irritant to the skin and mucous membranes, the merest whiff of ipecac causing some individuals to sneeze and have symptoms of hay fever and even asthma. Ipecac is rapidly absorbed, and promotes the secretion of the glands of the mucous membranes and of the salivary glands. The drug and its alkaloid emetine are eliminated to some extent through the intestinal walls, and during such elimination kill the ameba which may be harbored there in amebic dysentery. In combination with opium in the Dover's powder it promotes perspiration.

Over-action. The most frequent symptom of over-action of ipecac is, of course, nausea and vomiting, and it may also irritate the intestines and cause diarrhea. Large doses of emetine have caused paralysis, prostration, and even fatal cardiac failure. Some individuals who are very susceptible to the action of ipecac when taken internally, have an eruption on the skin, erythematous or urticarial in type.

Treatment of Poisoning. The treatment of poisoning, if such should occur, is evacuation of the stomach and bowels, the hypodermatic administration of morphine to stop the vomiting, and atropine and strychnine, hypodermatically, to overcome any depression that may be present.

Uses. The principal use of ipecac is as an emetic, and the best dose of the powdered ipecac for this purpose is 2 Gm,. (30 grains). If the syrup of ipecac is used, the dose for an adult is I or 2 tablespoonfuls.

As above outlined, a valuable use of ipecac is to cause increased secretion of dry mucous membranes, thus diminishing their congestion. As soon as the mucous membranes of the air passages secrete freely, distress is diminished, obstructive swelling is reduced, and if the bronchial tubes are affected, coughing becomes easier and the secretion is more easily expectorated.

The use of emetine in amebic dysentery has already been described; see page 181. It has also been stated that emetine bismuth iodide is perhaps the best preparation to give by the mouth for the treatment of that disease. This preparation is not official.

Emetine, either used locally or given by injection, destroys the ameba which occurs in pyorrhea alveolaris, but as it does

DRUGS TO DECREASE SECRETION OF MUCOUS MEMBRANES 205

not destroy the more important pathologic germs always associated with the endameba, and as it has not been shown that the endameba has any pathogenic importance, the much lauded emetine treatment of pyorrhea alveolaris becomes of little importance.

DRUGS USED TO DECREASE THE SECRETION OF THE MUCOUS MEMBRANES

Ammonium chloride in medium sized doses is often successful in hurrying an inflammation of a mucous membrane back to health. Terpin hydrate is another very useful drug for this purpose. Morphine and codeine will not only act as sedatives in irritated conditions of the mucous membranes of the upper air passages, but they also tend to dry the mucous membranes, often more than is desired. Atropine dries the nose, throat, and bronchial tubes, much as it inhibits most other secretions. Atropine is rarely advisable except as an abortive treatment for colds, when it may be given in small doses, frequently repeated (as 500 of a grain of atropine sulphate every three hours for ten doses), and in such profuse bronchorrhea as would occur in the undesirable action of pilocarpine.

Many of the balsams and aromatic oils, either inhaled or administered by the mouth, often tend to diminish the secretion of the air passages.

The best treatment in continued colds and continued simple bronchitis is often by tonics, as represented by the following prescription:

Take a capsule three times a day, after meals.

The above tonic capsule is a suggestion, but any tonic treatment is of value. The hypophosphites are absolutely of no value, and the only reason that a hypophosphite preparation does good is because it is combined with quinine, strychnine and iron.

Cod-liver oil may be a very valuable treatment in certain conditions of prolonged bronchitis; when the circulation is impaired, digitalis is of benefit.

Change of climate to a drier air and especially to an atmosphere of pine woods, is often advisable, even when no serious trouble with the lungs is suspected. Prolonged colds and coughs, and recurrent colds and coughs, should be considered as possible precursors of tuberculosis and treated accordingly. There is absolutely no need for, and no value in, all of the many old so-called expectorants, cough syrups and cough mixtures. The drugs mentioned above are sufficient for the treatment of bronchitis.

At times a prolonged cough with expectoration may be well treated by small doses of sodium iodide, which seems to promote healing. An iodide is especially indicated when there is an asthmatic condition with the bronchitis.

Terpin Hydrate.-Terpin hydrate occurs as colorless prisms, which are slightly bitter in taste and practically insoluble in water. It is non-irritant and non-poisonous in all ordinary doses. It is best administered in powder, in capsules, or as tablets to be crushed with the teeth before swallowing. The dose is about 0.30 Gm. (5 grains), taken with plenty of water, three, four, or five times a day. This drug tends to dry up secretions of the air passages, and does not interfere with the appetite or irritate the stomach in any way. Tablets of terpin hydrate in combination with heroin are very frequently ordered, and have been extensively used, but it is best not to administer heroin. If a sedative is required, codeine is better; heroin is not needed.

DRUGS USED TO RELAX SPASM

Contractions of parts of the air passages occur in asthma and in croup. In spasmodic croup an emetic such as the syrup of ipecac is indicated, with inhalations of steam and hot moist applications to the neck.

Asthma is a frequent and very troublesome condition, and an asthmatic attack requires treatment by one of the drugs suggested in this classification. An asthmatic condition may be due to a chronic disturbance as emphysema, and it may be due

to an insufficient heart. The blood-pressure may be too high or may be too low, and proper treatment, in the first instance to reduce the blood-pressure, and in the second instance to increase the strength of the heart, will tend to remove the asthmatic condition.

Many times the best treatment of acute asthma is by nitroglycerin in doses of 1100 of a grain, dissolved on the tongue, and repeated in fifteen minutes, if relief is not obtained. When frontal headache is caused by this drug the spasm of the bronchial tubes will be relaxed. If there is considerable venous congestion and the heart is laboring and insufficient, suprarenal preparations given for absorption in the mouth, either as 5 to 10 drops of adrenalin solution (1-1000), or as a suprarenal tablet dissolved in the mouth, will be useful.

Various substances to be burned and the fumes inhaled, or to be smoked, all containing atropine in some form, most frequently as stramonium leaves, and most of them containing a nitrite (generally the nitrate of potassium) tend to relax spasm and cause relief. It is probable that atropine sulphate injected hypodermatically will act as well as the inhaled fumes of stramonium leaves. The slower acting but often effective bromides and chloral may be administered, provided the circulation is good.

Morphine should be given only in exceptional cases and when the indication is urgent. Many an asthmatic patient has become addicted to the use of morphine, and the physician cannot be too careful lest he cause such a habit.

CLASS IV

DRUGS USED FOR ACTION ON THE CIRCULATION

The care of the heart and circulation becomes of more importance every year, as we have developed a condition of nervous tension, and the circulation is easily thrown out of balance. The advance of civilization has weakened the circulatory power as evidenced during the ages, first by patients surviving most terrible bleedings; then vomitings; then purgings; then the use of aconite; then the use of alcohol as a "stimu

lant;" then the use of coal-tar drugs to combat fever; and then the starvation era. Next came the recent strychnine age; and now we have reached the digitalis age, and each, in its era, was considered the proper treatment of serious illness. This chronological story shows that the reserve strength of the heart has grown less and less, and it is the reserve strength of the heart upon which the individual must depend in emergencies.

The following are some of the reasons for the progressive circulatory insufficiency, and especially for the lack of reserve strength of the heart at the present time:

1. Less sleep than is necessary for rest of the brain and heart. 2. More excitement: rapid travel, constant dangers, more evening amusements, bright lights, more noise, more calls on one's attention, and the need for rapid execution of duties.

3. A large assortment of rich foods that cause, sooner or later, substances to be produced and absorbed that are irritant to the brain or depressant to the heart, or that cause high tension. 4. Too much tea and coffee.

5. Too much tobacco.

6. Strenuosity needed to keep up with the times.

7. Strenuosity not needed, but assumed: too much competitive athletics, too much dancing, too much misdirected exercise by those who are not in condition for it.

8. Business and household frets of the age.

9. Impatience with, and unwillingness to stand, even a little pain, and the consequent taking of depressant analgesic drugs, especially the coal-tar and synthetic drugs.

10. Mouth infection, and consequent endocrine gland disturbance.

These are probably not all of the causes of the weakened hearts of this age, but be the causes what they may, the physician's primary duty to-day, with every illness and with every operation, is to care for the heart. The blood-pressure must be watched; the anesthesia must be short; even nerves must be blocked to relieve shock; strychnine, atropine, caffeine, camphor, epinephrine and pituitary stimulation may have to be given; transfusion may be required; and, now, even purging