Bismuth Subcarbonate.-Administration.-The subcarbonate of bismuth occurs as a yellowish white powder, insoluble in alcohol and water. For action in the stomach it is best administered in powder in a dose of 0.50 to 2 Gm. It may, or may not, be combined with bicarbonate of sodium, but many times the sedative action in the stomach is better when so combined, as I Gm. of subcarbonate of bismuth and 0.50 Gm. of bicarbonate of sodium, taken three times a day, just before meals. If it is very disagreeable for the patient to take a powder as such, the bismuth salt may be given in a small glass of vichy or other sparkling water; the bubbles suspend the heavy salt and the whole may be drunk as a liquid.

If it is desired that the stomach should be well coated with bismuth for sedative and astringent purposes, as perhaps in ulcer, the best method is to give a large dose, at least 2 Gm. (30 grains) at one dose, before breakfast, preceded half an hour by a cup of hot water.

For action on the intestines, as for acute diarrhea, a gram of the subcarbonate of bismuth may be given every two hours for ten doses, best combined with phenyl salicylate (salol) in 0.30 Gm. (5 grain) doses. For astringent action for a chronic condition in the bowels, bismuth subcarbonate may be given in capsules of 0.30 to 0.50 Gm., or in 5 or 10 grain tablets every three or four hours for some days. Bismuth should not be given too long, as it tends to cause constipation and the formation of hardened masses of feces in the intestines.

Action.-Bismuth subcarbonate has no action on the skin except that of a dry protective powder; on ulcerated surfaces it has a slightly astringent action. Bismuth powder should not be used on a fresh raw surface, whether an acute burn, a blister, or a denuded surface from an injury, as absorption and metallic poisoning may occur.

The action of bismuth throughout the alimentary tract is a local one. It is soothing and mildly astringent. In the large intestine sulphide of bismuth is formed which causes the stool to become black and the feces to have more or less of a sulphurous odor.

It is doubtful if bismuth subcarbonate can cause poisoning.

The subnitrate has, rarely, caused poisoning, sometimes serious, (possibly sometimes contaminated with arsenic) due to the formation of nitric acid and nitrites. The symptoms have been inflammation of the duodenum, liver, and kidneys. When bismuth salts have been absorbed from fresh wounds the symptoms are those of a metallic poison, not dissimilar to mercurial poisoning; the treatment is the same as that for other metallic poisons.

Uses. The principal use of subcarbonate of bismuth is in gastric and intestinal irritations and inflammations. It is of little value in inflammation of the lower part of the small intestine or of the large intestine. It is of value in ulceration of the large intestine when given by colon injections.

Bismuthi Subnitras.-Subnitrate of bismuth occurs as a heavy white powder insoluble in alcohol and water. It has been used much more frequently than the subcarbonate of bismuth and for the same purposes, and in the same doses. The action is the same, with the exception, as above stated, that the subcarbonate is a safer preparation to use.

Bismuthi Subgallas.-The subgallate of bismuth ("Dermatol") occurs as a bright yellow powder, and is insoluble in water and alcohol. This preparation has been used externally as a drying powder more frequently than the other forms of bismuth, especially on moist eczemas, and for sweating axillae and feet. It is a finer, lighter powder than the other salts of bismuth. Its best action internally is in chronic intestinal disturbances, and is best given in capsules containing 0.30 to 0.50 Gm. (5 to 71⁄2 grains), three or four times a day. The action is similar to that of the subcarbonate.

Bismuthi Betanaphtholas.—Bismuth betanaphthol (“Orphol") is a compound of bismuth and betanaphthol, containing not less than 15 per cent. of betanaphthol. This preparation occurs as a yellowish or grayish-brown powder which is insoluble in water and alcohol. In the intestines the naphthol is released from this salt and causes more or less antiseptic action. It has been used as an astringent antiseptic in diarrhea, best given in capsules, in doses of from 0.30 to 0.50 Gm. (5 to 71⁄22 grains); but the combination of bismuth subcarbonate and

phenyl salicylate, as above suggested, is better in diarrheal conditions.

Bismuthi Tribromphenas, N.N.R.-Bismuth Tribromphenate (Xeroform) is an amorphous, yellow, tasteless powder, which is very slightly soluble in water. It is recommended for use externally in the place of iodoform. as being non-irritant and having mild antiseptic properties.

Other official preparations of bismuth are not needed.

Barium Sulphate, N.N.R.-This preparation has largely superceded bismuth subnitrate and bismuth subcarbonate in roentgen-ray examinations of the stomach and intestines. About 2 ounces of barium sulphate are administered, mixed with some cereal gruel. There is no medicinal use for barium. The preparation in this dose seems non-poisonous.

EMETICS

The irritant emetic drugs in the order of their activity are: mustard, ipecac, zinc sulphate, copper sulphate. The simplest of these, namely, mustard, may be given in a dose of a tablespoonful or more, stirred in a glass of warm water. The emetic dose of powered ipecac is 2 Gm. (30 grains), also given stirred in a glass of water; or the syrup of ipecac may be given in 1, 2, or 3 teaspoonful doses, and repeated in ten or fifteen minutes, if vomiting has not been caused. The emetic dose of zinc sulphate is 2 Gm. dissolved in half a glass of water, not to be repeated. If vomiting does not occur within ten or fifteen minutes, the stomach should be washed out.

A good combination to be carried in the emergency bag is: 1 Gm. of zinc sulphate and 2 Gm. of powdered ipecac, a powder to be administered at once, and repeated in fifteen minutes, if vomiting has not been caused.

Copper sulphate is the most active of these irritant emetics, and the dose should be 0.50 Gm. (71⁄2 grains) dissolved in warm water, given at once. If vomiting does not occur in five or ten minutes, the stomach should be washed out.

The emetic drug that acts on the vomiting center, when administered hypodermatically is apomorphine.

Apomorphine Hydrochloride.- Administration.—Apomorphine is an alkaloid prepared from morphine by the abstraction of one molecule of water; the hydrochloride is the official preparation. This salt occurs as minute white or greenish-white prisms, which soon become green, and the solutions become green, on exposure to light and air. It is not very soluble in water.

There is no good use for this drug except as an emetic, and as such it should always be given hypodermatically. The hypodermatic dose is 0.005 to 0.006 Gm. (12 to 10 grain).

Action.-When given hypodermatically vomiting occurs within a few minutes, unless some narcotic poison has been taken, when it may take longer for its action. The vomiting is caused by direct action on the vomiting center in the medulla. The emetic dose rarely requires to be repeated, but if nausea persists or vomiting is frequent, prostration is caused and sometimes collapse. For this reason, as soon as the stomach has been thoroughly emptied, stimulants, best atropine and caffeine, should be given. Of course in poisoning that necessitated the use of apomorphine, the particular poisoning must be treated, but if the poison was a depressant, apomorphine must be used with care.

Uses. Although apomorphine has been recommended as an expectorant, to be used to promote secretion of the air passages, it is not good treatment, as it is too depressant. There is no real good reason for administering apomorphine for any purpose except to cause vomiting, and then it should be given hypodermatically or intramuscularly. It may be used to produce vomiting in such conditions as when there is intense gastric pain from contractions of the stomach with the cardia and pylorus closed. Apomorphine will almost instantly relax the spasm of these sphincters, especially of the cardia.

CLASS V

DRUGS USED FOR LOCAL ACTION IN THE INTESTINAL CANAL

CARMINATIVES

All spices, preparations of spices and aromatic oils increase peristalsis and hence have carminative action. Of the spices, capsicum, ginger,and peppermint are the best, while asafetida

(a garlic) is also a promotor of peristalsis. Onions act as carminatives, hence onion broth is as efficient as asafetida pills. Anise is often given to babies for intestinal flatulence.

Turpentine enemas are given to relieve intestinal distention, and cold to the abdomen promotes peristalsis. Heat applications to the abdomen in the form of stupes relieve localized abdominal congestion and may thus relieve spasm of some part of the intestines and promote peristalsis. Dry heat applications to the abdomen also relieve local congestion and spasm and hence promote normal peristalsis.

Intramuscular injections of ergot are of value in intestinal paresis, and atropine, in large doses, is of benefit in intestinal spasm and colic by relieving a spastic condition of some part of the intestine and thus allowing normal peristalsis to occur. Pituitary extracts, given hypodermatically, also increase peristalsis.

CATHARTICS

These drugs are well sub-classed, for therapeutic purposes, into laxatives, purgatives, saline purgatives, and irritant purgatives.

A laxative drug is one that may be used ordinarily for a long time without causing inflammation of the gastrointestinal tract or a tendency to a worse condition of constipation.

A purgative is a drug that is used once (repeated if needed) to more or less rapidly evacuate the bowels. These drugs should not be used continuously, or be taken repeatedly, as they are likely to irritate the intestine; cause inflammation; cause too much depletion; and increase a tendency to constipation.

The saline purgatives are mineral salts, which are very useful in causing rapid evacuation of the bowels. In certain conditions a small dose of one of these saline drugs, given before breakfast, may be good medication, as in over-weight, in plethora, at times in insufficiency of the kidneys, and in high blood-pressure; but simply for the treatment of constipation saline purgatives should not be used.

The irritant purgatives are those that cause very active, more