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Barium Sulphate, N.N.R.-This preparation has largely superceded bismuth subnitrate and bismuth subcarbonate in roentgen-ray examinations of the stomach and intestines.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. preparation in this dose seems non-poisonous.

The

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: I 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

or less rapid movements of the bowels. If they are given in large or in repeated doses they are likely to cause inflammation, and very prostrating, if not poisonous effects. In other words, the drugs classed as irritant purgatives should not be used unless there is a positive indication for their use, such as systemic poisoning, or when some poisonous drug has been taken and very rapid evacuation of the bowels is necessary.

Cathartic drugs and even the laxative drugs are used too much; the people of this country seem to be cathartic crazy. One has but to read the advertisements of nostrums in one of our second class daily papers to realize that the American world must think itself constipated. If these advertisements did not sell the nostrums they represent, the cost of the advertising could not be paid.

Before discussing the indications for the use of cathartics, it is well to suggest when cathartics should not be used: (1) They should never be used habitually, even the laxatives, except by a small percentage of individuals. (2) Unless there is some special indication they should not be given as routine practice before operations. (3) Unless there is some special reason they should not be given too soon after an operation, or too soon after parturition. (4) They should not be given after a profuse diarrhea, although they should be given if the diarrhea has just begun. (5) They should not be given when there is acute abdominal pain, except possibly after a careful consideration of the diagnosis, when castor oil may be administered. (6) They should not be given in acute heart weakness. (7) They should not often be given in cardiac dropsy. (8) They should not be given in too large doses even in systemic poisoning.

In the beginning of most acute infections it is generally advisable to unload the bowels with some purgative, and to greatly modify the diet. It is also advisable during illness, when the heart is in good condition and the patient is taking food, to have the bowels move at least every other day. Under these conditions they may require the aid of some simple laxative or of an enema. The simplest and most effective enema is an ounce of glycerin and an ounce of water. It may be well to have the bowels move every day during illness, when the glycerin enema may

be given on one day and some simple laxative on the alternate day, if the bowels do not move without such treatment. If much fruit can be given, the bowels may move without help.

It has been a mistake to purge every patient before operation. It is also a mistake to give such a patient either divided doses of calomel or a saline too soon after an operation, and divided doses of calomel are almost always a mistake. A single proper dose is much better.

It is a mistake to cause purging in cardiac failure, in cardiac dropsy, and in cardiovascular-renal disease, as many a time the severe purging is the last straw to cause the patient to succumb.

It is not proposed to discuss here the whole treatment of constipation, but except for a short time it is a mistake for most individuals to take laxatives. Constipation is best treated: (1) by the regular habit of going to stool at the same time every day, best after breakfast; (2) by diet; (3) by exercise; (4) by massage and exercise of the abdominal muscles.

Constipation is a very common symptom of most diseases, and when the diagnosis is made and the general condition corrected the patient may have normal movements of the bowels. The frequency with which chronic abdominal disturbances cause constipation should also be recognized-whether gall-bladder disturbances, chronic appendicitis, ovarian disturbance, or some ulceration. The constipation then is purely a symptom.

The habit of the individual must be considered in deciding whether it is best for him to have one or two movements of the bowels a day; ordinarily one should be sufficient. If, however, he has hemorrhoids, or a tendency to hemorrhoids or congestion in the pelvic region, it is well to have a movement of the bowels before going to bed, thus relieving unnecessary pelvic pressure. On the other hand, some individuals, generally women, are perfectly well and perfectly healthy and have good digestion though they have a movement of the bowels only on every second, and sometimes on every third day. Movements of the bowels every third day does not seem to be normal; but if every second day is the habit, and the patient is well, he should not be disturbed by cathartics.

Some patients, especially those who cannot take much exer