipating the bowels, nor creating thirst, nor leaving headache behind it. Modifying Circumstances. —In the whole range of the materia meclica, there is perhaps no article which differs so much in its ordinary effects as conium, so much so indeed as to have given rise to the most contradictory accounts in relation to its use in various diseases. Abundant evidence of this fact will be found by consulting the observations of those who have treated of this article. In a practical point of view it is important to appreciate the causes of this discrepancy, and they are mainly two —a difference in the strength and purity of the article, and a difference in the mode of using it. 1. Of the Strength and P urity of the Article. —As found in the shops, the preparations of conium vary greatly. This fact was noticed so long ago as the time of Dr. Oullen. He states that he frequently found the extract which was imported from Vienna, a perfectly inert substance. The same thing has also been observed by Dr. Jackson of Boston, in relation to that which is imported into this country from England. 2. Difference in the mode of using it. —This is another circumstance which may aid us in accounting for the discrepancy of testimony in relation to the effects of this agent. Some physicians, fearful of the effects produced by this powerful article, have given it in doses so small, or introduced it so slowly, that the system never properly felt the effects of it. While others, commencing with too large doses, abandoned the medicine at once, in consequence of the violent effects which it occasioned. There is no doubt tteit in both these ways the reputation of conium has greatly suffered. It becomes, then, a matter of importance NARCOTICS. 383 to know how far it should be carried so as to secure its beneficial effects to the fullest extent. As a general rule, no good is to be derived from it unless it produces some sensible effect on the nervous system, as manifested by giddiness and nausea. As conium differs so much in its strength, the safest plan is to begin with a small dose, say gr. j, to be increased every day until these effects are produced. As soon as this takes place, it should be discontinued until they subside, and then as large doses should be persisted in as can be borne without reproducing them. Mode of Administration. —1. Powder. —Of this the average dose is about three or four grains. This is the most certain form in which it can be used if freshly powdered, but it soon becomes inert. 2. Extract. —This is prepared by inspissating by a gentle heat the juice of the fresh leaves to a proper consistence. According to M. Brando, 100 lbs. weight of the leaves yield from three to five pounds of the extract. To be good, this should have a clear olive color, a foetid, odor, and a bitterish saline taste. The average dose is about five grains. 3. Tincture. —This is a good form of using it. The dose is from half a drachm to a drachm. Diseases in which the Conium has been used. —Notwithstand- what may have been said to the contrary, if the article be really good, and if it be used to a sufficient extent to produce its specific effects, there can be no question that in many cases Conium is a valuable remedy. Although known to the ancients,'* and used as an external application, it does not appear to have been used as a medicine internally, until about the middle of the last century. Cancer, Scrofulous and Malignant Ulcers* —These were the diseases in which conium was first used by Storck, and its virtues particularly lauded. As might readily be supposed from the character of these diseases, subsequent experience by no means confirmed the high character given of this article by him ; although it has established the fact of its affording a certain degree of benefit even in these intractable diseases. In genuine cancer, said to have been cured by Storck with it, abundant evidence has shown that nothing is to be expected from it. Alibert reports that of upwards of 100 cases of cancer of the uterus and other parts, which were treated with this remedy at the hospital of St. Louis, not one was cured, But though it is incompetent to a cure of genuine cancer, yet it is not without benefit that it has been used oven here. Dr. llutty states, that although he never knew a single case of cancer * By the Greeks it was used as a poison ; and it is this which is supposed to have been the article given to those eminent men of antiquity, Phocion and Socrates, when they were condemned to an ignominious death by their unjust, countrymen, 384 MATERIA MEDICA AND THERAPEUTICS. cured by it, yet in a great number of cases it retarded the progress of the disease, " lessened the tumors, alleviated the pain, mended the discharge, changing it from a thin, ichorous, and foetid condition to one more like a laudable pus, and disposing the parts to heal."* In scrofulous tumors and ulcers it has been of still greater advantage; and numerous cases are reported in which, under its use, they have been cured.f .In painful tumors and ill-conditioned ulcers, not specific, it has also been used with great advantage. Upon the whole, the result of experience in relation to conium in the preceding affections seems to be, that although possessed of no power to cure those of specific character, yet even in these, by relieving pain and allaying general and local irritability, it renders the patient more comfortable, improves the character of the discharge, and retards the progress of the disease. While in those which are not of a specific character, it places the system in a condition the most favorable to a cure. Syphilis. —In certain forms of this disease conium has been used with benefit. By Hunter it is recommended ; and in certain conditions of indolent buboes he speaks of it as one of the best remedies.J Cullen, too, speaks of it as in many cases of syphilis proving a valuable adjuvant. In syphilitic chancres of an irritable character, " conium given in very small closes will often do much good." Neuralgia. —In this disease the conium was, I believe, first recommended by Dr. Fothergill ;§ and by him several cases are recorded in which it was used with success. In the hands of others since his time, it has by no means sustained its reputation. Pulmonary Consumption. —In this disease conium may be used with much advantage. By Dr. Paris, especially, it is lauded in the highest terms. Like every other remedy it is, however, only palliative. That it tranquillizes pulmonary irritation in a remarkable manner is certain ; but that it can effect a cure, as Dr. Paris intimates, is expecting too much from it. lie gives it in doses of five grains of the extract three times a clay, to be continued till the specific effects of the article are produced.|| He recommends the following prescription: . Ext. conii Ext. hyoscyana. aa 3ij, Mucilago acaciae 3 ij. Tere et adde * Med. Obs. and Inq. vol. iii. p. 234. f Boyle, vol. iii. p. 620. See Eberle's Practice. [Med. Obs. and Inq. vol. iii. p. 284. ± On the Venereal, p. 260. Bell, vol. ii p. 234. Cullen, vol. ii. p. 189. § Obs. and Inq. vol. v. 1 On Diet, pp. 199, 200. NARCOTICS. 385 Liquoris ammonice acetatis 3 i. Aq. puree 3 ivss. Vin. ipecac. 3 i- Syrupi rhajad. 3 ij Ft mistura, de qua sumantur coch max. ter in die. In the New York Hospital I have used the inhalation of the saturated tincture of conium with iodine, according to Scudamore's prescription, with great benefit. It certainly relieved the cough and lessened the expectoration, and altogether made the patients more comfortable. Chronic Rheumatism. —Here it is also a remedy of value. Dr.Th.pmson says he has seen it produce more beneficial effects in chronic sciatica than any other medicine.* In a case of this kind in the New York Hospital, the disease which has resisted a great variety of remedies yielded readily to the conium, in grain doses repeated every two hours. It is also used and with great benefit in syphilitic rheumatism. ATROPA BELLADONNA. This is the deadly nightshade, a perennial plant indigenous in Great Britain. It grows in woods and shady places, and is also frequently cultivated in gardens. It has a thick root with three or four stalks branching from it, and growing to the height of from three to five feet. Its flowers are of reddish color and bell-shaped. It bears beautiful berries of a large size and purple color. The whole plant is poisonous, and the berries have frequently proved fatal. The part generally used in medicine is the leaves. Properties. —When fresh, the leaves have a faint narcotic smell, which they lose by drying, without having their active properties at all impaired. Their taste is subacrid and slightly nauseous. Chemical Properties. —According to the analysis of Mr. Brande, belladonna contains an active principle of an alkaline character. This is atropine, and exists in combination with malic acid. Besides this it contains a green resin, wax, starch, gum, lignin, albumen, and various salts. Both water and alcohol dissolve the active principles of belladonna. Atropine. —This substance is in needle-like crystals of a brilliant white color, without taste or smell; almost insoluble in water and in cold alcohol, but very soluble in boiling alcohol. In ether and oil of turpentine also'insoluble. It unites with the acids, forming crystallizable salts, and seems to possess a greater neutralizing power than any of the vegetable alkalies. * Mat. Med. vol i. p. 575. 386 MATERIA MEDICA AND THERAPEUTICS. Effects. —These differ with the dose. In very small doses, no sensible effect is produced, with the exception perhaps, in some cases, of a dilatation of the pupils. In these doses the action of this agent is probably in a great measure local. In larger doses,such as it is generally given in medicine, the most marked effects are a sense of fulness about the head, dilatation of the pupil, more or less dimness of the vision, with a sense of dryness and constriction of the throat, accompanied frequently with a difficulty of swallowing. On discontinuing the use of the article, these effects speedily disappear. On the vascular system no marked effect is produced. On the secretions and excretions it produces little effect, although by some it is supposed to increase the secretion of urine. Of all the effects produced by belladonna, the most curious is that of dilating the pupil. This effect will follow, whether taken internally, applied around the eve, or to a wound. When taken internally, so as to affect the pupil, the sight also is much obscured. Applied externally, it generally dilates the pupil without affecting the sight. This, however, is not invariably the case.* The dilatation comes on about an hour after the application, and passes off in the course of two or three days, if the use of the article be discontinued. In poisonous doses it produces dryness of the throat, vertigo, dilatation of the pupil with obscured vision, and a peculiar delirium resembling intoxication. This is accompanied generally with excessive and ungovernable laughter, sometimes with constant talking, and occasionally with a total loss of voice. After continuing some hours, this is succeeded by stupor, slight agitations of the muscles without regular convulsions, and finally death. From the foregoing it would appear that belladonna makes a peculiar impression upon the nervous system, lessening sensibility and irritability. This is. more especially manifested in the throat and the eye, upon both of which it produces transient paralytic effects. It is accordingly used in medicine with the view of allaying pain and spasm, and obtaining its peculiar effects upon the organ of vision. Modes of Administration. — Powder —made from the dried leaves, is the most uniform in its strength, and is therefore preferable on this account to the other preparations. The dose to begin with is about one grain, to be given once or twice a day, and increased gradually until the specific effects of the article begin to show themselves. To children one eighth of a grain is sufficient as a dose. * Mr. Tyrrell relates two cases of temporary amaurosis produced by the extract, applied to the surface of irritable ulcers of a malignant character. In one case the disease was situated in the vagina, and in the other in the rectum. The pupils of the eyes were extremely dilated, as from the application of the extract to the organ itself, and the patients were incapable of distinguishing any objects for some hours. In the case of ulcerated vagina, the application was repeated, when it produced exactly similar effects. —A. Cooper's Lectures, vol. i. p. 79. 387 NARCOTICS. Extract. —This is prepared by bruising the fresh leaves in a mortar, then sprinkling a little water over them, expressing the juice, then evaporating to a proper consistence. Of this the dose is one half a grain repeated two or three times a day. To a child one twelfth is sufficient. Like the extract of hemlock, this is apt to vary in its strength. Diseases in which the Belladonka is used. — Various Affections of the Eye. —As already stated, wdien applied to the eye, it dilates the pupil and produces a partial paralysis. In Cases of Cataract this is resorted to with great advantage. By the great dilatation of the pupil which it occasions, it enables us in the first place to ascertain the nature and extent of the disease, whether the iris be adherent to the capsule of the crystalline lens or not, whether the cataract be complete or only partial. Then, in the operation, it gives great advantage in fixing the iris and destroying the irritability of the onxan. In Inflammation of the Iris, where adhesions are constantly threatened, this application, by dilating the pupil, prevents, and sometimes breaks up partial adhesions.* Finally, in irritability of the eye it answers admirably in allaying irritation ; it is also used in opacity of the cornea.f The mode of applying it in these cases is to drop a little of the infusion into the eye, or a little of the extract dissolved in water may be applied to the lids.J Upon the same principle it has been applied, locally, with success to continued rigidity and spasm in other parts of the system. By Chaussier it was used in cases of rigidity of the neck of the womb, interfering with delivery. For this purpose he employed an ointment made by rubbing two drachms of the extract with an ounce of lard. Of this, a bit the size of a filbert was applied to the neck of the womb, and generally succeeded in relaxing the os uteri.§ By Dr. Conquest the same practice was resorted to with great success. In applying the belladonna in cases of this kind it is to be used, however, with caution, as the paralysis may extend to the uterus itself. A case of this kind is related by Blackett, in which both the neck and mouth were dilated and the womb paralyzed. Six hours intervened before the contractions of this organ * See Mackenzie, specially, p. 358. f See Bayle, v. ii. p. 512. Diet. Mat. Med. \ Mackenzie directs that, the evening previous to the operation, extract of belladonna, moistened to the consistence of cream, be smeared on the eyebrow and eyelids, and allowed to remain till about half an hour before the operation, when it is to be washed off with a sponge and tepid water. If the pupil is not by this time fully dilated, a little filtered solution of extract of belladonna in water is to be dropped on the conjunctiva, riot rudely dashed, with a hair pencil.—P. 502. ,§ See Eberle, v. ii. p. 18. Diet. Mat. Med. v. i. p. 492. 388 MATERIA MEDICA AND THERAPEUTICS. returned.* [Used in this way it has produced the poisonous effects of the drug.] By Chaussier it was applied -also in uterine convulsions. With the same view it has been successfully applied, externally, in cases of spasmodic strictures of the urethra and of the rectum, in chordee,\ hemorrhoids, and in strangulated hernia. Four cases of this latter kind are stated to have been completely relieved in this way.J Hooping Cough. —In this disease belladonna has been extensively resorted to. On the continent of Europe its reputation stands exceedingly high. Dr. Eberle states that he used it in twenty cases, and in the majority with great advantage.§ He recommends it to be given by dissolving four grains of the extract in an ounce of sweetened water, and of this giving from eight to twelve drops three times daily to a child under two years old.|| By Dr. Thomson one eighth of a grain was given to a child eight years of age, and gradually increased to one fourth of a grain. By Hufeland the proper period for commencing the use of this remedy is said to be about the fifteenth or twentieth day of the disease. 4. Neuralgia. —In this rebellious form of disease, belladonna has been used, and in many cases with great success. Among those who recommend it most highly is Dr. John Bailey of England. The cases recorded by him were all neuralgic affections of the head and face, and it is when seated in these parts that he considers the belladonna peculiarly efficacious. The preparations used by him were the extract and the tincture.^[ [Dysmenorrhea. —Belladonna has been used with success in this disease, both taken internally, applied to the back as a plaster (empl. belladonna)), and introduced into the vagina as a suppository. Combined with ipecac (half a grain of each), it has in my hands exercised more control over this affection than any other one thing. —Ed.] DATURA STRAMONIUM. This is commonly known by the names of the Thorn apple, Jamestown weed, Stinkweed, &c. It is an annual plant, growing to the height of three or four feet. It is found in every part of the United States, Canada, Mexico, South America, also in Europe, Africa, and Asia. With regard to the native country of this plant there has been con- * Bayle, v. ii. p. 513. % Ibid. Bayle, 613. | Mat. Med. ii. 75. % f Diet. Mat. Med. v. ii. p. 492. § On Children, 483, also Mat. Med. v. i. 75. Diet. Mat. Med. vol. i. p. 492. 389 NARCOTICS. siderable difference of opinion. The common belief seems to be in favor of its being a native of this continent, and that it travelled through the East Indies and Persia to Europe. In the earliest English writers on plants it is called the thorn apple of Peru, and the Spaniards assert that the first seeds of it were received from Peru, under the name of cachos, and that it had previously been held in high repute as a medicinal plant both by the natives and the Spaniards in Peru. Into England it was introduced in the reign of Queen Elizabeth from Constantinople. That the stramonium is not a native of the United States there is every reason to believe. It is always discovered along the roads and near habitations, never in the woods and mountains. Mr. Bafinesque says the Indians call it " the white people's plant," and he adds that its migrations can be traced from New England and Virginia, and that in the Western States it has sprung up only since their settlement, and from seeds carried there. This plant blossoms from May to September in the Southern States, and from July to October in the Northern. Properties. —The whole of this plant possesses active properties, and has a foetid, narcotic smell, which of itself sometimes causes headache and stupor. The parts chiefly used in medicine are the leaves and seeds. The leaves are large, from five to- six inches in length, of a deep green color on the upper surface and pale green underneath. When fresh and bruised they have a foetid, narcotic odor, which they lose on drying. Their taste is bitterish and nauseous, and when chewed they give the saliva a green tinge. The seeds are small and of a dark color, having the peculiar taste of the leaves, but destitute of smell. Chemical Properties. —By Brande the seeds were ascertained to contain a peculiar alkaline principle, which he called daturine, gum, a butyraceous matter, orange-colored extractive, together with various salts. The active properties of the stramonium are yielded both to alcohol and water. Daturine exists in the seeds of the stramonium in combination with malic acid. In its pure state it is in the form of acicular prisms, almost insoluble in water and in cold alcohol. In boiling alcohol it is very soluble, and with the acids it forms crystallizable salts. Effects. —In its action on the system, stramonium resembles belladonna. In moderate doses, it causes slight vertigo, and sometimes pain in the head, dimness of vision, and dilatation of tl*e pupil. In some cases nervous sensations are excited in the fauces, amounting even to a sense of suffocation, but more commonly only heat and thirst. Although not soporific like opium, it produces a slight tendency to sleep. On the circulation the effect is not very striking; in some cases increasing 390 MATERIA MEDICA AND THERAPEUTICS. the frequency of the pulse somewhat, while in others it is rendered slower.'* The bowels are moderately relaxed, and the secretion of urine increased. If it be given in somewhat larger doses, say three or four grains of the powdered leaves, in a few minutes it produces giddiness, nausea, difficulty of speech, with great thirst, with symptoms analogous to those of intoxication from alcohol.f Like belladonna, it uniformly dilates the pupil. This is the case especially when applied locally, either in the form of extract or watery solution. This effect comes on in about half an hour after its application, and continues for about two days.| In poisonous doses, the prominent effects are sickness at stomach, loss of vision, dilatation of the pupil, delirium,§ amounting sometimes to actual mania and stupor; in some cases spasms, and occasionally palsy occur. After continuing for a longer or shorter period, patients recover from these effects, although sometimes death is the result. [I have seen perfectly well marked chorea produced in a child of eight years by swallowing the seeds of stramonium. The symptoms went off in about twelve hours.—Ed.] Modes of Administration. — Powder. —Both the leaves and seeds are used. Of the powdered leaves, the dose is from two to three grains; of the seeds, which are stronger than the leaves, one grain may be given twice a day. Extract. —Of this there are two kinds, the one made from the leaves, the other from the seeds. The extract from the leaves is prepared by bruising the fresh leaves in a stone mortar, sprinkling on them a little water, then expressing the juice, and evaporating to a proper consistence. Prepared in this way, it is uncertain as regards its strength, differing according to the mode of conducting the process of evaporation, and the season when the leaves are gathered. The average dose is about a grain, night and morning, gradually increased until the system is affected. The extract from the seeds is prepared by macerating a pound of the seeds in a gallon of boiling water for four hours ; then taking out the seeds and bruising them, after which return them to the liquor; boil down to four pints, and strain while hot. After this evaporate to a proper consistence. The extract prepared in this way is about twice as strong as that from the leaves, and is more certain in its effects. The dose is from }to{a grain twice a day. This may be increased every day or two ] of a grain, until some decided effect is produced. Tincture. —This is prepared by macerating four ounces of the bruised seeds in two pints of diluted alcohol for fourteen days, and then filter- * See Experiments by Cooper, in Caldwell, p. 174, for 1805. , f Ibid. p. 184. \ Cooper, p. 173. § For a striking illustration, quote from Cooper in Caldwell's Therap., p. 186. NARCOTICS. 391 ing. Of this the dose is from ten to twenty drops ; may ho taken two or three times a day, and gradually increased. Ointment. —One pound of the leaves cut into pieces, melted with lard, one pound ; yellow wax, half a pound. Diseases in which it is used. —From the analogy in effect to the belladonna, it has been found useful in very much the same kind of diseases. Affections of the Eye. —In cataract, inflammation of the iris, &c, it is used with similar intentions and effects as the belladonna already noticed. Asthma. —In this disease the use of stramonium in the form of smoke is an old and popular remedy. In the spasmodic form of it especially it has been found beneficial during the paroxysm. It is not, however, infallible in its operation. In some cases I have found it exceedingly advantageous, while in others it has produced little or no effect. The mode of using it is to cut the dried leaves into small pieces, and then smoke in a common pipe, precisely like tobacco. Used in this way, it produces all its narcotic effects on the system. For those who have been accustomed to smoking tobacco, two pipes a day will do to begin with, but for others, and females, a single pipe will be sufficient. As the system gets accustomed to it, the quantity may be increased to several pipes a day. As soon as nausea or vertigo come on, the smoking should be suspended. Stramonium has also been used internally in asthma. Epilepsy. —This was one of the diseases in which the stramoninm was earliest used, and in the hands of some with considerable success, while in those of others it has not accomplished much. By Odhelius, a Swedish physician, fourteen cases of this disease were treated with it in the Royal Hospital at Stockholm. Of these, eight were cured and five relieved, and only one did not receive any benefit. During its use the patients suffered transient headache, numbness, and obscurity of vision. Neuralgia. —In this disease the success of stramonium has only been partial. By Lcutin, a physician of Hanover, fourteen cases of tic douloureux were treated with this remedy without curing a single case. By Dr. Read of Massachusetts three cases are recorded, in all of which the stramonium effected a radical cure of the complaint. They were all of considerable duration, and various other remedies had been tried without any essential benefit. It was given in the form of extract, from \ to \ a grain. ANAESTHETICS. THE EDITOR. This term is applied to agents which diminish or temporarily suspend the general sensibility of the body. The idea of controlling or diminishing the pain of surgical operations has long been a favorite one, and various means have at different times been resorted to with a view of realizing it. These attempts had generally failed altogether, or met with a very partial success, till the introduction of ether inhalation. Sir Humphrey Davy had indeed reported his success in controlling pain in his own person by the inhalation of nitrous oxide, and Mr. Horace Wells made some trials, not altogether without success, with the same agent so early as 1844* But it was not till 1846 that Dr. Morton of Boston, after many cautious trials on himself and some of his patients, induced Dr. J. C. Warren to use sulphuric ether inhalation in an operation at [* My attention was directed by my friend Professor Ellet to the following passage in the works of Berzelius which contains the germ of the idea of anaesthetics of the general character of ether, chloroform, etc., viz. the compounds into which hydrogen enters largely. It is certainly curious, and all the more so in that it affords another striking proof of the possibility of a discovery being almost made long before its actual and practical realization :—Ed.] Une atmosphere compose de gaz oxygene et de gaz hydrogene substitue au gaz nitrogene rend, au bout de quelques temps, lourd et comme engourdi, mais ne produit pas d'autres signes de malaise. Allen et Pepys ont vu des cochons d'Inde qu'on avait laisses au milieu d'une pareille atmosphere, finir par tomber dans un sommeil profond. On a des exemples d'hommes qui, apres avoir respiree pendant longtcmps un melange de gaz hydrogene et d'air atmospherique, se trouvaient pris chaque fois de sommeil, &c. —Berzelius, torn. i. p. 85, Bruxelles, 1838. Lorsque Allen et Pepys firent respirer des cochons d'Inde dans une atmosphere de quatre parties de gaz hydrogene et une partie de gaz oxygene, ces animaux ne tardercnt pas a etre plonges dans un etat d'assoupissement, et tomberent dans le sommeil, sans que du reste aucun symptome de maladie se manifestat en eux. Dans un experience fait a Stockholm par Charles de Wetterstedt, qui laissa respirer pendant un quart heure un melange d'une partie de gaz oxygene, et de quatre parties de gaz hydrogene a une fille de vingt ans, atteinte de phthisie pulmonaire, il arriva presque chaque fois que la malade, jnsqu'alors tourmentee par l'insomnie, fut pris d'envie de dormir, et tomba dans un sommeil paisible, sans que du reste aucun changement survint dans la marche de la maladie.—Berzelius, torn, iii. p. 556. ANAESTHETICS. 393 the Massachusetts General Hospital. This operation was performed Oct. 15, 1846. The anaesthesia was but partial. The next day another operation was performed by Professor Hayward, in which ether was used with the effect of rendering the patient completely insensible to pain. From this beginning, the use of ether spread over the whole civilized world in an astonishingly short time, and from every quarter the most extravagant reports were promulgated of its wonderful success. In January, 1847, ether inhalation was first used to control the pains of parturition by J. Y. Simpson, M.D., of Edinburgh. It was used in Paris, Jan. 27, by Dr. Deschampes; and Feb. 8, in his Obstetrical Clinique, by Dubois. In London it was tried first by Professor Murphy, Feb. 13, 1847, and in this country by Dr. Kemp, April 7, 1847. Thus the use of ether in midwifery may be said to have spread over Europe and America in less than six months. In November, 1847, Dr. Simpson, after making very many experiments with various agents with a view of discovering some substitute for ether, was induced to prefer chloroform, and soon used it in a case of difficult labor, and with complete success. Introduced to the notice of the profession by a gentleman so distinguished, it soon gained great favor, and for a time seemed likely to supplant the ether, but a terrible check was given to the use of this article in particular, and to that of anaesthetics in general, by the occurrence of several cases of death from its use. These cases very soon amounted to eighteen or twenty, all from chloroform, and the apprehension that many more were concealed by the criminal want of candor of those in whose practice they occurred, excited in the minds of many professional men a dread of the new practice, and as rapidly as it gained its favor, anaesthesia lost a part of it, but not all. It continued to be used in severe surgical operations, in obstetrical operations, and by some in cases of natural labor. It soon became the subject of very vehement disputation, and objections of all sorts, moral, medical, and theological, were urged against it. But at length the practice, in some sort, recovered its ground, and now it seems to have established itself as a valuable, reliable, and, if cautiously used, a.safe means of relieving our patients from the pain of surgical and obstetrical operations, and also of controlling several very severe diseases. This appears to me to be the present state of professional opinion on this subject. Effects of Anaesthetics. —The first effect is stimulating ; the ears ring, the patient is restless and sensible of confusion of intellect, a numbness is felt in the limbs, sometimes he is excited to violent efforts or loud shouts; this soon passes away, and a sleep more or less profound follows ; consciousness is lost, the muscles are rigid, and sensibility is only blunted. Next follow muscular relaxation and a deeper sleep, consciousness and sensibility completely gone, breathing sometimes stertorous, though regular; pulse regular. The next stage is irregular or inter- 26 394 MATERIA MEDICA AND THERAPEUTICS. rupted respiration, pulse weak and fluttering, and no doubt if this condition is allowed to continue for a few seconds, respiration would be altogether and for ever interrupted, and death ensue. These are the ordinary effects of the inhalation of anaesthetics, but there are very many irregularities in their order and degree. Sometimes the state of excitement is not at all noticeable, and the system passes at once into profound narcotism. I once saw a lady plunged into a state of the profoundest anaesthesia, with weak, irregular pulse, snoring, and interrupted respiration, by making three or four inhalations of chloroform. The time was not ten seconds. This, however, is rare, and the probable cause of it will be alluded to hereafter. Very frequently the stimulating effects pass by so rapidly that they are hardly noticed, and certainly would not be were they not carefully watched for. Then again they are violent and long continued, so as to impede the inhalation very much, and the patient is, if an operation be attempted while in this condition, more unmanageable than if no anaesthetic were used. Sometimes consciousness survives sensibility ; this, though denied by Dr. Snow (Lancet, Feb. 12, 1848), is undoubtedly true. I have seen it very many times in labor, consciousness perfect, perceptions clear, yet sensibility to pain markedly diminished or completely destroyed. Irritation of the stomach and vomiting are not very unfrequent, especially if food has been recently taken. Sometimes sensibility seems to remain, though consciousness is lost; the patient screams or gives other evidence of suffering; but memory has no place for these sensations, for after returning consciousness the patient is utterly unaware both of the suffering and the manifestations of it be may have given. These are the chief effects of anaesthetics. Modus Operandi of Anesthetics. —That they are absorbed is "beyond doubt; they have been found in the blood in very many cases. Being then conveyed by the blood to the great nervous centres, these in succession lose their power. The order in which they are affected is thus given by Flourens. First, the cerebral lobes lose their power and intellect is impaired ; then the cerebellum is affected and the power of regulating locomotion is lost; afterwards the spinal marrow, and sensation and motion are gone ; lastly, the medulla oblongata, the motive power of respiration, breathing, ceases, and death is the result. This sounds very well, but it seems to me that any one who has studied this matter by the bedside will be quite unable to reconcile what he there sees with the ordo of Mr. Flourens. What, for example, was the state of the cerebrum and cerebellum in the Irishman operated on at London Hospital, who made faces and jokes while insensible of the pain of an amputation f * Is the cerebrum and cerebellum affected when a patient * Lond, Med. Gaz., Jan. 22, 1847. ANAESTHETICS. 395 in labor takes the handkerchief from her attendant, presses it to her face, and expresses in the warmest terms the relief from pain which it affords her ? All this must manifestly be restudied. Circumstances modifying the effect of Anesthetics. —On this subject we want facts. Age does not seem to contra-indicate their use, as Professor Gross says he has administered chloroform to patients of every age from sixteen months to seventy years without any evil effects. Sex, too, seems to have little influence, and if any such power belong to climate we are yet unable to appreciate it. State of the System. —The only thing from which we should, d priori, expect a modification of the effect of anaesthetics, is present pain, but I am not sure that there is any difference in the facility with which the anaesthetic state is produced in the patient about to submit to a surgical operation and the woman actually suffering pain of labor at the time the anaesthetic is given. The one seems to me to pass into the anaesthetic state as readily as the other. States of the System unfavorable and favorable to the use of Anesthetics.—The conditions under which anaesthetics are most likely to act irregularly are.—1. Very great plethora ; from the observations of Dubois and others, it would seem most prudent to remove this plethora before the agent is administered. Yet having done this, care must be taken as to the manner in which the anaesthetic is given, as it usually acts much more promptly immediately after a bleeding, or when the system is much reduced, than under other circumstances. In the case to which I have already alluded, where its effects were so rapid and so serious, the chloroform was given immediately after a free bleeding. 2. The presence of serious disease of the heart or great vessels has been by Mr. Wakley and others said to contra-indicate the use of anaisthetics. This has been denied—certainly the existence of such organic affection, should make us pause and duly reflect on the question, and if we judge it best to use the anaesthetic, no doubt great care should be taken to shorten or avoid altogether the period of excitement. Mode of Administration. —A very great variety of inhalers have been proposed. They have nearly all gone out of use, and ether is now almost constantly poured upon a cupped sponge and held over the nose and mouth, while chloroform is dropped upon a handkerchief and held in the same way. Rules for the Administration of Anesthetics. —1. The patient should not take food immediately before the operation. 2. The mind should be as far as possible calm and composed. 3. Quiet around is of the utmost importance—loud talking, addressing questions to the patient, &c., are all likely to interfere with the production of the anaesthetic state. 4. As to how rapidly the patient should be hurried through the state of excitement there is difference of opinion, and a different rule 396 MATERIA MEDICA AND THERAPEUTICS. should prevail as the agent is ether or chloroform. If ether is used, the stimulation is often troublesome, and the deeper stages of narcotism not readily produced. We ought, therefore, to hurry forward the process, place the cupped sponge over the nose and mouth, not pressing on the skin, but quite near, and urge the patient to take full free inspirations— let them follow each other as rapidly as is consistent with their being full and deep. As to chloroform, Prof. Simpson advises that the patient should be plunged as rapialy as possible into complete anaesthesia. This is not the course 1 would recommend. I think the practitioner will do better to feel his way a little, and allow the effects of the agent to develop themselves gradually. There will every now and then be trouble with the stimulating effects, but there will be less danger. 5. Care should be taken that the supply of atmospheric air is at all times adequate. There is little doubt but that several of the fatal cases depended on an inadequate supply of air. 6. Watch the case from the first inhalation till consciousness and sensibility have completely returned. One person should in all operations have charge of the anaesthetic, and he should think of nothing else. In one fatal case the attendant who should have watched the patient was looking at the operation, and the man died. The person who has this charge should keep his finger on the pulse and watch the respiration every single moment of the time—not one inspiration, not one beat should the heart give that he does not take note of. The moment the respiration is irregular or the pulse begins to flag or flutter, the inhalation should cease, and a puff or two of fresh air be blown into the face. As to the degree to which the effects should be carried, it will differ in different cases. In natural labor we need ordinarily go no further than to obtund pain, and this can generally, I think, be done without disturbing consciousness. In surgical operations, complete relaxation of the muscles and profound sleep is generally required. This state, however, must be watched, and when the breathing becomes stertorous the inhalation should be suspended. If the breathing is irregular or interrupted the danger is most imminent, and every means of keeping up respiration should be resorted to. Artificial respiration is the sheet anchor in such cases, and I have known great danger removed by prompt and continued artificial respiration. Everything will depend on the coolness and self-possession of the operator. 7. When the patient is allowed to emerge into consciousness everything that can startle or shock should be avoided, and the brain allowed quietly to recover its equipoise. Ammonia, oxygen, galvanism, &c. &c, have been proposed as remedies in excessive anaesthesia. They amount to nothing. Artificial respiration is the alpha and omega. Applications to Disease. — In Surgical Operations anaesthetics are almost universally used. On this subject, having no experience of my 397 ANAESTHETICS. own, as I do not practise surgery, I will quote the emphatic language of my distinguished friend, Prof. Gross. " I have never noticed in any of my cases that the use of chloroform exerted any injurious effects on the recovery of my patients."* In Midwifery. —Here the fate of anaesthetics has been very different from that which it met in surgery. From its first introduction into obstetrical practice to the present time, objections of all sorts have been urged against it, and evil consequences of all kinds attributed to it. It was immoral, for it excited in the patient indelicate ideas, and might prompt to improper words. was irreligious —God had said to woman " in sorrow shalt thou bring forth children"—anaesthesia tried to escape this curse. It predisposed to haemorrhage, to puerperal convulsions, to mania, n becomes white and hard. It seems to me that our surgeons ought to give this plan of Arnott's a full trial. My friend, Prof. White of Buffalo, tells me that he has used carbonic acid as an anaesthetic in cancer uteri, with good effect. A bent tube connected with the gas generator was introduced into the vagina. [As Dr. Beck did not lecture on anajsthetics, I have been obliged to supply this sketch.—Ed.] STIMULANTS. Stimulants are those medicinal agents which increase the vital movements of the system at large. Their general effects are simple and obvious; almost as soon as taken into the stomach, they produce a sensation of warmth, which soon diffuses itself over the whole body. The action of the heart and arteries is accelerated ; the pulse more frequent and stronger; the muscular system is invigorated, while general energy is imparted to the brain and nervous system. In all cases the effects are more or less temporary, varying with the stimulant and the quantity used. Some are peculiarly evanescent in their action, others more permanent. All are followed by languor and debility. Let us analyse a little in detail the effects of these remedies on the different parts of the system. 1. On the Brain and Nervous System.—The brain experiences a marked increase of power and activity. The senses all become more acute. The intellectual faculties, the imagination more especially, are stimulated, the passions excited, and every good and evil propensity roused into exercise. 2. On the Urinary System.—The effects of these agents are striking and peculiar. In the first place, they usually increase the quantity of urine secreted. This may be accomplished by the general impulse given to the circulation, involving the kidneys in the universal excitement. In the second place, besides increasing the quantity they alter its quality. It becomes high colored and irritating. Hence the heat and uneasiness which it occasions in all the surfaces over which it passes. 3. On the Skin.—In the general excitement of the circulation which follows the use of stimulants, there is no part which participates more decidedly than the skin. The capillaries are filled, heat is developed, and the secretion from the surface augmented. 404 MATERIA MEDICA AND THERAPEUTICS. CIRCUMSTANCES MODIFYING THESE EFFECTS. Age. —This modifies the effects of stimulants in a very striking manner. Their power is always manifested in proportion to the degree of sensibility and mobility in the system. In early life their action is, therefore, much more decided than afterwards. When judiciously used, their effects are most remarkable in invigorating the system. When improperly given their evil effects are quite as decided. The reason of this is plain ; in early life the circulation is naturally rapid and irregular, hence local congestions arc common. Now, stimulants still further hurry the circulation and increase the danger. At this period, therefore, stimulants should be generally avoided. In old age, on the contrary, the circulation is sluggish, the sensibility exhausted; here stimulants may be used with freedom, and their effect is less, but their use is unattended with the dangers which it has in infancy and childhood. Sex. —From the greater delicacy and excitability of the female system, stimulants produce a more decided effect on women than they do on men. Besides the general difference of constitution there are other circumstances which modify the effects of stimulants in the female. This is especially the case during pregnancy. In this condition of the female system, there is always increased excitement present. Hence it is very evident that the general effect of stimulants must be very different from what it is in the ordinary state of the system. Temperament and Constitution. —In sensitive and sanguine temperaments, stimulants produce more excitement than in the melancholic and phlegmatic. In the application of this class of agents to the treatment of diseases this fact is always to be borne in mind. Climate. —Of all the circumstances modifying the effects of stimulants this is, perhaps, the most striking. The inhabitants of Northern regions, whose sensibility is blunted by the rigor of the climate, can bear much larger quantities of ardent liquors than those of warmer latitudes. The apathetic Russian can take with impunity what would prove destructive to the sensitive inhabitant of the South of Europe. Even in our climate temporary exposure to the benumbing influence of cold will produce a similar effect. A person thus exposed may safely take, without any, or at least a trifling effect, what would be sufficient, under other circumstances, to intoxicate him. Repetition. —The same general law holds good here that is found to prevail in other classes of agents. The system becomes gradually habituated to the impression which they make, and to produce the same effect larger quantities are required. Illustrations of this fact are familiar to everybody. It is exemplified in the history of every person addicted to the use of intoxicating liquors. I once knew a man, now 405 STIMULANTS. dead, who began his career of intemperance by taking brandy in drops. What the number of drops was at first I do not know. He did this with the intention of its serving as a check upon any excess into which he might be tempted. Finding, however, as a matter of course, that the exhilarating effects of his drops were gradually lessening, he increased the close, and in this way he went on practising a constant deception upon himself until he became a perfect sot. In the use of stimulants in the treatment of diseases this fact is of importance. It shows that when they are required the dose must be gradually increased, if you wish to keep up a certain effect. Actual Condition of the System. —The effects of stimulants vary continually with the varying condition of the individual. If the stomach is empty, they are much greater than when it is full. This is known to everybody. Double the quantity of liquor of any kind can be taken after dinner than before. The reason is, that the excitability of the stomach is, to a certain extent, exhausted by the process of digestion. This is evidenced by the tendency to torpor and sleep which succeeds this process. A still more striking illustration is met with in persons who, either from necessity or inclination, have fasted or kept themselves on short allowance for any length of time. In all these cases, from the accumulated excitability in the system, the smallest quantity of stimulating food or drink produces the most extraordinary effect. The celebrated Venetian nobleman, Cornaro, who attained to the age of upwards of one hundred by his abstemious mode of life, relates that he had a violent fever excited, which lasted for several weeks and threatened his life, by increasing the quantity of his daily allowance of food from twelve to fourteen ounces. Another interesting case occurred in the history of Captain Bligh, who commanded the ship Bounty. In her voyage in 1787 to the South Sea Islands to convey the bread-fruit tree to the West Indies, the men mutinied, and the commander with eighteen men was sent adrift in an open boat. In this condition they performed the unparalleled voyage of 4,000 miles in the open sea. Their sufferings during this period from exposure and want of food were dreadful. They were kept all the time in a state approaching starvation. In this state a teaspoonful of rum dealt out to them occasionally is stated to have acted as a powerful stimulant in enabling them to complete this extraordinary voyage without the loss of a single individual. Another illustration of the modifying effect of the actual condition of the system is to be found in those cases where the excitability, instead of being accumulated, has been from some cause or other exhausted. Here immense quantities of stimulating articles can be taken with little or no effect. The advanced stages of typhus furnish many examples. 406 MATERIA MEDICA AND THERAPEUTICS. In these states, it is astonishing what immense quantities of wine and other stimulants have been administered with but little effect. STATES OF SYSTEM FAVORABLE AND UNFAVORABLE TO THEIR USE. As the effects of stimulants differ so materially according to the actual condition of the system, it is exceedingly important to mark, if possible, with some precision, those in which they may be used with advantage, as well as those in which they may prove injurious. A state of active irritation or inflammation of the stomach is decidedly unfavorable to the use of stimulants. Whenever, therefore, this state of the stomach exists, you are to avoid agents. In speaking of irritation of the stomach, you are to make, of course, a proper distinction. In many cases this organ becomes exceedingly sensitive and irritable without the least inflammation. You see this in cases of ordi- nal sea-sickness; in the sickness resulting from the use of tobacco, &c. Here stimulants, so far from being objectionable, are the best things that can be used. The existence of active local irritation or inflammation in any other part of the system is decidedly unfavorable to the use of stimulants, also the existence of general febrile excitement. If given, their effect must be an increase of vascular excitement, and perhaps local congestion. I do not wish yo to uunderstand by this, that I consider the use of stimulants improper in every state and stage of what is commonly denominated fever. On the contrary, in the advanced periods of the disease, where the energy of the nervous system is exhausted, and a general collapse has taken place, this class of agents is essential, and they may and must be given in very large quantities, as before stated. General plethora of the system is unfavorable to the use of stimulants. In this state there is always clanger of some local embarrassment, either congestion or inflammation, whenever anything hurries the circulation. Now, stimulants quicken the circulation at a time when the heart and blood-vessels are so distended as to be unable to carry the blood freely through the system. Hence obstructions take place, and apoplexies and the like result. Organic disease of the heart and arteries is unfavorable to the use of stimulants. The hurry and vehemence with which circulation takes place under the influence of stimulants tends to increase organic disease, and endanger rupture of the vessels in case of aneurism. From all this the condition of system favorable to the use of stimulants is evident. It is that in which there is general constitutional debility or nervous exhaustion, especially if unaccompanied by local inflammation, or embarrassment, or organic disease. With these general observations I shall, after a word or two on the difference between stimulants and tonics, 407 STIMULANTS. pass at once to the consideration of the application of these to the cure of disease. The points of resemblance between tonics and stimulants are, that they both tend to augment the vital powers, to increase muscular strength, and to invigorate every part of the system. The differences are : Stimulants act with greater promptness; their effects follow almost immediately on their administration. Tonics, on the contrary, manifest no influence at all upon the system, till they have been used for some considerable time. The effects of stimulants pass off as promptly as they are induced ; while of tonics, as the impression is slowly made, so it passes away slowly. They differ in the degree in which they excite the vital powers. By stimulants this excitation is very great; vital power is augmented, and vital functions are performed with a degree of vehemence, so to speak. From tonics no such effects result; the exaltation of the vital powers which they produce is moderate ; no violent action follows their use, nor can this effect be produced by any mode of administering them. Increase the dose of a stimulant, and you increase its stimulating power; increase the dose of a tonic, and its effects are no longer tonic, they are in a high degree irritative. Before passing to the application of stimulants to the treatment of various diseases, I will give you a few general rules for their administration. This is the more necessary, as there is perhaps no class of medicines which vary so widely in their operation according to the mode in which they are given. This, indeed, often entirely decides the question whether they are to do good or harm, to save or to destroy. Administered judiciously, there are few remedies more valuable. Given carelessly, there are none more dangerous. Rules to be observed in the use of Stimulants. —Begin with small doses, and increase them only as they obviously fail of producing the desired effect. In this way you will often get from a moderate amount the best effects, and you avoid the very great evil of being obliged to oppress the stomach by a large quantity. Change the stimulant as the system becomes accustomed to it. When it no longer responds promptly to the impression of one form of ardent spirits, try another; if beer after doing well for a time loses its power, resort to wine, and so on. You will often find that the system, when it has become quite insensible to the impression of one stimulant, will be roused by another, even though feebler in its general action. This shows a diversity in the impression made by different articles of this class, and proves the fallacy of that theory of the operation of stimulants which gives to them all a uniformity of action, and allows only a difference in degree between one and another. If this were so we should need but one stimulant, and could get all the effects of the class from one individual article. Every day's experience disproves this idea. 408 MATERIA MEDICA AND THERAPEUTICS. To avail yourself of the advantage to he derived from following the last rule, use stimulants uncombined. Give one form, and only one, till the system ceases to respond to it, and then resort to another to be used in the same way. Practical Applications of Stimulants. —There is, perhaps, no class of remedies which has been more abused than the one we are now considering, and there is none which requires more discrimination in their use. The reasons of this are obvious. The general indication for which they are given is to remove debility, either of some particular organ, or of the system at large. Now, debility may exist along with many different and opposite conditions of the system. It may be apparent, or it may be real. It may be the result of excessive action and inflammation, or of deficient action. Now, if stimulants be given in these various conditions of the system merely with the view of counteracting debility, the most opposite and disastrous effects must be produced. It is evident, then, that the mere presence of debility is no guide to the use of these agents. In all cases, the accompanying state of the organs and the cause of the debility must be taken into consideration. This shows the necessity of extreme caution in their use. All this will be strikingly illustrated in noticing some of the diseases in which stimulants are prescribed. 1. Fever. —There is no form of disease in which there has been a greater difference of opinion in relation to the use of stimulants than in fever. While by some they have been freely used, and even considered essential to the cure, by others they have been totally interdicted. That these opinions on both sides have been carried to an unwarrantable extreme cannot be questioned. The cause of this difference of opinion and practice is, that the treatment has been deduced in too many cases too rigidly from certain theoretical notions which have been entertained in relation to the nature of fever. Thus for example, by the Brunonians, fever was looked upon as a disease of debility, and accordingly stimulants were proper remedies. On the other hand, the Broussains, discarding altogether the idea of the existence of fever as an idiopathic disease, and looking upon it as always the result of local inflammation, considered antiphlogistic remedies as the only ones proper. A more enlightened observation has shown the fallacy of both these doctrines. Fever is not to be considered as a disease of pure debility, or as originating in local inflammation, and yet in the different forms and stages of it both these may be present. In its varied and protracted career, fever presents phenomena entirely different, and these require a corresponding difference in the treatment. In the early stages, where the prominent symptoms are —increased action of the heart and arteries, heat of skin, impaired secretion—stimulants are obviously improper; 409 STIMULANTS. bleeding, purging, and other antiphlogistics are essential, but in the progress of the disease, symptoms of sinking and collapse come on, and here the very free use of stimulants may be required to preserve life. This will not happen in every case, and generally speaking, patients do vastly better even in the last stages of fever without stimulants *, especially is this the case in the intermittent and remittent fevers which prevail throughout our country. In typhus the case is widely different, and stimulants are much more frequently required. In the last stage, where general torpor and collapse exist, the judicious use of stimulants is exceedingly beneficial, and from the great insensibility that prevails we are frequently warranted in giving them in very large quantities. Both the quantity given and the continuance of the remedy must depend on the effects which it produces ; it is, therefore, essential that the patient be carefully and intelligently watched. Where under the use of stimulants the pulse becomes slower and fuller, the skin uniformly warm and moist, the respiration more equable and slow, the tongue moist and clean, delirium abates and sleep follows : the stimulants are doing good. Where on the contrary the pulse is quickened, face flushed, heat augmented, thirst and restlessness produced, and delirium either comes on or is aggravated, the stimulants are failing of their proper effects, and should be stopped. Dr. Stokes says that the use of wine is indicated when in typhus the heart's impulse is diminished with feebleness or extinction of the first sound. This state of the heart's action is to be noted by the stethoscope, not by examination of the pulse. — Dublin Jour. 1839. As to the quantity of stimulant that may be required there can be no fixed rule ; the effect, and not the quantity, should guide us. The previous habits of the patient will afford some indication. The particular stimulant to be used must also depend on circumstances. Sometimes snake root and volatile alkali will suffice, then brandy in the form of grog, milk punch, &c. &c, must be given with a liberal hand. To control the effects of those poisons which operate by a purely sedative influence, stimulants may be used with very great freedom, and with excellent effect; e. g. Ammonia has, in this way, controlled the action of the poison from venomous snakes. Haemorrhages.—In no case are stimulants more obviously necessary, and very seldom do they so plainly show their curative powers, as in rousing patients from the prostration consequent on the loss of blood. The most striking illustration of this is in the Haemorrhages after parturition. Here the prostration is frequently so great as to require the administration of large quantities of the most potent stimulants to save life. In some cases, even after the haemorrhage has ceased, the patient will become pulseless ; faintness comes on, nausea and vomiting super- 27 410 MATERIA MEDICA AND THERAPEUTICS. vene, and almost everything is rejected. Even wine will be thrown off. In this state of things nothing but brandy, judiciously administered, will answer. Small doses of this mixed with water, and frequently repeated, will remain on the stomach, and support the sinking powers when everything else fails. The beneficial effect of it is to be judged of by its lessening the morbid frequency of the pulse. 3. Delirium Tremens. —This peculiar disease will be noticed when speaking of the effects of alcohol on the human system. With regard to the use of stimulants in it, there is much difference of opinion. By some they are supposed to be wholly unnecessary, while others consider them as essential. Everything here depends upon the precise character of the case. Where the patient is not broken down by long continued intemperance, and where there docs not appear to be any particular prostration of strength, I conceive stimulants to be not merely unnecessary, but injurious. Moderate purging, keeping the patient in a dark room, abstracting all irritants, in the way of company, &c, together with the judicious and moderate use of opiates, will almost always cure. In a large majority of cases, this treatment, variously modified to suit particular circumstances, will answer. At the same time cases may and do occur, where the general prostration is so great as absolutely to require some cordial or stimulant to support the sinking vitality, to preserve life from moment to moment. These cases, however, do not occur so often as is supposed ; and I am inclined to think that this complaint, as a general rule, can be managed with much less free recourse to stimulants than is commonly supposed. 4. Dyspepsia.—In the whole range of m'edicine there is, perhaps, no disorder which has given rise to such various and contradictory treatment as this. The reason is obvious, when we reflect upon the endless and variegated symptoms to which it gives rise. Among the agents most commonly resorted to are stimulants of various kinds. In no disease have they been more abused, and in none has their use led to more serious and melancholy consequences. The temptation to their use on the part of the patient is always great and present. Generally speaking, they give temporary energy to the stomach and to the system, and in this way induce the patient to believe that they are absolutely essential to the process of digestion. Thus habits fatal to life and character are contracted. Indeed instances of this kind occur so frequently that it is a question, not merely of professional but of moral interest, whether this class of remedies ought ever to be prescribed. Now it is very evident that a question of this kind can only be settled satisfactorily and correctly by understanding accurately the nature of the disease; otherwise everything that maybe said in relation to it amounts to little more 411 STIMULANTS. than idle declamation. It is out of my province to give you anything like a full account of this protean disease. I shall content myself with such general statements as will enable you to judge how far stimulants may or may not be useful and proper. Dyspepsia consists essentially in a debilitated and disordered state of the stomach. From the sympathy, however, existing between the stomach and the neighboring organs, such as the intestines, the liver, &c, the stomach cannot long be affected without involving these organs. Dyspepsia, too, may originate from different causes, from influences acting immediately on the stomach, such as excessive eating or drinking, or from diseases of some neighboring organ, as the bowels, the liver, and in five minutes he lay motionless and insensible, the respiration was laborious, and in one hour and fifteen minutes he was dead. In animals killed with this poison, the stomach is of a cherry red color. In the human subject, taking large quantities at once (as persons do who drink for a wager) coma comes on suddenly, the face is sometimes livid, more generally ghastly pale, the breathing is stertorous, the pupils sometimes contracted, more commonly dilated and insensible, and if relief be not offered speedily, death takes place sometimes almost immediately, at others after a few hours. It is not in this way, however, that alcohol is generally taken. It is used in smaller quantities and taken more gradually, and then it produces various striking effects. 1. The first of these is intoxication. This is an effect peculiar to alcohol. There are, it is true, other agents which produce a sort of inebriation, such as opium, stramonium, camphor, nitrous oxide, the inhalation of sulphuric ether, chloroform, etc., but this is different from that produced by alcohol, both in its general phenomena, as well as in its results. A paroxysm of intoxication may be divided into three stages. During the first the system is only pleasurably excited. The impression made imparts energy to the mind and vigor to the body. Care and anxiety are dispelled and a general serenity pervades the system. The imagination becomes unusually stimulated, and wit and eloquence frequently flow forth in spontaneous exuberance. Such being the first effects of this kind of excitement, it is not to be wondered at that it has been so universally coveted by mankind. Go where you will—traverse the globe from pole to pole—and you will not find a people so savage as not to possess some substance capable of yielding this pleasure. It is the solace of the dejected, imparts confidence to the timid, courage to 419 STIMULANTS. the coward. Could the effects of alcohol be limited here, we should not have so much to regret in relation to its use. Other effects now follow of a different character and constitute the second stage. In the first stage the brain, though powerfully stimulated, retains its controlling power, and the mental faculties, though highly exalted, are still under the command of reason. Not so now. The brain gradually loses its power, and a sense of giddiness is felt. The senses become perverted—the vision is disordered—objects change their color and become multiplied—volition is now impaired or lost, and all the faculties become irregular in their action. The drunkard imagines a thousand things which have no existence. He is continually mistaking one person for another —incessantly talking, while his speechbecomes thick and noisy. If he attempt now to use his muscles, he finds they have lost their power, and unable to support himself, he falls to the floor. This is the period which, in fashionable language, is called getting under the table. And now comes on the third stage, the third scene in this disgusting drama; if consciousness be still retained, everything is confusion and chaos —the blood circulates wildly through the brain —the head throbs and the heart beats violently—strange noises ring through the ears — the faculties, still imperfectly awake, are creative only of wild and monstrous images. Finally all this is overcome by sleep. Such, briefly detailed, are the phenomena attending a fit of intoxication, or rather of poisoning. Now it is very evident that it is not possible for the system to go through all this convulsive excitement without leaving its traces behind it. Accordingly when the patient awakes from his slumber he is in no very enviable condition. The secretions are all shut up—the tongue is furred and dry —there is excessive thirst —the skin hot and feverish—the mouth foul—the breath offensive—the nervous system in a state of perfect exhaustion—the eye has lost its fire —the head aches and is giddy —there is sickness at stomach and a degree of dejection and prostration proportioned to the preceding excitement. Nor is this all. A person who has been once intoxicated will probably become so again. Every succeeding fit will increase his desire for the accustomed stimulus, while it undermines and destroys the power of resistance. Every case of intoxication does not terminate in this way. Sometimes apoplexy and death are the results; then the drunkard's deep dreamless sleep " knows no waking." Another of the effects of the immoderate use of alcohol is the production of a peculiar disease, generally known by the name of delirium tremens. Other names are given to it, as mania a potu, mania tremulcntia, brain fever of drunkenness. When fully formed this affection consists of a certain degree of mental alienation, accompanied with a tremulous motion 420 MATERIA MEDICA AND THERAPEUTICS. of the hands and frequently other parts of the body. More commonly it occurs in persons who have been long accustomed to the intemperate use of liquor, and whose nervous systems, from that and other causes, have become greatly deranged. In some cases, however, it is brought on by a single fit of intoxication, and this I believe is more likely to happen when it has been the result of some mental trouble or affliction. The symptoms of this affection are, loss of appetite, oppression at stomach, followed by nausea and vomiting, tremor of the hands and mental aberration, the eye is wild and the whole manner furious and ungovernable, differing, however, very much in different subjects. They now become the prey of diseased sensation and disordered imagination. Generally speaking, fear and suspicion give the hue to all their fancies. In their incoherent wanderings they imagine themselves beset on all sides by knaves or enemies—their business has been ruined, their hopes are blasted, and even their persons are in constant danger. If the patient should fall into a sound sleep, all this will pass off, and he will be restored to the integrity of his faculties. In other cases sleep is unattainable, and then it runs on to a serious termination. The pulse becomes more rapid—the skin is cold and covered with clammy sweat—subsultus tendinum—coma or convulsions come on, and death closes the scene. It has been the general opinion that delirium tremens results from the sudden abandonment of liquor, after the immoderate use of it. Dr. Armstrong is of this opinion. On this subject Dr. Channing states an interesting fact. In the almshouse at Boston, where habitual drunkards were daily admitted, and at once deprived of liquor and kept on a low diet, not a single ease of delirium tremens occurred. (New Eng. Jour, v. viii. p. 28.) But intoxication and delirium tremens are not the only effects of the .abuse of alcohol. Various diseases are produced, functional and organic. That the stomach should be permanently deranged in its functions, from repeated and excessive stimulation, is not to be wondered at. From the law of the system already alluded to, that excitement is followed by collapse, it is a necessary consequence that the tone of the stomach must sooner or later be permanently impaired, the appetite is lost, and the powers of digestion enfeebled ; not merely, however, functional disorder, but actual organic disease takes place as a necessary result of the continued irritation and determination of blood kept up in the stomach. We have chronic inflammation of the stomach and scirrhus of the pylorus. Besides the stomach, other organs also suffer eventually from the poisonous influence of alcohol. Among these the most prominent is the liver. From the repeated congestion to which it is subjected, it eventually becomes fatty, or cirrhosed. Along with this comes ascites, and jaundice, from obstruction of the gall ducts. The kidneys, too, are affected with 421 STIMULANTS. a peculiar form of disease, -which is generally accompanied with albuminous urine. This is the granular kidney of Bright. Not merely the solids suffer, the fluids also become affected. That alcohol is absorbed into the circulation is well established, and that it pervades every part of the system is abundantly proved by the poisonous breath the confirmed drunkard. The mind eventually suffers, and permanent mental aberration takes place, showing itself, according to the temperament of the patient, in the ravings of furious mania, or in the stupidity of hypochondriasis. If you wish for information on this subject, you have only to analyse the records of our lunatic asylums, and you will find that a large proportion of the cases of insanity arise from this cause. TREATMENT OF THE EFFECTS OF EXCESSIVE USE OF ALCOHOL. Intoxication.—This, of course, resolves itself into two divisions, viz. the management of the fit of intoxication, and the cure of the habit. The first is comparatively easy, the second infinitely difficult. (a.) Of the Fit. —As a general rule, the best plan is to let the person sleep it out, and trust to the recuperative powers of nature. In some cases the symptoms are of such a nature as to make it desirable to break in upon the stupor under which the patient is laboring. In these cases the remedy first to be resorted to is vomiting. This is to be done with the double view of emptying the stomach, and of making the peculiar impression on the brain and nervous system which we know results from this process. To excite vomiting, copious draughts of warm water or salt and water, or chamomile tea, will answer every purpose. In other cases more powerful articles are required, and then ipecacuanha or the vitriolic emetics may be used. When the insensibility is so profound as to render the patient unable to swallow, the stomach pump may be used. Next to vomiting, the boivels should be unloaded, and the quietest and best mode of doing this, of course, is by means of a stimulating injection. The common enema with a couple of tablespoonfuls of salt will answer every purpose. Cold applications to the head are also exceedingly advantageous, and ought to be continued for a length of time. This may be done either by cloths dipped in cold water, or by pouring cold water on the head, as in cases of poisoning by opium. If a person is found drunk in the streets, a very good plan is to have him carried to the next pump, and have cold water poured on his head for about a quarter of an hour. Very generally this brings him to his senses. 422 MATERIA MEDICA AND THERAPEUTICS. [This, as I before stated, is a remedy of very great power, and must not be used carelessly. I have known one instance where, used by nonprofessional persons, it had nearly destroyed life. In old, broken-down drunkards it is full of peril; their system has so little power of resistance that, if the cold dash be carried far, reaction is impossible. Use this remedy, then, but use it carefully.—-Ed.] Immersion of the whole body in cold water frequently counteracts the insensibility produced by drunkenness. This happens very frequently at sea. Sailors in a state of intoxication very often fall overboard ; when taken up, they are generally sober. Buffon states that " among the savages in the isthmus of America the women throw their drunken husbands into the rivers, in order the more speedily to remove the effects of intoxication." With regard to the use of cold in this way, proper discretion must of course be exercised. If the person has already been long in the cold— if he is feeble, pulse small, &c, nothing can be more injurious than this treatment. To sustain the action of cold, and be benefited by it, requires a certain degree of constitutional vigor as well as animal heat. If proper reaction does not take place, it may prove fatal. When apoplectic symptoms are present, as they not unfrequently are, the propriety of bloodletting becomes a question. In the use of this remedy, however, I would advise you to be cautious. Cases may occur in which depletion may be very proper, but, generally speaking, its effects are injurious, and sometimes even fatal; at any rate, bleeding should not be resorted to unless there be present a good deal of constitutional vigor. It is the observation of experience, that persons under the influence of liquor do not sustain well the loss of blood. Acids have long been celebrated as possessing the power of counteracting the effects of drunkenness. Vinegar has, accordingly, been used in large quantities for this purpose with success. (See Macnish, p. 100.) (6.) The Care of the Habit. —This, I fear, is a task almost hopeless. It depends not upon the physician, but upon the patient himself. He can do it, if he possesses sufficient fortitude and decision; but unfortunately the habit of intemperance has already undermined so completely the moral energy, without which nothing can be done, as to render the case almost without a remedy. If moral energy sufficient be still left, the patient ought to be recommended to break off at once the use of ardent spirits. On this subject I am aware that a difference of opinion exists. By some it is supposed to be dangerous to break off immediately, and it is therefore recommended to be done gradually; and various devices have been suggested for doing this. This is not meeting the enemy fairly. It is compromising and sporting with him ; and lamentable experience, I believe, will prove that, in a majority of cases, such a course has proved abortive. In some cases however, it has proved successful; for example, the cele- STIMULANTS. 423 brated Dr. Pitcairn once cured a Highland chieftain who was a patient of his " by exacting a promise that he would every day drop a certain quantity of sealing-wax into his glass. He did so, and as the wax accumulated the capacity of the glass diminished, and consequently the quantity of whiskey it was capable of containing. By this plan he was cured of his bad habit altogether." (Macnish, p. 163.) Those who object to the immediate and total abandonment of ardent spirit, do it on the ground that the system may be brought into a state of dangerous collapse, and delirium tremens, &c, induced. This may certainly sometimes be the case, although it does not happen so frequently as is generally supposed. To obviate anything of this kind, a good plan (as recommended by Dr. Rush) is to substitute bitter vegetable infusion, beer, wine, and opium. He says, " by the temporary use of these substitutes for spirits, I have never known the transition to sober habits to be attended with any bad effects, but often with permanent health of body and peace of mind." The first thing then to be done is, to endeavor to operate upon the still remaining moral sensibility in such a way as may induce the person to make a great effort to break off the habit at once. The means by which this is to be brought about are obviously as different as the peculiarities of natural disposition in different individuals—as their modes of living—occupation—various relations in life, &c, &c. No general rule can be laid down for the physician, except to gain by every means in his power the respect and confidence of the patient, so far as to induce him to listen to his representations. When this is gained, he may sometimes address the reason, or the passions, or the fears, in such way as to produce a salutary influence. The first mode, then, of attempting to cure the habit of drunkenness is addressed to the mind exclusively. The second is addressed to the body, and the principle upon which it is conducted is to associate with liquor something so unpleasant to the taste, smell, or its general operation on the system, as to give the person a disgust to it. This is the general principle on which all the nostrums for this purpose have been made. In many cases they have succeeded admirably. Dr. Rush says he once cured a negro of his fondness for liquor by putting a few grains of tartar emetic in his rum. He was so sickened by it that he thought he was poisoned. For two years afterwards he could not bear either the smell or the sight of rum. Generally speaking, the cure in this way is only temporary, unless aided by moral restraints. They are, however, exceedingly beneficial as giving time for reflection, &c. 2. Treatment of Delirium Tremens. —On this subject I can only make a few remaks. Although various opinions are entertained in relation to the remedies proper in this curious affection, there can be no general difference in regard to the general principles upon which 424 MATERIA MEDICA AND THERAPEUTICS. the management of it ought to be conducted. In this disease there are two leading conditions of the system which require to be attended to. The digestive organs are generally more or less deranged, and the brain and nervous system in a state of irritation. Our remedies, therefore, ought to be directed mainly to the correction of these two conditions. With respect to the first, as a general rule, the best remedies that can be resorted to are purgatives, and of these the best are a mixture of rhubarb, magnesia, and mint water. By the judicious use of these, you unload the bowels, promote secretion from the liver and intestinal canal, determine from the brain, and in all these ways quiet nervous irritation, besides preparing the system for the subsequent use of other remedies. This, then, is the first thing to be done, and the extent to which it must be carried is to be regulated by the period of the disease and the peculiar symptoms attending it. As a general rule, purging as well as all other evacuating remedies should be limited to the earlier periods of the disease. Another class of remedies that has been highly recommended for the accomplishing the same object is emetics. These were, as before stated, first advised by Dr. Klapp of Philadelphia, in the year 1817, and since then have been approved by many distinguished physicians. The objects to be attained by them are to unload the stomach, to act on the liver and change the secretions from that organ, and by the general shock given to the system to produce a salutary impression on. the brain and nervous system generally. If, therefore, the stomach and liver be much deranged, emetics may be valuable remedies. Great care, however, should be taken in the selection of the article used. Tartar emetic is too powerful a sedative, and in many cases has caused fatal prostration. If it be used at all, two things should be attended to: 1. That the patient's strength be not too greatly impaired to bear so active an article. 2. It ought only to be used in the early stage of the disease. Having in this way corrected the condition of the digestive organs, the next thing to be done is to quiet nervous irritation and produce sleep. This is effected in two ways: 1. By the abstraction of all kinds of stimulants, and letting the patient wear himself out until he falls asleep. Thus, by keeping a patient in a dark room, so arranged that he cannot injure himself, and leaving him entirely alone, he will frequently, after a while, become exhausted and fall asleep. When sleep is attained the fit passes off and the patient recovers. 2. Opiates. —On this subject there is a difference of practice, some giving them in very large doses and repeating till sleep is produced. Others take a moderate course, using opiates occasionally and in smaller doses. As to the merits of these two plans: STIMULANTS. 425 1st. If the former succeed, if sleep, deep and continued, result, the cure is nearly certain, but, 2d. If it fail, the patient is certain to be injured, and very probably may be killed outright. Use it therefore, if at all, with care. [I have used chloroform with most admirable results in this disease; calm, quiet, and protracted sleep followed its administration, and the patient was entirely rational on waking.—Ed.] Many persons have been led into the use of liquor from the idea that it has a good effect on the mental faculties; and this notion has been sustained by the fact that some men never can make any great mental effort without the aid of artificial stimulation. In this way I fear many a noble spirit has been wrecked, habits of intemperance having been gradually acquired under the pleasurable excitement of moderate stimulation ending in the total prostration of mind and body. Now, with regard to this idea of stimulating the mental faculties, let me lay down a few common-sense precautions. First with regard to the imagination: If any man takes liquor to stimulate his imagination, let him first be sure that he has an imagination to stimulate. This imagination is a rare gift, vouchsafed by God to only a few of his creatures. If a man has no imagination he may stimulate till he is tired, without finding corresponding results. He might as well try to draw water from the flinty rock, or strike fire from a potatoe. Remember the old philosophical axiom, ex nihilo nihil Jit. Even if a man is satisfied he has an imagination he should recollect that liquor only stimulates it to a certain extent; beyond this it only makes the man ridiculous ; for the imagination, sublime and soaring as it is, requires to be well balanced. Recollect, if alcohol stimulates the imagination, it impairs the judgment and clouds the reasoning faculties. Now, it is not imagination, but judgment and reason, which is required in the grave business of life. In the practice of our own profession, especially, we want no flights of fancy: we want sound judgment and plain common sense ; we do not want a man in the clouds, we want him on terra firma, and therefore physicians, above all others, should be careful how they go ballooning it in the air. Rely on it their patients will not follow them. Alcohol can only stimulate the faculties, it cannot create them; it must stimulate a man's faculties such as they are. If he has mind it may develope that, to be sure ; but if he is naturally stupid, it will be just as sure to develope his stupidity. It can do nothing more. There is an old maxim, in vino Veritas, which is generally translated to mean, that under the influence of wine a man speaks the truth; but it means a great deal more. Its true meaning is, that under the influence of wine a man's true character is developed. That is the maxim. Wine acts like nitrous oxide gas. Hence it is that when a knave wants to 28 426 MATERIA MEDICA AND THERAPEUTICS. take advantage of another man and find out his true character, he tries to get him under the influence of liquor. Let a man, therefore, beware how he suffers himself to be duped in this way. The truth is, gentlemen, the less a man in health has to do with alcohol the better. To the young this is peculiarly applicable. Their blood courses rapidly enough in their veins already without any stimulation. In the ordinary business of life the great thing is to keep cool and collected, and when great enterprises are to be undertaken let the enterprise —let the occasion be the stimulus. Do you think Napoleon or Wellington needed any other stimulus than the great stake for which they were contending at the battle of Waterloo ? Look even at the picture, disgraceful in some respects, but instructive in others, presented by the recent pugilistic combat in our country. Read the account of the training which Tom Hyer and Yankee Sullivan underwent, and see if liquor was one of the aids to which they resorted ? I make these remarks, gentlemen, not so much for yourselves, but for the sake of the patients. Judicious advice, cautiously given, has saved many a man from ruin. Aqua Ammonia. —Aqua ammonia is water holding in solution ammoniacal gas. Water is capable of holding a third of its weight of gas, or 430 times its volume, and increases in bulk about two-thirds. The aqua ammonia of the shops, however, does not contain this proportion, but varies according to the mode of preparation. Properties. —Aqua ammonia is a colorless liquid, with a caustic alkaline taste, and a pungent odor. Turmeric paper when held over its fumes is turned to reddish brown. It is lighter than water, and its strength varies with its specific gravity. It readily attracts carbonic acid from the atmosphere if not kept in tight bottles. It unites with oils, and forms liquid soaps or liniments. Sp. gr. varies from 880 (aq. ammon. fortiss.) to 960. Effects. —In its local action aqua ammonia is irritant, whatever be the part to which it is applied, the degree of irritation varying with the strength. When applied to the skin, if of any strength, it causes redness, heat, pain, and eventually actual vesication. If held under the nostrils, its fumes produce irritation of the mucous membrane of the eye, of the nostrils, and if inhaled a similar effect is produced upon the air passages. Taken into the stomach in small quantities, it produces a slight sense of warmth in the mouth, throat, and epigastric region. In large quantities, it acts as an irritant poison. In its remote action it produces the effects of a stimulant; the pulse is rendered fuller and more frequent; the muscular and nervous power of the system is augmented ; the heat of the surface is increased, while a tendency to perspiration is induced. From this combination of properties, it is an article of great value, 427 STIMULANTS. and may be used with advantage in many cases where a prompt and efficient stimulant is required. From the tendency which it has to act on the skin, it may, as well as the carbonate, be used frequently in febrile affections at a much earlier period than many other stimulants. Mode of Administration. —From five to ten drops may be given in a cup of cold water or milk, and repeated every two or three hours, or oftener, as it is very evanescent in its operation. Ammonia has been given, and in a few cases with success, to cure the bite of venomous snakes. Carbonate of Ammonia. —This salt is prepared by triturating muriate of ammonia and carbonate of lime together, and then subliming from a retort into a cold receiver. Properties. —When recently prepared it is in colorless, translucent masses, about two inches thick, moderately hard, and of a striated and crystalline appearance. Its smell is pungent, and its taste sharp and penetrating. " Turmeric paper when held over it is turned of a reddish-brown color by the ammonia, which escapes." It is soluble in four times its *vcight of cold water. By boiling water or alcohol it is decomposed with effervescence. When exposed to the atmosphere it gradually loses its smell, becomes opaque and friable, and is converted into the bicarbonate. Effects on the System. —Carbonate of ammonia is a local as well as a general excitant. Smelling and inhaling its vapor cause irritation of the mucous membrane of the nose, larynx, and trachea. When swallowed in moderate closes, it produces no obvious local effects; in larger doses it proves emetic, and in still larger doses it causes irritation, pain, and sometimes actual inflammation in the stomach. In its remote action on the system it increases the force and frequency of the pulse, and operates on the skin as a diaphoretic. [It is the stimulant for extreme prostration after uterine hemorrhage ; of the many valuable practical hints for which I am indebted to my old master, the late Dr. Joseph Parrish of Philadelphia, no one has been of more value to me than his emphatic, " Pour down the volatile alkali as fast as she can swallow it," in a case of tremendous uterine hemorrhage. " Peace to the good man's memory ; let it grow Greener with years, and flourish in the lapse of ages."—Ed.] Mode, of Administration. —The best forms of giving this article are in pill or in solution. From its volatile nature it should never be given in powder. The pill may be made with some vegetable extract, and should be kept in a tight bottle. [The dose is from five to ten grains every two or three hours. The Volatile julep —carb. ammonia 3 ij pulv. gum. Ara- 428 MATERIA MEDICA AND THERAPEUTICS. bic. 3 ij—sacch. alb. 3 ij, water six ounces, is the form I use. The dose is a tablespoonful.] As an emetic it is used sometimes in paralysis —dose grs. xxx. Camphor.—This is a substance found in a great number of vegetables, such as peppermint, sage, thyme, «fec, from which it is obtained by distillation. The camphor of medicine, however, is obtained from the Camphora officinarum, a large tree,* which is a native of China and Japan. The camphor is obtained from the leaves and twigs, Avhich are first steeped and boiled in water, from which it is sublimed. In this state it is the coarse camphor imported into Europe, where it is afterwards purified by resublimation. Another kind of camphor is obtained from the Dryabalanops Camphora, a tree of great size growing in the forests of Sumatra. In this tree the camphor exists in concrete masses of considerable size in the trunk of the tree, from which it is obtained by splitting it. By the Chinese this is considered as superior to the other, but it is not exported to Europe. Camphor was unknown to the Greek and Roman physicians, and Ave are indebted for our first knowledge of it to the Arabians. With the Chinese physicians it is a very favorite remedy. Camphor is a concrete substance, of a Avhite color, semi-transparent, and capable of assuming a crystalline form ; it is tenacious and somewhat unctuous to the touch ; though brittle it is somewhat ductile, and therefore not easily pulverised ; smell penetrating and fragrant; taste bitter and pungent; specific gravity 0.9887. It is very volatile, and in warm weather evaporates very rapidly by simple exposure to the air. It is highly inflammable; burns with a brilliant flame and much smoke, but does not blacken, and leaves no residue. In water very sparingly soluble, an ounce dissolving not more than half a grain. It imparts, however, both its odor and taste to water, and may be suspended in it in large quantity, by means of mucilage, sugar, or yolk of eggs. In alcohol, ether, and the oils, both essential and expressed, it is soluble. Sulphuric and nitric acids dissolve it, but it is again separated by the addition of water. Its most powerful solvent is strong acetic acid. The alkalies have no effect upon it. With the hardest resinous substances it unites, and converts them into a soft tenacious mass. By distillation with nitric acid it forms camphoric acid. It is composed of 1 eq. camphagin (C. 20 H. 14) and two of water. When given in moderate doses, the first effect is to produce slight exhilaration, and to increase someAA'hat the heat and strength ; after this it quiets irritation, allays spasm, and causes a tendency to sleep. When * Mr. Abeel saw a tree twenty feet in circumference, fifty feet high, and having branches nine feet in circumference. STIMULANTS. 429 given in large doses it causes great anxiety —vertigo, tremors, coldness of skin, convulsions, and death. From its effects on the nervous system, it has been used by some as an habitual stimulant like alcohol or opium. A case is related of a female who, from " the casual application of camphor as a remedy for toothache, contracted a fondness for it so fascinating and irresistible that she at length consumed it in large quantities, and could not be induced to relinquish it by all the remonstrances of her friends, or her own conviction of its pernicious consequences." [I have known a similar case. —Ed.] Camphor is a special stimulant of the genito-urinary apparatus; in moderate doses augmenting the energy of these functions, causing voluptuous dreams, erections, &c, also ardor urinae. Gouch thought it especially useful in controlling uterine irritation, dysmenorrhoea, irritable uterus, of iodine, and one eq. of arsenic. (Pereira.) Mode of Administration. —Internally it has been used by Dr. Thomson of London, with success in cases of lepra and impetigo. He began with j\ of a gr., three times a day, increased to £ of a gr. Beyond this, its use is dangerous. Ointment. —Iodide of arsenicum, grs. iij ; lard, § j. Used by Biett in phagedenic tubercular disease of the skin. V. Iodide of Lead.—This is a powder of a beautiful yellow color,, partially soluble in acetic acid and in alcohol. In cold water it is insoluble, but perfectly so in boiling water, from which it separates as the solution cools in fine brilliant scales. It consists of one eq. of iodine and one eq. of lead. It is prepared by the reciprocal actions of solutions of iodide of potassium and acetate of lead. Iodide of lead is precipitated and acetate of potash in solution. The precipitate to be washed and dried. Perfect solubility in boiling water is the test of it* purity. 526 MATERIA MEDICA AND THERAPEUTICS. Effects. —In its local action on the skin iodide of lead does not appear to be irritant; internally it is mild, though in some cases it has produced irritation of the stomach and constipation. Its general action is alterative, like iodine. It is used internally and externally in cases of glandular enlargement. Less active than iodine. Mode of Administration. —One-fourth to half a grain twice a day, gradually increased. Ten grains may be given without inconvenience. (O'Shaugnessy in Lugol.) Ointment. —- 3 j to § j of lead. 8. Iodide of Sulphur.—This is a compound of a massy appearance, of a dark color, and a lamellated structure. It is prepared by heating gently four parts of sulphur with one of iodine. Part of the iodine volatilizes, while the remainder unites with the sulphur. (Pereira.) It has the peculiar smell of iodine, and stains the skin as it does. If it be boiled in water the iodine volatilizes with the steam, and the sulphur is deposited nearly pure. It consists of one eq. of iodine, and one eq. of sulphur. Mode of Administration. —Not used internally, only as an external application in the proportion of about 3 j to § j of lard. 9. Iodide of Zinc. —This is a white crystalline salt in needles, very deliquescent, and very soluble in water. It has a disagreeable and styptic taste. It is prepared by the joint action of solutions of sulphate of zinc and iodide of baryta, filtering and evaporating to dryness, or by subjecting to heat and subliming twenty parts of zinc with 170 iodine. I am not aware that this has been used internally. It is recommended as an external application for discussing tumors by Dr. Pre, who proposes it as a substitute for the ointment of the iodide of potassium : Ointment Iod. — 3 j to 3 j lard ; a drachm of this to be rubbed on the tumor twice a day. 10. Iodide of Gold. —Of a greenish-yellow color, insoluble in cold, but slightly so in boiling water. Heated in a crucible, iodine vapors are given off, and metallic gold is left. It has been used internally in venereal affections in doses of from to r ' 7 of a grain. (Pereira.) Effects and Uses of Iodine. —When taken in small and repeated doses, iodine operates like the other agents belonging to this class of alteratives. It alleviates certain diseased conditions without producing any sensible effect on the system. In this way it may be taken for weeks and even months. During this time the functions of the digestive organs are generally improved, and the appetite is frequently 527 ALTERATIVES. greatly increased. Lugol states that at the Hospital of St. Louis, where this remedy was extensively used, this effect was so decided that the ordinary hospital allowance was not sufficient to satisfy the patients. In many cases this is the only effect produced. In other cases, from its general operation on the secreting and absorbing system, its effects are more visible. Sometimes it proves powerfully diuretic, while in others this is not observed, and sometimes it acts as emmenagogue, while at others, again, it produces no effect on the uterine organs. On the glandular system effects of a peculiar and striking character have occasionally been noticed. These are a diminution and wasting of the mammoB in females, and of the testicles in males. Occasionally salivation is produced by it. On the adipose tissue its effect varies; sometimes it occasions emaciation, while in others a contrary effect is produced. According to Lugol it always increases the growth and size of the body. There can be no question that iodine acts on the whole system of capillary vessels, exciting, under different conditions of the system, sometimes one organ and sometimes another. If the use of iodine be persisted in too long, it affects the system like a poison. In some cases the stomach and bowels become disordered, there is vomiting and purging accompanied with general excitement and disturbance of the system. In other cases the nervous system is assailed by tremors; general prostration, loss of appetite, and emaciation are the prominent symptoms. diseases in which iodine has been used. 1. Bronchocele.—This was the disease in which iodine was first used, and it is to Dr. Coindet, of Geneva, that we are indebted for its first introduction into practice. It was originally suggested to this physician by his reflecting on the fact that iodine had been discovered in the sponge, an article which in the form of burnt sponge had long held a high reputation among the vulgar as well as among physicians, as a cure for bronchocele, and from this circumstance he was induced to suspect that the virtues of the sponge depended upon the presence of iodine.* Living in a district of country where this disease prevails extensively, he had immediate opportunities of putting his suggestions to the test of actual experiment, and was speedily gratified by obtaining the most decisive proofs of its efficacy. Immediately on the annunciation of the beneficial effects of iodine in this disease, experiments were made with it by practitioners in various parts of Europe, all of whom concurred in celebrating its virtues. In this country it was tried, and * Memoir de M. Coindet in Bayle's His. vol. i. p. 6. 528 MATERIA MEDICA AND THERAPEUTICS. with equal success. From the extensive experience which we have thus had of this remedy, we are now able to form an impartial opinion in relation to its real virtues. Although not a specific in this disease, as it was first supposed, yet it exercises a wonderful control over it, and such as no other medicine is capable of. Bayle has made a summary of the cases treated by a number of physicians, and as the result he states that of 354—there were 264 cases of goitre cured.* 2. Scrofula. —This is another disease in which this remedy has been peculiarly successful, and it is to Dr. Coindet that we are also indebted for suggesting its use here.f It has been used by different physicians, but by none so extensively or successfully as Lugol of Paris. It appears that during seventeen months, 109 scrofulous patients were treated with iodine alone, at the Hospital St. Louis, of which 61 were males and 48 females. Of these, 39 (29 males, 10 females) were still under treatment at the time of the report; that 30 (17 males, 13 females) had left the Hospital much improved ; that in four cases (2 males and 2 females) the treatment was ineffectual; and that 36 (13 males and 23 females) were completely cured.J By Lugol the iodine is used both internally and externally, and, what is new in his practice, in the form of baths, to which he attaches the greatest efficacy. 3. Chronic Enlargements of the Viscera.—In enlargements of the liver, spleen, mamma?, testicles, and ovaria, iodine has been used with great advantage. 4. Dropsies.—In some cases of ascites, I have used iodine with the happiest effects. By Dr. Thomson three cases of ovarian dropsy are stated to have been cured by the internal and external use of this agent.§ 5. As an emmenagogue, iodine is particularly spoken of by Coindet and others. In several cases, I have witnessed its effects on the uterine organs. Magendie states that he gave it in a case represented to be one of suppressed menstruation, and in three weeks abortion was the result.|| 6. Nervous Diseases. —In eleven cases of chorea it was used by Dr. Munson with success. By the same physician it was also used with advantage in cases of paralysis, arising from tumors or fluids pressing on the brain or spinal marrow, or from morbid thickening of the investing membrane of the cord itself. * Therapeutique, vol.' i. p. 194. f Ibid., p. 25. % Lugol on Iodine. Translated by O'Shaugnessy, p. 8. § Mat. Med. vol. i., p. 346. || Bayle, pp. 10, 195. ALTERATIVES. 529 7". Diseases op the Skin.—Where, as is very common, diseases of the skin are connected with, if not dependent on, scrofula, iodine may be used with the greatest advantage. Chronic cases, of eczema in particular, yield to it promptly. 8. Lastly. In syphilitic diseases it has recently been used, and with apparent advantage ; also to arrest salivation. Gold. —This metal is found in almost every part of the world, and only in the metallic state, either alone or alloyed with other metals. It is of an orange yellow color, and exceeds all other metals in malleability and ductility. Exposure to air and moisture for any length of time produces no change in it. It is not oxydized or dissolved by any of the pure acids. Its only solvents are chlorine and nitro-muriatic acid. According to Sir II. Davy, the agent in both cases is the chlorine. Physiological Effects. —When taken in small and con tinned doses, this article operates like most of those belonging to this class. It gently stimulates the digestive organs and improves the appetite, at the same time that it moderately excites the pulse. The only marked and sensible effect, however, which is produced, is that of increasing perspiration and the flow of urine. The latter it does uniformly and to a very decided extent.* If it be given in larger quantities, it produces a general febrile excitement of the system, accompanied with an universal heat of the skin. The bowels are generally constipated. In some cases there is dryness of the mouth and throat. The gums become affected, and salivation ensues. According to M. Niel, the salivation produced by gold differs from that of mercury in many important respects. It is always mild—never producing the severe irritation and inflammation of the gums and mouth which so frequently accompany mercurial salivation. It is less protracted in its duration, and is unattended by the disgusting foetor of mercurial salivation. preparations of gold. 1. In the state of Metal.—By Chrestien and others it has been used, and is said to produce the same effects as the salts of gold. This is supposed to be the mildest of the preparations of gold, but equally efficacious, though more slow in producing its effects. It is given in doses of from a quarter to one grain three or four times a day in pill or powder. 2. Chloride of Gold. —This is prepared by dissolving by the aid of * Niel, p. 59. Delafield Med. Rep. v. ix, p. 182. 530 MATERIA MEDICA AND THERAPEUTICS. heat, one part of gold in three parts of nitro-hydrochloric acid.* The solution is to be evaporated until vapors of chlorine begin to be perceived, and then suffered to crystallize. This salt is in small crystalline needles, of an orange red color, without smell, and of a strong, styptic, acid taste. It is readily soluble in water, alcohol and ether. It consists of 1 eq. of gold and 3 eq. of chlorine. It is, therefore, a terchloride of gold. Effects. —This is a very active preparation, resembling somewhat corrosive sublimate. It requires, therefore, to be given in small quantities and with caution. Dose. —One twentieth to one eighth of a grain once or twice a day, made up into pills with starch, or in solution with distilled water. 3. Chloride of Gold and Sodium.—This is prepared by dissolving eighty-five parts of chloride of gold to sixteen of chloride of sodium in distilled water. The solution is to be evaporated by a gentle heat until a pellicle forms, and then set by to crystallize. —(Pereira.) It consists of large quadrangular prisms, of a beautiful yellow color. They are soluble in water, and consist of 1 eq. of chloride of gold, and 1 of chloride of sodium, and 4 of water. This is a milder preparation of gold than the preceding. It is, also, less expensive, and is, therefore, the most used of any of the preparations of this metal. It is given in the same doses as the chloride. 4. Oxide of Gold.—" This is prepared by boiling four parts of calcined magnesia with one part of chloride of gold and forty parts of water. Then wash, first with water, to remove the chloride of magnesium, afterwards with dilute nitric acid, to dissolve the excess of magnesia."— (Pereira.) The oxide of gold is of a brown color, in the form of hydrate, reddish yellow, insoluble in water, but soluble in hydrochloric acid. It consists of 3 eq. oxygen and 1 eq. of gold. It is, therefore, a teroxide of gold. It is given in pills in closes of one tenth of a grain to one grain a day. With regard to the use of the salts of gold, there are certain objections to their internal use. In the first place they are very active, and sometimes cause a good deal of local irritation in the stomach. In the second place, they are very readily decomposed by a great variety of substances, and thus lose their activity. * Aqua Jtegia, —One part of nitric and two of hydrochloric acid. 531 ALTERATIVES. DISEASES IN WHICH GOLD IS USED. 1. Syphilis.—This is the disease in which gold was specially recommended by Dr. Chrestien, as a substitute for mercury. This interesting fact was announced in a work which appeared in the year 1811,* in which a number of cases are reported in which it proved successful. According to the representations contained in this work, it would appear that gold is capable of curing syphilis under all its forms, and that in its general operation on the system it possesses many advantages over mercury. It is efficacious, yet gentle. It may be administered with perfect safety at any season of the year, and under any complication of the disease. Persons of either sex may be put upon it with equal safety. The only precaution which he enjoins during its use, is the observance of strict temperance. In other respects, the patient is not required to change his accustomed mode of living. Very shortly after the appearance of this work our distinguished countryman, Dr. Samuel L. Mitchill, made the medical public in this country acquainted with its contents, and immediately commenced a series of experiments with gold in the New York Hospital. The result of his experience is contained in the following letter to the late Dr. Dyckman : " The efficacy of the medicine has been tried year after year in the New York Hospital. My practice with it there has been witnessed by all the attendants of the wards. It possesses admirable virtues against syphilis. Without presuming to affirm that it is capable of eradicating the distemper in every instance, my opinion, upon the whole, is that the muriate of gold will effect all that is achieved by the muriate of quicksilver, with incomparably less inconvenience to the patient. He gets well under the operation of the former without the hazard of a sore mouth or a salivation, and with very little wear and tear of constitution. I consider the introduction of this preparation into common use as one of the greatest improvements in modern medicine; and I wish it was already as universal as the malady it is intended to remove. The muriate of gold is found to increase the quantity of urine, in many instances to such a degree that it ought to be ranked among the diuretics of the materia medica."f In 1812, Dr. J. C. Cheesman, of this city, published an inaugural dissertation, in which are detailed a number of cases of primary syphilis which had been successfully treated by this remedy in the New York In 1816 its use was again revived in that institution, and in 181V a report was published by Drs. J. K. * De la Methode Iatraleptique, etc., par J. A. Chrestien, Paris, 1811. \ Duncan's Edinburgh Dispensatory, edited by Dyckman. \ New York Med. Rep., vol. xix. p. 180. 532 MATERIA MEDICA AND THERAPEUTICS. Rodgers and Delafield, containing an account of 81 cases of syphilis successfully treated by the same remedy. The results of all this experience at the New York Hospital seem to be then: 1. That in the treatment of primary syphilis, the muriate of gold possesses powers fully equal to those of mercury. 2. In cases cured by gold, secondary symptoms did not supervene more frequently than in cases which have been cured by mercury. 3. In secondary syphilis, gold is not to be depended upon for a radical cure. Never having used the gold myself, I can add nothing from my own experience in relation to it. Although not used much at present, there are still physicians in our city who are in the habit of using it, and Who rely upon it with great confidence. 2. Scrofulous Affections. —Several cases of this kind are recorded by Chrestien as having been cured by the use of gold.* Similar cases have also been reported by Niel. 3. Goitre. —By both Chrestien and Niel cases of this disease are stated to have yielded under the use of this remedy. 4. Dropsy.—From the decided effects of gold in promoting the flow of urine, it has been used in this form of disease, and in some cases it has proved successful. The late Dr. J. Low of Albany relates that he tried it in a well marked case of ascites, and that it " was attended by the best effects." [Oleum Jecoris Aselli (Cod Liver Oil). —This oil, which has of late years gained so much celebrity, is obtained from the livers of various species of the genus Gadits, especially the G. Morrhua, G. Callarias, G. Molva, G. Carbonarius. It is, however, probable that much of the oil of commerce is obtained from other species, or indeed from species of other genera, especially the Raia. Three species of oil are spoken of ? the brown, the light brown, and the pale or yellow. These varieties do not depend upon the species of cod used, but upon the manner in which the oil is obtained. If the livers are, as is often done, thrown into a tub with a perforated bottom, and the oil which runs spontaneously from them promptly collected and skimmed or strained, it is pale; if this is allowed to remain on the livers till they become putrid, or the oil is kept in a wet place, if due care is not taken in its preparation or preservation, it takes a darker hue, and then we have the light brown oil. When, after the pale oil has run off, the livers are boiled in iron pots for * Methode Iatraleptique. 533 ALTERATIVES. from twelve to twenty hours, an oil is obtained of a dark color, rank unpleasant smell, and nauseous taste; this is the brown oil. Physical Properties of Pale Oil. —Fluid at ordinary temperatures, of a bright yellow or golden color ; fishy taste, more or* less strong, and a smell resembling in the very pale qualities that of freshly-boiled cod, but stronger. Between this and the dark brown oil there is every shade of difference in color, and every degree of rank fishiness in the taste and smell. The pale oils have generally the consistence of olive oil, and are clear; the browner are thicker and more or less turbid. There is a very great difference of opinion as to the relative merits of the varieties of oil. The Germans, who of late years have used the oil most freely, prefer the darker kinds ; in England and in this country, the paler are preferred ; and it is confidently asserted that the oil can be deprived of its most offensive properties of smell and taste, and yet retain its remedial powers. Chemical Analysis. —Cod liver oil is composed of margaric and oleic acids, biliary matter, iodine, phosphorus, butyric and acetic acid, a peculiar substance discovered by De Jough, and by him called Gaduine, with several organic salts and acids in small proportion. These ingredients exist in the varieties of oil in varying proportions. The pale oils contain most iodine and inorganic salts, while the darker sorts have most biliary matter, butyric, and acetic acid. Effects on the System. —Cod liver oil does not produce marked sensible effects with any constancy. Sometimes it offends the stomach, causing nausea or even vomiting. In some rather rare cases, it purges; in a few cases it has increased the flow of urine, or the perspiration, but generally it affects none of the secretions. No effect can be expected from it, as a general rule, unless its use be continued for a considerable time; say on an average three to four months. Use in Disease. —The use of cod liver oil, though now a fashion, is by no means a strictly new thing. The oil was used nearly a century ago by Percival and Bardsley, in England ; and in Germany it has been a popular remedy from time immemorial. The attention of the profession was again directed to it about thirty years ago, by several German physicians, who published in rapid succession histories of cures effected l>y cod liver oil in rheumatism, gout, scrofula in all its varieties, and finally in phthisis pulmonalis. From Germany the practice passed into France and England, and has been adopted in both countries. In England the oil has been highly appreciated by Dr. J. Hughes Bennet, and most extravagantly lauded by Dr. Williams. But amid all the laudation and enthusiasm which the new remedy has excited, not a few have declared it of little value, and a still greater number have confessed that enlarged experience has very much moderated their expectations of 534 MATERIA MEDICA AND THERAPEUTICS. benefit from it. The disease in which it was first used by Schenk, in Germany, was rheumatism. He reported a large number of cases of chronic inflammatory rheumatism, in which its use produced the best effects. Subsequent observations have, to a certain extent, confirmed the views of Schenk. The forms of rheumatism in which it was first likely to do good are those in broken-down habits, those depending on imperfect digestion, and those occurring in scrofulous subjects; and where in old people the tendons and muscles are rigid, the joints stiff, &c. Gout. —In this disease the oil has been given a good deal, but not with the same amount of success as in rheumatism. Scrofula. — The Scrofulous Diathesis. —Here it is that cod liver oil has gained most of its reputation, and by many it is still considered almost a specific. Now that the steady and pretty long-continued use of the remedy has, in very many cases, produced the most admirable effects, cannot be doubted, and it seems to do this chiefly by its influence in correcting various derangements of secondary assimilation. Whether this change is effected by supplying to the digestive organs a material with which they can repair the various results of defective nutrition, or whether it is by giving to the digestive function power to perfect the assimilation of food taken, is by no means easy to say. Be this as it may, in very many of these cases, whether of caries, of scrofulous ophthalmia, of tabes mesenterica, or tubercular peritonitis, or of various diseases of the skin, connected more or less closely with scrofula, as eczema, herpes, and some forms of impetigo, it has produced excellent effects. Under its use the constitution in general seems to gain vigor, the complexion is clearer, the eye more lively, the mind cheerful, the strength improved, and a remarkable tendency to the deposit of fat shows itself. While the change in the natural functions is going on, as manifested by the general improvement in the aspect of the patient, the disease frequently gives way; chronic ulcerations heal, enlarged glands diminish in size, chronic eruptions disappear, the scrofulous ophthalmia is relieved. Phthisis Pulmonalis. —In this disease the oil has been used, and by some of its vehement admirers it is said to be equally beneficial in every stage. This is not, however, the common opinion ; generally the best effects were found to follow its use in the early stage, where the tubercles had not yet begun to soften, or where the process had but begun. Here the use of the oil has in very many cases been followed pretty promptly by diminution of the expectoration, disappearance of the night sweats, and by very marked increase in size, not occasioned by the mere deposition of the fat, but also by an augmentation of the size of the muscles, and a proportionate augmentation of the muscular power. In some cases this improvement has been persistent, and the proportion of such cases, where the disease was in its early stage, has been large. In ALTERATIVES. 535 phthisis, with softening, after the formation of cavities, though the relief for a time has been very decided, the night sweats ceasing, the cough becoming freer, and the expectoration less profuse, in some cases, too flesh and strength being regained in a most remarkable degree, yet this apparent cure has only amounted to an arrest of the disease for a time. In a few months the symptoms return, and the fatal event, though postponed, is not prevented. Such and so great are the advantages which some of the most eminent men among our contemporaries think they have observed from the use of this agent in that most dreadful of all diseases, phthisis pulmonalis. Is there, then, hope that this terrible scourge is to be at last subdued ? Will it finally acknowledge the curative power of this medicine ? We may hope, but cannot yet confidently believe. In the meantime, what is our duty to our patients and our profession ? Try this remedy fairly, but carefully. Let us ascertain, if possible, what are the circumstances under which it is most likely to do good; what are the cases most likely to be benefited by it; what are the states of system which contraindicate its uses; what cases are likely to be injured by it. These most important questions are all yet to be settled. On no one of them is our present knowledge at all what it must be before cod liver oil can be given in any other way than empirically. It is generally supposed that a state of plethora, of active irritation, of general or local inflammation, or of great nervous irritability, contraindicate the use of this oil. On the other hand, it is believed most likely to succeed in those patients who are of sluggish, apathetic habit of body, and those most deeply and most fully tainted with scrofula. Modes of Administration. —Although many modes of covering and disguising the smell and taste of this nauseous oil have been proposed, yet none have availed anything. It can best be taken either alone or floating on some aromatic water. The dose at first should be small, say a teaspoonful thrice a day; never to be taken on an empty stomach, which it is almost sure to offend, but usually about one or two hours after meals. As the stomach becomes reconciled to it, the dose may be increased to an ounce three or four times a day. By Mr. Emery so much as a pint, and in some cases a pint and a half, was given in cases of lepra every day; and the result, he reports, is most encouraging, some very protracted cases being entirely cured by it. Such doses are rarely necessary, and very rarely could patients be persuaded to swallow them. Sometimes, when the stomach rejects the oil, if it is omitted for a few days or weeks, and then given, it will be retained. [Little has been added to our knowledge of the oil since the above was written ; few doubt its value in phthisis.—2nd Ed., Editor.] Sarsaparilla.—This is the root of a number of species belonging to the genus Smilax. It has generally been supposed to be a product of 536 MATERIA MEDICA AND THERAPEUTICS. the Smilax sarsaparilla. It is doubtful, however, whether auy of the sarsaparilla of commerce is obtained from this source. The species which are now supposed to yield it, are the Smilax officinalis, Smilax medica, and the Smilax papyracea. These grow in Mexico, Guatemala, and the warm regions of South America. The smilax is perennial, and has a climbing or trailing stem, beset with prickles. The name sarsaparilla is derived from two Spanish words which signify a small thorny vine. The part used in medicine is the roots, which consist of long and slender runners, issuing from a common head with the stem. These runners are the preferable part. As found in the market, they come in bundles from about two to four feet long. . They are about the thickness of a common quill, cylindrical, and with longitudinal fibres, and with more or less radical fibres upon them. They consist of a thick cortical part, covered with an epidermis which can easily be separated ; a thin inner layer of woody fibre, and a central medulla or pith. The color of the exterior varies from red to brown and grey. In the dry state they have no smell; on boiling the smell becomes decided. The taste is mucilaginous, and if chewed for a little time, decidedly acrid. Varieties of Sarsaparilla. —The principal varieties of this drug in the market are the following : 1. The Lisbon or Brazilian sarsaparilla. This is the product of the Brazils, and until of late years found its way to the different parts of the world through the port of Lisbon. Hence its name. It is supposed to be the root of the Smilax papyracea. This kind of sarsaparilla is of a reddish brown color, and abounds in amylaceous matter, both in the bark and pith. 2. The Jamaica Sarsaparilla. —Supposed to be the product of the Smilax officinalis. It comes from the bay of Honduras, and derives its name from its being brought to England from Jamaica. It is distinguished by its reddish color, from whence it is called the red sarsaparilla. It has more radical fibres attached to it than the preceding. Contains but little amylaceous matter. 3. Honduras Sarsaparilla. —This comes from the bay of Honduras, and is of a dirty or greyish brown color. It has very few fibres attached to it. Under the epidermis is a thick amylaceous layer, which gives it a mealy appearance: hence called mealy sarsaparilla. 4. Vera Cruz Sarsaparilla. —This is supposed to be the product of the Smilax medica. It comes from Mexico. This has very few fibres attached —of a light greyish color. It is more fibrous than the other varieties, and contains no starch. Tests of the Quality. —The best test of the quality of sarsaparilla is 537 ALTERATIVES. the taste. The more nauseous and acrid this is, the better. In addition to this, the roots which have a red color, and have the greatest number of root fibres, are considered the best. The quantity of starch contained in them, so far from being a proof of goodness, is perhaps the reverse. Effects. —Sarsaparilla does not produce any direct and sensible effects on the system with constancy. Sometimes it is diaphoretic, again diuretic ; in very large doses it irritates the stomach, and is said to produce vertigo. In medicinal doses it acts as an alterative merely, improves the appetite, strengthens the digestion, and invigorates the whole system. It is given with advantage in secondary and tertiary venereal diseases, especially where the system has been broken down by the disease and the abuse of mercury. In these cases it is usually united with stimulating diaphoretics, as mezereon, sassafras, &c. In chronic rheumatism,, not connected with syphilis, it often does good; so, too, in chronic diseases of the skin, especially if they occur in broken-down constitutions. Mode of Administration. —Sarsaparilla is given in infusion and decoction, syrup and liquid extract, and usually united with guaiac, mezereon, and sassafras. The officinal syrup and liquid extract used are the preferable preparations. MEZEREON. The tree which yields this is the Daphne Mezereon, growing wild in England and the north of Europe. It is a very hardy plant, growing to the height of four or five feet. The bark of the root is the part used in medicine, the ligneous part being nearly inert. The proper season for digging up the roots is the autumn, after the leaves have fallen. By Vauquelin, a peculiar principle has been discovered in the mezereon, to which he has given the name of Daphnin. Mezereon is a powerfully stimulating diaphoretic, exciting the action of the vascular system, and acting also on the bowels and urinary organs. If given too freely it causes nausea, vomiting, and purging. In its general operation, therefore, it is much more active than either guaiac or sarsaparilla. In'substance the dose of this article is from five to ten grains. It is seldom used in this Avay, however. The best form is that of decoction. This is made by boiling 3 ij of the mezereon with 3 ss of liquorice root in lbs iij of water down to a quart. Of this four or five ounces may be given three or four times a day. Even thus* however, it is at present seldom used alone. SASSAFRAS. This is the sassafras officinale, a tree growing in great abundance throughout the United States. It grows frequently to the height of 35 538 MATERIA MEDICA AND THERAPEUTICS. thirty or forty feet, and even more. The wood, root, and bark, are ai used in medicine. Its active properties are extracted both by alcohol and water. Sassafras is a stimulating diaphoretic and diuretic, and is used in the same cases with the preceding articles. The best form of giving it is the infusion, as decoction dissipates the oil. In this way it is much used as a common domestic remedy. The oil is also a good preparation in doses of gtt. ij to iv, rubbed up with sugar and water —seldom used, however. guaiac. The tree Avhich yields the Guaiac is the Guaiacum Officinale, a native of Jamaica and South America, rising generally to the height of forty feet. Every part of this tree possesses medicinal properties, but the wood and a peculiar substance, guaiacum, afforded by it are the only parts used. This peculiar substance exudes spontaneously from the trunk of the tree in the form of tears, or from incisions made into the trunk. From these it flows out very copiously, and is concreted by the sun. Formerly this was supposed to be a gum resin, but Mr. Brando declared it a substance sui generis, differing both from gum and resin. "Its most remarkable property," according to him, "is the change of color which it undergoes when subjected to oxygenating agents." When reduced to powder its tint is pale grey, but by exposure to air and light it soon becomes of a dingy green. It is now considered a peculiar resin. It is upon this substance that the virtues of the guaiac wood entirely depend. The guaiac wood comes in large, solid, and heavy pieces, of a yellow color, having but little smell, and a slightly warm, subacid taste. When used for medicinal purposes it is rasped. The guaiac resin is sometimes found in the form of tears, but generally in large fused masses " with little smell and taste, brittle and semi-transparent, and of a greenish brown color."—Brando. " The sensible effects of the guaiac are a grateful sense of warmth in the stomach, dryness of the mouth, and thirst, with a copious flow of sweat, if the body be kept externally warm, or if the guaiac be united with opium and antimonials; but when the body is freely exposed, instead of producing diaphoresis, it augments considerably the secretion of urine." (Thomson's Disp.) Guaiac is a warm, stimulating diaphoretic, and has been much used as an alterative remedy in cases of secondary syphilis, cutaneous affections, and the like. It was originally employed by the native Indians of St. Domingo as an antidote to the lues venerea. It was from them that the Spaniards became acquainted with its virtues, and in the year 539 ALTERATIVES. 1508 it was introduced into Spain. It speedily gained great celebrity throughout Europe, and until the last century continued to enjoy so high a reputation as a specific against the venereal that it was called the lignum sanctum. More accurate observation has, however, decided that it possesses no such powers. It nevertheless exercises some control over the venereal virus, and in cases where the skin becomes affected with ulcers and blotches it is a remedy of great value, when used in combination with some of the mercurial preparations. For the purpose of producing the greatest sudorific effect from the guaiac, the body should be kept warm, and the guaiac should be combined either with opium or antimonials. If the patient be freely exposed, it is apt to run off by the kidneys instead of producing diaphoresis. The gum guaiac may be given either in substance, in doses of from grs. x to 3 ss, in pill or bolus, or what is better, made into an emulsion with water, by means of gum arabic or the yolk of an egg. If given in larger doses it is apt to produce a purgative effect. An excellent preparation of it is the ammoniated tincture, or, as it is commonly called, the volatile tincture of guaiac. This is made by a combination of powdered gum guaiac with the aromatic spirit of ammonia. Of this, the dose is one or two teaspoonfuls, two or three times a day. Water decomposes it, and therefore it should be given saturated with some viscid substance. This is an admirable stimulating diaphoretic, and may be used with the greatest advantage in cases of chronic rheumatism. It possesses over the guaiac alone the advantage of a combination of the ammonia, which co-operates powerfully as a stimulating diaphoretic. [This was the favorite remedy of Dr. Dewees in amenorrhoea and dysmenorrhoea.] LOCAL ALTERATIVES. By these I mean those agents which possess the power of altering the condition of the part to which they are applied, in such way as to remove diseased action. They are the agents usually described under the names of caustics and cscharotics. These terms, however, are objectionable, as they are calculated to convey erroneous notions in relation to the effects and operation of many of the articles belonging to this class. This will be abundantly obvious, when we come to consider them in detail. NITRATE OF SILVER. Of all the local alteratives this is by far the most valuable, and exerts a most astonishing influence in changing the condition of the parts to 540 MATERIA MEDICA AND THERAPEUTICS. which, it is applied. When used in the form of the solid stick, its effects differ, of course, according to the mode of applying it. If lightly rubbed over the skin, previously moistened, or over the surface of a wound or ulcer, it first induces a white film, whifcb, when exposed to the air for a few hours, assumes a darker color, and finally becomes dark grey or black. As it undergoes these changes of color, it gradually becomes harder, and forms an eschar resembling black sticking-plaster. In the course of a few days the eschar becomes corrugated and begins to separate at its edges, and at length peels off altogether. Here the nitrate of silver makes a chemical union with the albumen of the skin forming the white film. This becomes gradually hardened, and the change of color is owing to the partial reduction of the silver. Again, if the skin be moistened, and a stick of nitrate of silver be rubbed lightly over it five or six times, vesication takes place. In the course of four or five days the blackened and separated cuticle falls off and the part heals. Again, if rubbed repeatedly on a part it acts as a caustic, destroying its texture. When applied to mucous membranes, it forms a thick white compound with the animal matter of the mucus. This protects the part underneath from the caustic effects of the silver, so that the effect is by no means so violent as it would seem. Simply stated, these are the effects of the local application of this agent, and it is upon these that it is used in a great variety of affections with the most singular success. The best form in which to use it is that of solid stick. 1. In cases of External Inflammation. —That nitrate of silver, locally applied, has the power of arresting inflammation, was first noticed by Dr. Higginbottom, who has written an invaluable treatise on the effects and uses of this agent. The mode of applying it is the following : the part is first to be washed with soap and water, and then dried. The inflamed and surrounding part is then to be moistened, and a long stick of nitrate of silver is to be passed over the moistened surface, takingcare that not only every part of the inflamed skin be touched, but also the surrounding healthy skin to the extent of an inch or more. The number of times the stick is to be passed over the inflamed surface, depends upon the degree of inflammation present. In some cases simply blackening the skin will be sufficient, while in others actual vesication may be necessary. In very slight cases, accordingly, passing the stick once over the part will be sufficient. In ordinary cases, two or three times will be necessary, while, as vesication is required, it must be applied more frequently. ALTERATIVES. 541 DISEASES IN WHICH THE NITRATE OF SILVER IS USED. These are various, and require to be noticed in detail, as in many of them a difference in the mode of applying is necessary. 1. Phlegmon.—In cases of ordinary phlegmon, simply moistening the part and rubbing it over with a stick of nitrate of silver, will sometimes have the effect of arresting the progress of inflammation, without any other application. 2. Paronychia— Whitlow. —In cases of this kind, frequently the best application to the part is nitrate of silver, first moistening the surface and then rubbing the stick once or twice over it. In case suppuration should have actually taken place, the best plan is to open the abscess, then applying the nitrate freely within the cavity, and afterwards cover the whole with a cold bread poultice. In most cases this will entirely relieve the pain and irritation, after the immediate smarting of the application has subsided. Should the inflammation be increased in a day or two, as it sometimes is, the application may be renewed. 3. Erysipelas.—There is perhaps no disease in which the effects of the local application of the nitrate of silver are so striking as in this. For the first suggestion of it, I believe we are indebted to Mr. Higginbottom, who has detailed some very interesting cases, in which it was used with success. As you all know, this disease is not always purely local. It is connected with constitutional derangement requiring general treatment. Bloodletting, purging, antimonials, etc., are of course to be first resorted to. If these should fail to arrest the disease, the best mode is first to moisten the whole inflamed surface and then pass a long stick of the nitrate over every part of it, extending the application a little distance beyond on the surrounding healthy skin. Strange as it may be, the progress of the inflammation appears to be immediately arrested, and in the course of two or three days frequently every appearance of inflammation will have disappeared. In about five or six days, the eschar separates. 4. Inflammation of Absorbents.—In cases of this kind, which frequently are so painful and dangerous, there is nothing so prompt and efficient as the local application of this remedy. Generally speaking, inflammation of this sort arises from some local injury extending in the extremities to the axilla and groin. In such cases the best plan is to rub the nitrate not merely over the part first affected, but over the whole course of inflamed absorbents. 5. Punctured Wounds. —In the slighter of these the effects of the 542 MATERIA MEDICA AND THERAPEUTICS. application of the nitrate are really astonishing, in arresting the inflammation and entirely curing the injury. In these cases all that is necessary to be done is to moisten the part first and then pass a stick of the nitrate to the wound, and to pass it once or twice over the whole inflamed part, extending it about an inch beyond on the healthy skin- Generally nothing else is necessary. Where the case has been neglected and matter has already formed, the matter is to be evacuated and the nitrate applied within the cavity. A cold poultice is then to be applied. In two or three days the application may be renewed, in case there should still be any swelling or inflammation left. In this Avay, ordinary wounds from instruments, etc., the bites of animals, inflamed leech bites, and wounds received in dissection, may be treated. Wliere the punctured wound has been extensive, a good way of treating it is to apply the nitrate first and then bring the edges together by adhesive plaster. In this way the excessive inflammation and suppuration which frequently attend these cases are kept down, and the part heals nearly as by the first intention.. 6. Bruised Wounds. —In these cases, whether of simple bruised wounds, or of the more severe kind, accompanied with inflammation or followed by sloughs, the application of the nitrate is attended with the same salutary effects as in punctured wounds. 7". Ulcers.—In the treatment of these intractable cases, the nitrate of silver proves an invaluable remedy. In small ulcers, simply applying it to the surface and a little on the surrounding skin, and after this covering the whole with gold-beater's skin, is all that is necessary. In large ulcers with inflammation, or in old ulcers, the treatment is the following: first apply a bread and milk poultice over the ulcer, and let the patient keep his bed for 18 or 24 hours. All the inflamed parts are then to be well washed with soap and water and wiped dry. They are then to be moistened with water, and a long stick of the nitrate is to be passed all over the inflamed and ulcerated surfaces twice, and rather more freely on the ulcer itself. It must also be carried somewhat on the surrounding skin. Lint must then be applied to the ulcer, and the whole inflamed and ulcerated parts covered with the neutral ointment,* spread on linen. A compress of linen five or six folds thick is then to be put over the ulcer, and a common roller to be * B Empl. riumbi lbs. ij. 01. Oliv. lbs. ij. Creta? ppt. § xvij. Aeetum Distillat. lbs ij. M. The acid and chalk to be well mixed in a mortar, the lead, plaster, and oil, previously slowly melted together, are next added, and the whole stirred till «0«1. 543 ALTERATIVES. loosely applied round the whole. On the fourth day the leg is to be examined, when it will be found that the inflammation is nearly if not entirely gone, and the ulcer is in a healing state. The nitrate must then be applied on the whole of the ulcer, and once lightly over the skin immediately surrounding it, one or two inches in breadth. The lint, ointment, etc., to be applied as before. Every third or fourth day this is to be repeated until the ulcer is healed. After the first or second application the patient may walk about. Caustic Potash.—This is the hydrate of potash. Also called the potassa fusa, or fused potash. It is prepared by evaporating a solution of potassa in a clean iron vessel over the fire until ebullition ceases and the potassa melts. It is then poured into proper moulds. The best kind of moulds are of iron and of a cylindrical shape. In this process all the uncombined water is driven off by the action of heat, and the potassa remains in the state of hydrate. It contains one equivalent of potassa 48, and one of water 9=57 ; or in 100 parts, 84 potassa and 10 water. When perfectly pure, the hydrate of potassa is of a white color. The officinal preparation, however, owing to impurities, is greyish or bluish. It is soluble in water and alcohol, but usually not entirely so, in consequence of the impurities; when pure, it is entirely soluble. It has a very strong affinity for water and carbonic acid, which it attracts rapidly from the atmosphere, and, in consequence of this, it deliquesces. Hence the necessity of keeping it in tightly-stopped bottles. Purity. —The officinal hydrate contains various impurities, such as peroxide of iron, carbonate of potash, silica, alumina, &c., which exist in the carbonate of potash, from which the solution of potassa is prepared. These, however, do not interfere with the medicinal virtues of the article. They may be separated by digesting it in alcohol, which takes up only the pure alkali; by evaporating this alcoholic solution to dryness and fusing the mass thus obtained. Effects. —This is the strongest caustic that we possess, and hence was known by the name of causticum commune acerrimum. When applied in the solid form to any part, it quickly destroys its vitality, and extends its action to the parts beneath, forming a slough, which is afterwards thrown off, leaving behind it an open ulcer. The principal use of this article is to form issues. In using it for this purpose, however, it is necessary to be cautious. As it is very deliquescent, it is apt to spread, and thus extend its effect too far. A piece of adhesive plaster should, therefore, be first applied to the part, with a hole cut in it of a suitable size where you intend making the issue. To this open part the caustic, moistened at one end, should be rubbed until 544 MATERIA MEDICA AND THERAPEUTICS. the part becomes discolored or dies. It is then to be washed and a poultice applied. When the eschar separates, the issue is to be continued by keeping a pea in it. It is also used to destroy warts and fungous growths. Potassa cum Calce. —This is also called the Causticum commune mitius, or the Causticum commune cum calce. This is prepared by evaporating solution of potassa to one third, and then adding as much newly slacked lime as will bring it to the consistence of a solid paste. This is then to be preserved in well-stopped bottles. This consists of the mixed hydrates of potassa and lime. It possesses the advantage of being less deliquescent than the caustic potassa. It is, therefore, more manageable. It is milder and slower. Its general action, however, is the same. When applied, it is made into a paste with rectified spirits. Arsenious Acid.—Although commonly ranked among them, this article produces effects very different from the simple caustics. When applied in small quantities to the sound skin, it does not produce any effect. When applied in considerable quantities, however, it has been known to cause local irritation, followed by a pustular eruption, and in some cases the constitutional effects of it have been developed. Several cases are recorded in which this article has been applied by mistake to the head for hair powder, and in all these constitutional effects have followed. One proved fatal. When rubbed on the sound skin in the shape of ointment, it produces generally a pustular eruption; sometimes an eschar, and not unfrequently the system becomes constitutionally affected.—(Christison.) When applied to surfaces deprived of the cuticle, the effects are much more energetic. Great local irritation is caused, while the poison is absorbed frequently with great rapidity, and all the constitutional effects of it developed. Applied to eruptions, ulcers, and wounds, it has frequently proved fatal. In its application to ulcerated surfaces, there is a circumstance of great interest which has frequently been noticed ; and that is, that while some persons are affected by a single application, " others have had it applied for a length of time without experiencing any other consequence than the formation of an eschar at the part."—(Christison.) For this two reasons have been assigned. The first is, the difference in the quantity applied. When a large quantity is applied, the part is speedily disorganized, and absorption is thus prevented. On the other hand, where the quantity is the local effect is trifling, and absorption readily takes place. " A second is the condition of the sore to which it is applied. If there be any bleeding vessels, absorption takes place very readily, and the system is easily affected. On the other hand, if there be no bleeding vessels, this effect is much less likely to happen.—(Christison, p. 223.) 545 ALTERATIVES. The practical conclusions to he drawn from the foregoing are important, and they are the following : 1. The arsenic should always be applied strong, so as to disorganize the part as speedily as possible. 2. Before applying it the part should never be prepared by cutting and paring, so as to cause bleeding. By attending to these precautions, the absorption of the article may probably in many cases be prevented, and many evil effects obviated. When properly applied to an ulcerated surface, the part is destroyed and sloughs off; a new action is thus created, and a healthier secretion promoted. . The disease in which arsenic has been chiefly used is cancer, and this is the article generally resorted to by empirics. In many cases it no doubt serves a good purpose in improving the character of the sore» and perhaps retarding the progress of the disease. Experience, however, has abundantly shown that it cannot eradicate the disease, while from the absorption the most dangerous and even fatal consequences have resulted. By regular practitioners it is, therefore, in a great measure abandoned. It is also used in Lupus with advantage, and more recently in Onychia maligna with great success. (Pereira.) Mode of Application. —The best form is the ointment. This is made by rubbing up one scruple of finely-powdered arsenious acid with one ounce of simple cerate. This must be applied with caution and the effects watched. The preparation used for onychia maligna is arsenious acid, grs. ij ; spermaceti oint. 3 i. [Hydrargyri Supernitratis (the Acid Nitrate of Mercury). —A. solution of the nitrate of mercury in nitric acid, under the name of the acid nitrate of mercury, is much used as a caustic in Paris, and has been adopted by some practitioners in England and the United States. It is chiefly used in cases of severe and extensive ulceration of the os uteri. It should be applied by a brush, and very great care taken that ft does not fall upon the vagina, or touch the healthy tissue of the uterus. —Ed.] CHEMICAL ALTERATIVES. The two most important classes of chemical alteratives are : 1st. Antacids, or those remedies which obviate acidity of the stomach by combining with and neutralizing the acid. 546 MATERIA MEDICA AND THERAPEUTICS. 2d. Lithics, or those remedies which are given to counteract the disposition to form urinary calculi. I shall speak of each of these in their order. Antacids.—The presence of acid in the stomach is essential to the performance of its functions. It is of course only when this is in excess that it becomes a proper subject for medicinal treatment. It is not yet well settled what acids are present in the gastric juice, nor in what state they exist in that fluid, some supposing that muriatic, acetic, and lactic acids exist in a free state. Blondelot, on the other hand, denies altogether the existence of. free acid in the stomach, insisting that the acidity of the gastric juice depends on the presence of the acid Diphosphate of lime. The probabilities are that free acids exist, and that the same acid does not exist in the gastric juice of different animals, nor in that of the same animals at all times; for though the acidity is essential, it seems that this quality in the absence of one acid can be communicated by another. The acids which are thought to exist in the normal state in gastric juice are, as before stated, the muriatic, lactic, and acetic, and it is probable that when acid is in excess, it is by the increase of one or other of these. They are in all cases developed from the food ; muriatic from animal food, lactic and acetic from vegetables. It is then to saturate the excess of these acids, and not to neutralize the gastric juice, or remove acid from the stomach, still less to render it alkaline, that antacids are given ; and if you remember, 1st. That the excess of acid is generated from changes in the food. 2d. That these changes depend on imperfect digestion. 3d. That digestion cannot but be imperfect, when there is in the stomach sufficient alkali to neutralize the gastric juice, you will readily understand the reason for a fact, long familiar to practical men, viz. that it is very possible to remove an effect of disease, and yet not remove, but actually aggravate the disease itself. Here the essence of the disease is the disposition in the stomach to produce an undue quantity of acid from the food, and in neutralizing this excess of acid, and thus removing an effect, we may aggravate the disposition in the stomach, which is the aisea.se. ' This injurious effect of antacids may be, in part and for a time, prevented by the use of vegetable bitters, and alkalies ought not to be long used, without giving the tonics; but even with these the evil effects cannot be prevented entirely, if the remedy is used freely, and for a long time. Always, therefore, discourage the long-continued use of alkalies, especially the too common practice of taking them immediately after each meal. Magnesia.—Under the head of cathartics this earth has already been 547 ALTERATIVES. noticed, and it was then mentioned that it was used in three forms, viz: the sulphate, the carbonate, and the pure magnesia, or magnesia usta. In either of these two latter forms, magnesia may be used as an antacid. The difference between them is, that when the carbonate is used, large quantities of carbonic acid gas arc extricated in the stomach. In some instances the extrication of this gas is objectionable, from the distension of the stomach which it occasions. Generally, however, no harm can arise from it, and the stimulus of the gas is, in many cases, rather grateful than otherwise to the stomach, and whenever nausea and vomiting are present, may be exceedingly beneficial. As an antacid, magnesia is one of the most efficacious articles that we possess. Next to ammonia, it has the greatest power of neutralizing acids of any of the alkalies or alkaline earths. It is peculiar to this article that, when it combines with an acid in the stomach, it proves purgative. In this respect it differs from the other antacids. Mode of Administration. —It may be given in doses from 3 ss to 3 j. in milk or water. To correct the flatulence which it occasions, a small quantity of some aromatic may be added. In dyspeptic states of the stomach, a little of the compound spirit of ammonia is frequently beneficial. Of the pure magnesia the dose may be about one third less than that of the carbonate. Creta—Chalk.—This is a friable carbonate of lime, and is found in great abundance in different parts of Europe. In the South of England, particularly, it exists in great quantities. Marble is the hard carbonate of lime. With the acids chalk effervesces, the carbonic acid gas beingextricated. With muriatic acid it effervesces violently, and dissolves almost entirely, leaving a colorless solution. When by levigation and washing the chalk is separated from any impurities thatmay be associated with it, it is called Cretapreparata or Prepared chalk. This is the form in which it is used in medicine. As an antacid, it has been and is still used. It differs from magnesia in not producing any purgative effect. On the contrary, it proves absorbent and astringent. It is, therefore, used with much advantage in cases in which magnesia would be improper. The dose of it is from 9 j to 3 j. The common form in which it is prescribed, is that of the chalk mixture. Lime Water. —This is a limpid, colorless fluid, without smell, and having a strong, styptic, acrid taste. It changes vegetable blues to green. It unites with oil, forming an imperfect soap. When exposed to the air, a pellicle forms on its surface, which, when it becomes of a certain thickness, cracks and sinks to the bottom. It is then succeeded 548 MATERIA MEDICA AND THERAPEUTICS. by others of a similar character. The explanation of this is the following: The lime of the lime water attracts carbonic acid from the air, and forms a carbonate on the surface, which is the pellicle just mentioned. By successive formations the whole of the lime is thus abstracted. It is for this reason that it is necessary to keep lime-water in closely stopped bottles. As an antacid, lime water is much used, and is an article of great value. Besides the power which it possesses of neutralizing acid, it has the still further property of dissolving the sordid mucus with which the stomach and bowels are generally loaded in dyspeptic and otherwise debilitated states of these organs. In the same way it proves serviceable in cases of worms by dissolving the slimy mucus in which these animals are imbedded. The dose is from 5 j to § ij, or § iij. Where the stomach is irritable, a good form of giving it is, mixed with an equal quantity of milk. Potash.—Carbonic acid combines with potash in two proportions, constituting a carbonate and a bicarbonate. (a.) Carbonate of Potassa. —(Salt of Tartar). —As found in the shops, this salt is in white grains, with an alkaline and nauseous taste; it changes vegetable blues to green, and unites with oils and forms soap. On exposure to the air it is very deliquescent, and forms a fluid of the consistence of oil. This salt contains one proportion of carbonic acid with one of potassa. It is soluble in water, but insoluble in alcohol. (b.) Bicarbonate of Potassa. —This salt is prepared by passing a stream of carbonic acid gas through a solution of the carbonate of potassa. When it ceases to absorb carbonic acid, it is to be filtered and evaporated slowly until regular crystals form. This salt contains twice as much carbonic acid as the preceding carbonate, or two proportions of acid to one of potassa. This is white, crystalline, Avithout smell, and having a weak alkaline taste, without any acrimony. On exposure to the atmosphere it does not undergo any change. It is soluble in about four parts of cold water. Effects on the System. —In their effects, these salts do not differ much. They are both powerfully antacid, and extend their operation from the stomach to the urinary organs, increasing the secretion of urine, and altering the chemical constitution of that fluid. Although possessing the same general properties, however, the bicarbonate has great advantages over the carbonate. It is less nauseous and acrid in its taste, and agrees better with the stomach. The dose is from grs. x to grs. xxx, in some mucilaginous vehicle. (c.) Liquor Potassa — (Solution of Potassa). —This is another form in which potassa is used. It is prepared by making separate solutions ALTERATIVES. 549 of carbonate of potassa arid caustic lime in boiling water, and then mixing these together, and when cold, straining, etc. Here the lime attracts the carbonic acid from the potassa, and leaves the alkaline base in a state of purity. To prevent its absorbing carbonic acid from the atmo* sphere, it should be kept in glass bottles, with ground stoppers. The liquor potassa?, when pure, is a limpid, colorless fluid; its taste is acrid and caustic. It changes vegetable blues to green, and does not effervesce with acids. It is a powerful antacid, and extends its operations to the urinary organs. It does not, however, appear to possess any advantage over the carbonate, and is more apt to disagree with the stomach. The dose is from gtt. x to gtt. xxx, taken in broth, milk, common table beer, or some bitter infusion. Soda.—Like Potassa, Soda combines with carbonic acid in two proportions. (a.) Carbonate of Soda.—This salt is in large, white crystals. It is Avithout smell. On exposure to the atmosphere it effloresces and crumbles into a white, opaque powder. It consists of one proportion of carbonic acid and one of soda. (b.) Bicarbonate of Soda. —This salt is prepared in the same way as the bicarbonate of potassa, and contains two proportions of the acid to one of the soda. It forms in crystals—less soluble in Avater than the carbonate. When dried, these crystals effloresce and lose part of their carbonic acid, so that what is usually found in the shops under the name of the carbonate is intermediate between the carbonate and the bicarbonate, forming a sesquicarbonate of soda. [A mixture of the two carbonates. —Graham.] Effects on the System. —The carbonates of soda are analogous in their operation, the only difference being that the bicarbonate is less alkaline and unpleasant in its taste, and generally sits better on the stomach, The carbonates of soda are generally more used than those of potassa. They are more pleasant, sit easier on the stomach, especially if their use is to be continued, and at the same time appear to be more efficacious. The dose is from grs, x to grs. xxx or xl, dissolved in water or almond mixture. A very pleasant mode of giving soda is in soda water. The taste of the soda is here almost entirely covered by the carbonic acid. Carbonate of Ammonia — (Volatile alkali). —This salt does not exist in nature, but forms spontaneously in the decomposition of animal matter. It is also prepared artificially for medicinal purposes. It has a penetrating, pungent odor, and an acrid taste. It is usually 550 MATERIA MEDICA AND THERAPEUTICS. in white semi-transparent masses of a crystalline appearance. On exposure to air it effloresces. It should be kept in well stopped bottles, for when exposed to the air, it gradually loses ammonia, becomes opaque, pulverulent, and less pungent, and ultimately passes into a hydrated bicarbonate of ammonia.. It possesses alkaline properties, and is soluble in about three parts of cold water. Effects. —As an antacid this salt possesses very active properties. Besides neutralizing acid, which it does very effectually, it has the advantage of being powerfully stimulant, and is on this account particularly useful in debilitated states of the stomach, accompanied with acidity and flatulence. Form. — Pill or bolus, in doses of from ij grains to x grs. CHEMICAL ALTERATIVES. Lithics.—Under this head I shall treat of those remedies which are calculated to correct some of the most common morbid states of the urine which are manifested by deposits. To make this subject intelligible, it is necessary to say a few words on the urine in health. Healthy urine, when recently voided and yet warm, is an ambercolored fluid, having a peculiar aromatic smell, and a saltish, disagreeable taste. On cooling, the smell changes to that usually called urinous, which it retains till it begins to decompose, when it has a foetid, ammoniacal odor. Its specific gravity may vary from 1005 to 1030, but its usual range is from 1015 to 1020. The quantity voided is subject to remarkable variations, even in perfect health, sometimes falling below 20 ounces, and at others exceeding 50. The average is about 32, or two pints. The quantity of solid matter in the urine is, like all its other qualities, subject to vary from a great number of causes. Its average is about 64 grains in 24 hours. This supposes that 32 ounces of urine of the specific gravity of T020 are passed, each ounce of the fluid containing 20 grains. Not only does the urine of different persons, and of the same persons at different times, vary, but there is a pretty regular change which the fluid, in all healthy persons, undergoes at different periods of the day. That passed after rising from bed in the morning, and of course after several hours of abstinence from food or drink, is commonly called urina sanguinis. It furnishes a fair specimen of the average density of the whole urine. That passed soon after the digestion of a full meal, called urina chyli, is of high specific gravity, while that which flows after the taking of large draughts of water, called urina potHs, has a low specific gravity, is of pale color, and is sometimes nearly pure water, The urine is a very complex fluid, and chemists are scarcely yet agreed 551 ALTERATIVES. as to its composition. Into the niceties of this analysis I need not enter : my purpose will be served by calling your attention to a very general view of its composition. It contains in one thousand parts: 1. Water, from 930 to 960 2. Urea, 24 to 14 3. Uric acid, 1-3 to 0'90 4. Alkaline and earthy salts, . 15 to 5 5. Other solid matters, . . . 30 to 20 Of the constituents of urine the most important are urea, uric acid, and the alkaline and earthy salts, these latter being chiefly phosphates of soda, lime and magnesia, sulphates of potash and soda, muriate of ammonia, and chloride of sodium or common salt. The proportion of these several ingredients may vary very much without exceeding the limit of health. When, however, the quantity of any one is very much either increased or diminished it constitutes, not always a disease —this is a matter of great importance and to be kept always in view—but a symptom of some diseased state of the system, very generally connected, more or less intimately, with faulty digestion. But the urine becomes morbid, not only by the faulty proportions of its normal ingredients, but it sometimes contains matters which are not properly constituents of the fluid; of these the most important are albumen, sugar, pus, blood, and bile. None of these are ingredients in healthy urine, yet even their presence is not always to be taken as an evidence of disease; it may be that they exist there in consequence of the vigorous efforts the system is making to eliminate noxious matters. From what is above stated it is obvious that morbid states of the urine may be divided into two general classes: I. Those in which some normal constituent of the urine is in excess. II. Those in which the urine contains some principle which is not found in it in the state of health. 1. Morbid states of the urine in which some normal ingredient is in excess. —The normal ingredients of the urine wdiich are most frequently found in excess are : 1. Urea; 2. Uric acid and the urates; 3. The phosphates. 1. Urine in which urea exists in excess. —Urine in which urea is in excess has a high specific gravity, and is very prone to decomposition : it has no other peculiar physical property. Test. —Add to a small quantity of urine in a watch glass about an equal quantity of pure colorless nitric acid ; if crystals appear urea is in excess, and the time within which they form, which may vary from a few minutes to two or three hours, and the quantity of crystals, will enable us to judge of the amount of the excess; or put tw T o or three drops of urine in a plate of glass and add two or three drops of nitric acid; if 552 MATERIA MEDICA AND THERAPEUTICS. crystals form they can he detected by the microscope : and by a comparison of healthy urine tested in the same way, a good idea of the quantity of urea may be formed. Symptoms. —A frequent desire to void urine, though the quantity passed at one time is commonly moderate. The quantity voided in twenty-four hours may not much exceed the normal standard, though it commonly does a little, but a remarkable feature of the disease is the facility with which diuresis is produced by trifling causes, as anxiety, a slight chill of the surface, and the like. There is pain in the back, indisposition to exercise, low spirits, with dyspeptic symptoms of greater or less severity. 2. Urine in which lithic acid or the lithates predominate. —Urine containing excess of lithic acid is usually of a high color, and if the excess is considerable the acid is deposited as the urine cools. It always appears as crystals, though they are often so small as only to be recognised by the microscope.* The urine is acid, but not of high specific gravity, unless, as not unfrequently happens, there is excess of urea also. Lithate of Ammonia* —This is often seen with lithic acid, and the urine containing it is usually high-colored and turbid, sometimes it is clear when passed, and of low specific gravity. The lithate is deposited as the urine cools as an amorphous mass. It has commonly a fawn color, verging towards red. It is the most common of the urinary deposits. The only one with which it can be confounded is earthy phosphates, and from them it is distinguished by being redissolved when the urine is heated and falling down again when it cools. It is dissolved by adding liquor potasste. Lithate of soda is usually found, and sometimes in very large quantities, in urine containing lithate of ammonia ; this is particularly true of the urine of gouty patients, in whose systems lithate of soda often abounds to such a degree that it is deposited in the joints, forming the so-called chalk stones. It has also been found in the blood of arthritics. Lithic acid and the lithates are also found in excess in the urine, in most cases of inflammatory disease, in rheumatism and gout. It is very common in fever. It is often increased by check of perspiration from cold, and sometimes accompanies chronic skin disease. When too much animal or highly nitrogenized food is taken, or the digestive organs are impaired so that they are unable to assimilate the usual quantity, the excess of nitrogen will often be eliminated from the kidneys as lithic acid and lithates. This is one of the cases where the presence of an urinary deposit is evidence of the efforts of the system to eliminate a * The color is yellow or red, varying through all the shades of pale and deep fawn color to intense orange red. 553 ALTERATIVES. noxious principle. On the other hand, in all diseases of debility, in anemia, hysteria, chlorosis, the quantity of lithic acid is below the normal standard. Therapeutics. —Where this acid or the lithates are in excess, the treatment must be directed by two indications. I. To remove the diseased state upon which the disposition to form acid in excess depends. II. To promote the solution of the acid and its salts. The means for fulfilling the first indication are : Those calculated to restore the healthy functions of the skin, and promote diaphoresis; and those which improve digestion. Of the former the most available are the warm or vapor bath, followed by very free and even violent friction of the whole surface, and moderate exercise; these measures will often produce the best effects. To improve the digestion, alteratives, and, if needful, mild tonic laxatives, as rhubarb, and soda or magnesia, may be followed by vegetable tonics, and in some cases chalybeates. Of the preparations of iron those are to be preferred in which the metal is united to an organic acid, as the ammonio-tartrate, the citrate, or lactate. Attention to diet is all-important; here, as in most other cases, the best rule is to take such articles only, and in such quantities, as the patient finds by experience he can thoroughly digest. Solvents of lithic acid and the lithates. —These are the proper and literal lithics. Their use is generally secondary to that of the remedies which have been mentioned as proper to remove the diseased state of the system on which the formation of the excess of acid depends. Still they are of importance, for they may ward off for a while the dreaded evil calculus, and give time for the proper operation of the other and more important class of remedies. Of the solvents of lithic acid the most important is water. This is the best lithic, not only for this, but for most other urinary deposits. All other lithics will usually fail, hardly acting at all, unless their operation be aided by free dilution ; and, on the other hand, very many of them act promptly and with great power, when presented to the system with plenty of water. Two or three pints a day is the proper quantity to be taken, and if a larger amount can be swallowed without impairing the digestive powers, the chance of the acid being "icashcd away" is greatly increased. A very curious proof of the efficacy of water as a lithic is afforded by the Medical History of Malvern Springs in England. These waters have, for a very long time, enjoyed great reputation in cases of gout, gravel, and other chronic affections; to their efficacy we have the testimony of Prout, Bird, and other writers. Now the water of Malvern Springs differs, except as to temperature, from common spring water, solely in its extreme purity, approximating that of distilled water. 3G 554 MATERIA MEDICA AND THERAPEUTICS. Potash. —Tliis alkali may be given in various forms, as the liquor potassa?, the carbonate, bicarbonate, tartrate, citrate, and acetate. The liquor potassse should be given in full doses, say 3 ss thrice a day in some mild fluid, or weak, bitter infusion. It is apt even in this form to offend the stomach, and its use cannot be persisted in a long time without seriously impairing the digestion. The bicarbonate of potash is a very efficient and rather pleasant lithic, it may be given an doses of 3 ss thrice a day. It is made more pleasant and grateful to the stomach by giving it with a few drops of some weak acid, acetic or citric, to be taken in the state of effervescence ; here the citrate and carbonate are taken together, in proportions which vary as more or less acid is added. If sufficient is added to drive off all the carbonic acid, you then have, of course, a solution of the salt of the vegetable acid, and this is the best way of taking citrate or tartrate of potash. Acetate of Potash. —This is the best lithic salt of potash. It is less apt than the others to disorder the digestion, and by the use of the full dose, 3 ss, three times a day, the urine may be kept alkaline, and the lithic acid diathesis kept in check for a long time. Still it must never be forgotten that this alkaline state of the urine may induce the formation of deposits of the phosphates, nor will the stomach always escape an evil influence even from this salt. Salts of Soda. —Of these, those chiefly used are lithics, the carbonate, the borate, the phosphates, and the salts of vegetable acids, in the form of effervescing mixtures. The carbonate is inferior to the salt of potash —so also are the salts formed with vegetable acids, though they are very much used in the form of soda powders. Borate of Soda — (Borax). —The virtues of borax as a lithic have long been celebrated among the Germans, and much relied on from the power its solution has of dissolving lithic acid ; in this it excels either of the alkaline carbonates. It has, too, the advantage that it can be used for a considerable length of time without any bad effects on the digestion. It is said to have a stimulating influence on the uterus, and to be on that account objectionable in females. Dr. G. Bird says he has known it to produce abortion in two cases. Phosphate of Soda. —The solvent powers of the solution of this salt are equal to those of borax, and it has been used as a lithic in many cases; its agreeable taste is a great recommendation ; it seems to sit well on the stomach, if given in a state of sufficient dilution. Dose. — 3 i to | ss twice a clay. It be taken in broth or gruel; its taste very nearly resembling that of common salt. In concluding the subject of the alkaline treatment of lithic acid diathesis, it is proper to repeat that alkalies exert no curative influence. The benefit to be derived from their use is palliation, and not cure." They correct acidity in the products of mal-assimilation, and ALTERATIVES. 555 for this purpose should be given in moderate doses, two to four hours after eating. Urine in which Phosphates are in excess. —Urine containing phosphates in excess is usually pale and of light specific gravity, 1.010, and secreted in large quantity.* It is usually acid when passed, but soon becomes alkaline when the phosphates fall in large quantity, as they are not in the absence of acid soluble in the urine. Unless the urine becomes alkaline, this deposit (spontaneous) of phosphates will not take place, even though they exist in very great quantity. The phosphatic deposit is white, or yellowish, or greyish white ; it is readily dissolved by adding hydrochloric acid, and reappears when this acid solution is supersaturated with ammonia; they are not affected by adding the alkalies or their carbonates, nor are they dissolved by heating the urine. On the contrary, if they exist in excess, the urine, though previously clear, is made turbid by boiling, so that we might suppose albumen was present. Adding nitric acid pretty freely to the urine will, by dissolving the phosphates, render it plain that albumen is not present. States of disease in which Phosphates occur in excess. —If the excess is but occasional, and varying in degree even when present —if the urine be deep-colored and of high specific gravity, the cause of the deposit is dyspepsia. The particular form of this disease in which we find these deposits, is that connected with great irritability, both of the system at large and the stomach, prostration of nervous energy, and general evidence of wear and tear of body and mind. When the urine is pale, of low specific gravit} 7 , and when the phosphates abound equally at all times of the day, and when this state of things continues for a considerable time, the phosphatic deposit probably depends either on organic disease of the bladder, prostate, or kidney, or some morbid state of the spine, consequent on injury or idiopathic disease. Therapeutics. —The deposit of phosphates very generally indicates a severe, and it accompanies a number of utterly uncurable diseases. The prognosis is, therefore, always grave when the deposit is constant. When it is but occasional, it generally depends, as before stated, on an irritative form of dyspepsia, but even here the probability is, that the nervous system is suffering severely. Very little can be done by lithics proper, in cither of these forms of disease. Some practitioners have strongly commended acids with a view of directly correcting the alkaline state of the urine. It is very doubtful whether either of the mineral acids have any such power, though some have attributed it to the nitric. * Sometimes the urine containing excess of phosphates is high-colored, and of a great specific gravity; this usually occurs where the precipitate depends on dyspepsia, and is only occasionally present. 556 MATERIA MEDICA AND THERAPEUTICS. Benzoic acid lias been highly praised, but its operation is excessively uncertain. These cases must be treated on general principles, and with particular reference to the disturbed state of innervation. Narcotics will always be required, and in many cases you will give them very freely. Tonics and alteratives judiciously combined, a well-regulated, plain, though nutritious diet, and good hygienic management, will do all that art can do for the more severe cases. the end. INDEX. Absorption of Medicines, 15 Acids, organic, 36 Acid, acetic, 336 arsenious, 483 citric, 335 nitric, 487 Bulphuric, 500 Aconite, 323 Aconitine, 325 Actea racemosa, 331 Affusion, 199 Alcohol, 415 Alkalies, organic, 39 Aloes, 119 Alteratives, 515 chemical, 545 local, 539 Alum, 499 Ammonia, 426 " carbonate of, 427 Ammoniac, 219 Anaesthetics, 392 Antacids, 546 Antimony, tartrate of, 80 wine of, 84 Antimoniali8 pulvis, 202 Antispasmodics, 430 Apium petrosilenum, 250 Apocinum canabinum, 246 Arabic, gum, 342 Argentum, 480 Aricinine, 469 Aristolochia serpentaria, 206 Arrow-root, 349 Arsenic, 483 Arum tryphyllum, 218 Ascarides, 149 Asclepias tuberosa, 205 Assafoetida, 238 Astringents, 489 Barley, 348 Belladonna, 385 Benne, 346 Bleeding, 269, 308 Brucine, 446 Buchu, 253 Cabbage (skunk), 439 Cahinca, 256 Cajeput oil, 440 Calomel, 141, 153, 189 Camphor, 428 Cantharides, 247, 507 Carrot, 253 Cassia fistula, 116 marylandica, 133 Castor oil, 110 Catechu, 494 Cathartics, 90, 109 Chalk, 547 Chamomile, 88 Charcoal, 121 Chemaphilla, 254 Chloroform, 400 Cicuta, 381 Cinchona, 458 Cinchonine, 469 Cod liver oil, 532 Codeia, 360 Colehicum, 321 Cold, 332 Colocynth, 137 Columba, 455 Conium maculatum, 381 Convolvulus pauduiatus, 244 Copaiba, 248 Copper, sulphate of, 84 Cornus florida, 469 Cotyledon umbellicus, 488 Co wage, 155 558 INDEX, Oeasof.e, 447 Greta, 547 Croton oil, 140 Cubebs, 251 Daucus carota, 253 Delphine, 329 Demulcents, 341 Diaphoretics, 191 Digitalis, 237 Diurotics, 226 Dogwood, 469 Doliehos pruriens, 155 Dover's powder, 204 Elaterinm, 138 Elm, 346 Emetics, 50, 65 Emetine, 79 Emmenagogues, 258 Enemata, 146 Ergot, 262 • Ether, 399 Eupatoiium, 204 Expectorants, 207 Fern, 156 Ferrum, 473 Flax seed, 347 Fowler's solution,j485 Gal lac, 493 Gall nut, 493 Gamboge, 135 Gentian, 457 Geranium maculatum, 497 Ginger, 413 Gold, 529 oxide of, 530 Goulard's Extract, 498 Guiac, 259 Hellebore, black, 136 Henbane, 378 Hop, 380 Humulus lupulus, 380 H3-drargyrum, 161 " cum creta, 186 Hydrargyri bichloras, 188 " oxidum, 186 " pilulffi, 143, 184 proto-chlor., 141, 168, 205,; " unguentum, 186 Hydrocyanic acid, 312 Hyosciumus niger, 378 Iodine, 520 " preparations of, 521 Ipecacuanha, 77, 231 Iron, 473 " nmmonio-tartrate 484 I " carbonate, 475 " citrate, 479 Iron, filings, 473 " lactate, 479 " muriated tincture, 479 " oxide of, 474 " phosphate, 478 " sulphate, 477 " tartrate, 478 Jalap, 122 Jujube, 346 Juniper, 245 Juniperus sabina, 259 Kino, 495 Kooso, 160 Lactucarium, 379 Lead, acetate of, 497 Leeches, 307, 289 Lemon, 334 Liquorice, 344 Liriodendron tulipifera, 471 Lithics, 550 Lobelia, 86 Lupulin, 381, 404 Mailia Azadarach, 159 Magnesia, 112, 569 " carbonate, 113 " sulphate, 126 Mallows, marsh, 344 Manna, 115 Marsh rosemary, 496 Materia Medica defined, 9 Matico, 501 May Apple, 123 Mezoreon, 537 Medicines, absorption, effects of, 12 " modus operandi of, 14 Medicines, classification of, 26 " combination of, 29 Mercury (see Hydrargyrum), " acid nitrate of, 545 Mindereri spiritus, 202 Morphine, 376 " sulphate of, 377 Moxa, 512 Musk, 436 Mustard, 81 Myrrh, 222, Narcotics, S53 Narcotine, 360 Nervines, 431 Nitre, 233 " sweet spirits of, 237 Nitro-muriatie liniment, 511 Nux vomica, 441 Oak bark, 496 Oatmeal, 348 Opium, 355 INDEX 559 Orange, 335 Papaver Somniferum, 855 Parturients, 262 Parsley, 252 Pereira brava, 255 Peril, balsam of, 220 * Phosphorus, 429 Phytolacca decandria, 123 Pill, blue, 143, 184 Pink root, 158 Pipsissewa, 254 Pluinbi acetas, 497 Podophyllum, 137, 156 Pomegranate, 158 Potassa, caustic, 543 citras, 203 " cum calce, 544 Potassaj nitras, 233 " carbonas, 548 " liquor, 548 " et sod. tart. 127 " acetas, 237 " sulphas, 129 " tartras, 127 Principles, vegetable proximate, 34 Prunus virginianus, 472 Pulse, 281 Pyrola umbellata, 254 Pyroligneous acid, 449 Quassia, 456 Quinine, 456 " sulphate of, 450 Refrigerants, 334 llevulsives, 502 Rhubarb, 117 Ricini oleum, 110 Rice, 349 Rochelle salts, 127 Rubefacients, 503 Sago, 350 Saliciue, 470 Salep, 352 Salix, 470 Salt, common, 159 Sanguinaria, 217 Sarsaparilla, 535 Sassafras, 537 Savin, 259 Scammony, 133 Scilla maritima, 84 Secale cornutum, 262 Sedatives, 269 Seneka, 215 Senna, 130 Sialagogues, 161 Silver, nitrate of, 481 " oxide of, 483 Simaruba, 45*7 Sinapis, 87 Soda, 549 " sulphate of, 124 " phosphate of, 129 Soot, 449 Spigelia Marylandica, 158 Squills, 84, 237, 261 Stimulants, 403 Stramonium, 388 Strychnine, 443 Sulphur, 114 Tamarinds, 116, 356 Tannin, 493 Tapioca, 351 Tartar, cream of, 128 " emetic, 80, 231 Tin, 155 Tobacco, 315 Tolu, balsam of, 221 Tonics, 450 Tragacanth, 343 Turpentine, oil of, 157, 2G3 Turpeth mineral, 88 Urine, states of, 550 Uva ursi, 254 Valerian, 437 Veratrine, 327 Veratrum album, 327 " viride, 327 Vinegar, 330 Water, 154 Willow, 470 "Winter green, 254 Worms, origin of, 15 " round, 149 " tape, 148 Zinc, oxide of, 486 « sulphate of, 83