bile. Obviously, then, it would be a mistake to administer hydrochloric acid or pepsin before the meal, and it would also be a mistake to give an alkali two hours after a meal. As a matter of fact, the pepsin of the stomach is rarely deficient, except in certain cases of pathologic conditions of the mucous membrane. The hydrochloric acid is often deficient. Therefore, many times indigestion will be quickly corrected by a proper arrangement of the diet and the administration of 5 or 10 drops of dilute hydrochloric acid, in water, after meals. Also an aid to digestion is a moderate amount of water, taken, not too cold, in the latter part of a meal or after a meal.

Unless the starchy food has been greatly diminished, sodium bicarbonate in 0.50 to 1 gram dose, combined with 0.50 to 1 gram of bismuth subcarbonate, taken three times a day, before meals, will also often aid digestion. The bismuth soothes a possibly irritated mucous membrane, and the bicarbonate of sodium prolongs the starch digestion.

Some of the so-called "hyperacidity" and pyrosis occurs because food remains too long in the stomach, from lack of motility of the stomach or from some other reason, and is due to the formation of lactic acid and is not due to an excess of hydrochloric acid. The administration of dilute hydrochloric acid in these cases corrects the condition by hastening the completion of normal digestion and apparently hastens the passage of the food into the duodenum. In these cases a glass or two of water drunk three or four hours after a meal is of benefit. If the hydrochloric acid increases the sensation of burning and acidity, it should, of course, be stopped.

As stated, unless there is some serious disease of the stomach, as atrophy of the gastric mucous membrane or cancer, pepsin is rarely needed, but in these conditions pepsin, in good sized doses, may be given in any pleasant manner.

While pancreatin will digest protein in neutral, as well as partially, perhaps, in faintly acid, medium its greatest activity is in alkaline medium. It has lately been disputed whether or not it is destroyed by passing through the stomach, namely, through the acid digestion, before it reaches the duodenum where it is normally active. It seems entirely unnecessary to

spend any time discussing this subject, as it is not necessary to give pancreatin as a digestant. To pre-digest food pancreatin is very valuable, and for this activity it is combined with a small amount of sodium bicarbonate.

A brief description of the drugs of this class will be found under their titles in Part II, the section of the United States Pharmacopoeia.

ANTACIDS

Treatment by drugs for this purpose is purely symptomatic treatment. Alkalies should not be used too long or too frequently, as they not only antagonize hyperacidity, but may cause irritation of the stomach by constantly stimulating the antagonistic action of the acid-secreting glands. As stated above, an alkali before meals may prolong the diastatic action of the saliva on starches, but if given some time after meals, will interfere with gastric protein digestion.

It is better, by diet and proper management, to prevent hyperacidity rather than to treat it, and the treatment of heartburn, pyrosis, and distress from hyperacidity is symptomatic, and many of the symptoms of hyperacidity are due to lactic acid. Too much hydrochloric acid may be secreted in nervous irritability and in mental tire and reflexly from some abdominal disturbance, or it may be due to some increased irritability of the stomach mucous membrane. Butter, bland oils, and arrangement of the diet may control the condition. Atropine so much used for hyperacidity generally fails to help 'this condition.

The drug most frequently used to combat gastric acidity is sodium bicarbonate, given either alone or combined with bismuth, or with peppermint, charcoal, or pepsin, and at times with ginger. The value of all of these so-called digestive tablets or powders lies principally in the bicarbonate of sodium. An effective dose of sodium bicarbonate is 0.50 to 1 Gm., repeated in fifteen minutes or half an hour, if needed, taken with plenty of water, and most efficacious in hot water. If there is much gas, causing distress, the official Spiritus Ammonia Aromaticus in half a teaspoonful dose, taken well diluted, is an efficient remedy. This may be repeated in half an hour, if needed.

A more sedative antacid for the stomach is magnesia, and the best preparation is a milk of magnesia, given in warm water in 1, 2, or 3 teaspoonful doses. It may be repeated in an hour, if needed. Magnesia has slight laxative properites.

Magnesium oxide may also be used as a mild antacid. Calcium is also used as prepared chalk (Creta Præparata), as the precipitated calcium carbonate (Calcii Carbonas Præcipitatus), or as the official lime water (Liquor Calcis). These drugs and preparations are described in Part II, under the section on the United States Pharmacopoeia.

DRUGS USED TO RELIEVE IRRITATION IN THE STOMACH

Irritation or inflammation of the stomach mucous membrane is the same as irritation or inflammation of any mucous membrane, and requires to be soothed in the same way. The food must be bland, if it is not temporarily prohibited, plenty of water must be taken, and many times demulcent drinks, as albumin water, flaxseed or slippery elm tea, or some other bland drink. When properly prepared and in good condition, milk of magnesia given with warm water is one of the most soothing preparations.

The drugs most frequently used to relieve gastric irritation are the bismuth preparations, and of these the best is the subcarbonate. Sometimes the subgallate with its slightly greater astringency is the salt of preference. The subnitrate of bismuth is the salt that has been and is still used the most. In certain conditions of the stomach and intestines, such as a fresh ulcerated absorbing surface, this salt may cause poisoning. The subcarbonate cannot cause such poisoning.

There is no good reason why silver nitrate should ever be given internally, although it has been used frequently in chronic inflammation and ulceration of the stomach. It may do harm.

Suprarenal preparations have been used to prevent or inhibit hemorrhage from the stomach. Tannic acid has been used for stomach conditions, but it is more or less nauseating and slightly irritant. The non-irritant protein combinations of tannic acid do not develop tannic acid action until they have reached the intestines.

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 71⁄2 grains); but the combination of bismuth subcarbonate and