temic toxins through the bowels has been over estimated. The salines, when given in concentrated solutions and when the amount of water ingested is diminished, may cause absorption of exudates and effusions.

IRRITANT PURGATIVES

The drastic or irritant purgatives that are most used are colocynth, croton oil, elaterium, and jalap. Colocynth is never used alone, but always in combination with some other cathartic. It is doubtful if the drug is needed.

Croton oil is a very rapidly acting cathartic, and in some comatose conditions, when there is no obstruction of the bowels it has therapeutic value.

Elaterium has been much used to cause watery purging, with the object of eliminating toxins, by the bowels, that cannot be excreted by deficient kidneys. It is doubtful if nitrogenous poisons can be much eliminated by this method. Elaterium has also been much used in dropsies, with the object of eliminating large amounts of water by way of the intestines, thus promoting absorption and aiding the removal of effusions. It is thought to be especially valuable when the kidneys do not work and diuretics are not satisfactory. Catharsis from this drug is very weakening, and unless the heart is strong, the drug should not be used.

Jalap is generally given in combination with some other cathartic, also with the object of causing watery stools, and therefore depletion. Its action is not so depressant to the circulation as is elaterium.

To sum up the discussion of irritant purgatives, it may be stated that croton oil is rarely needed, but is a most efficient, quickly acting cathartic; that elaterium is very rarely indicated; and that jalap may be occasionally used. These drugs have come into disrepute because it has been found that large depletion by the bowels is very depressant to the circulation, and that in most dropsies there is cardiac insufficiency, and anything that increases that insufficiency is serious for the patient. Many a patient with cardiac dropsy has had his death hastened by profuse catharsis. Another reason that

these drugs have come into disrepute is because it has been learned, as above stated, that in insufficiency of the kidneys the irritants that are retained in the blood and act as toxic poisons cannot be eliminated in any great amounts by profuse purging. Colocynth (Bitter Apple) when used at all is given in combination with other drugs. It is an active irritant cathartic, and would not be mentioned here if the official Compound Extract of Colocynth (which contains, besides colocynth, aloes and resin of scammony) was not, unnecessarily, frequently added to cathartic combinations. It is also mentioned because it enters into the combination of the Compound Cathartic Pill, which is used so largely in all hospitals.

Croton Oil is a yellow fixed oil, irritant to the skin and mucous membranes. When rubbed on the skin it will cause a pustular eruption, and has been used as a counterirritant, but is now rarely used externally. Internally it is an irritant, unless well diluted. When absorbed from any part of the alimentary canal it will soon cause purging. Over-action of this drug, as of any of the other irritant cathartics, will cause an inflammation of the intestine. The dose is one or two drops, well diluted. If the patient is comatose, it may be given on granulated sugar for absorption in the mouth. Catharsis generally occurs in from one to two hours.

Jalap is used only in some preparations. It is an active, mildly irritant cathartic, causing watery movements in three or four hours. It enters into the combination of the Compound Cathartic Pill in the form of the official resin. The best preparation of jalap, if watery movements of the bowels are desired without danger of much irritation or much depression, is the official Pulvis Jalapa Compositus. This powder contains 35 parts of jalap and 65 parts of potassium bitartrate, and the dose is 2 Gm. (30 grains), which may be repeated in four to six hours, if it has not satisfactorily acted.

Compound Cathartic Pills are ancient and fairly honorable, but are certainly not up to date. Few prescribers recognize that this pill represents a combination of eight ingredients, namely, colocynth, aloes, scammony, calomel, jalap, gamboge, cardamom seed and soap. This shotgun prescription may

produce the desired results, but its use is simply a matter of habit. Other more simple purgatives will succeed as well, and in this age of simplicity in the medicinal treatment of disease the compound cathartic pill should be eliminated.

DRUGS USED TO DIMINISH INTESTINAL PUTREFACTION

It has long been a question of doubt as to the efficiency of the so-called bowel antiseptics. Certain specific germs can be killed in the intestine with special germicides, but, of course, it is impossible to render the intestines aseptic. On the other hand, the different flora of the intestines can be changed, not only by diet, but by drugs. A change from an animal protein diet to a vegetable diet will change the intestinal flora. A change from a mixed diet to a pure milk diet, or the reverse, will also change the intestinal flora. Probably many drugs act as antiseptics in the upper part of the intestine; most of the salicylic acid preparations and some of the phenol combinations have such action. Perhaps some of the synthetic drugs, especially the antipyretics, and some of the metallic drugs, especially calomel, will have some antiseptic action in the upper part of the intestines; but the drugs that are most successful in causing some sort of antiseptic action in this region are betanaphthol and salol. Betanaphthol can act as a depressant poison, and consequently, except when intestinal parasites are to be eradicated, the drug should not often be used in intestinal putrefaction. Salol (phenyl salicylate) is the best of the bowel antiseptics, as it is changed in the upper intestine (in alkaline solutions) into salicylic acid and phenol. In ordinary doses for a short length of time it is non-poisonous, and the only symptoms of poisoning are those of a weak phenol.

The most successful method of diminishing intestinal putrefaction is by a radical change in the diet in which all protein is temporarily removed, especially all meat proteins. Various forms of lactic acid bacilli and various forms of fermented milk are used to check putrefaction.

It has long been considered that the B. bulgaricus was the best of the lactic acid bacilli for the purpose of changing the bacterial flora in the intestine and for preventing putrefaction. Lately,

however, Rettger1 has shown that this bacillus cannot be transplanted into the intestine, but that it allows to develop the B. acidophilus, a normal constituent of the intestine, and it is this bacillus which is capable of changing the intestinal flora. Consequently, theoretically it would seem more logical to administer directly the B. acidophilus, perhaps preferably as milk soured by this germ. Besides the various forms of bacillary milk offered, liquid cultures may be obtained and taken with water or the tablets of Bulgarian bacilli may be chewed up and swallowed after meals. If the food previously taken has not contained starch and sugar, a small amount of sugar, best sugar of milk, should be eaten or taken with the tablets or culture.

Yeast, both brewers' yeast and the ordinary compressed yeast, is valuable in changing the intestinal flora. The organism this yeast contains is the saccharomyces cerevisia. Yeast contains a large amount of nuclein. It may liberate lactic acid, and not only yeast preparations, but also the Bulgarian bacilli preparations, should not be given for any great length of time, as they tend to cause hyperacidity and joint pains. It is best to give lactic bacilli preparations intermittently, thus changing the intestinal flora for a time, then allowing the reverse change by stopping the treatment, and then to again give the bacilli. Lactic bacilli treatment combined with the proper diet will many times completely eliminate intestinal putrefaction.

Yeast has long been administered in infections, and is frequently a very valuable treatment. It cleans the tongue, causes movements of the bowels, stimulates the production of white corpuscles, and seems at times to combat streptococcic infections. It has also been used locally for various purulent conditions in douches and washes. Brewers' yeast can be used in full strength or diluted for such purposes. Internally, the dose is a tablespoonful of liquid brewers' yeast, well diluted, or from to 1⁄2 of a compressed yeast cake, dissolved in a glass of water. This dose may be taken once, twice, or three times a day, as deemed advisable, the dose to be reduced, if it causes

1 Proceedings of the National Academy of Sciences. Vol. 6, No. 7, p. 423 July, 1920.

purging or nausea. This soured drink is not disagreeable to most people, and may be agreeable to those who have fever.

Dried preparations of brewers' yeast may be obtained, but they are not quite as satisfactory as are the fresh preparations. The dried brewers' yeast is quite efficient as a carrier of vitamines that are activators of nutrition and stimulants to the appetite. The dose for this purpose is one gram (15 grains) three times a day, taken with the meals. Unless special care is taken in the method of drying and preserving this yeast, it readily becomes wormy.

It has been learned that sugar of milk (lactose), dextrose (glucose) and dextri-maltose (i.e., dextrine and maltose) act more or less as preventives of intestinal putrefaction. They are therefore valuable additions to the foods of individuals who are suffering from that condition, and prevent such putrefaction when added to the milk and other artificial food of young children.

ANTHELMINTICS

The intestinal parasites that are common and must be medicinally eradicated are the tapeworms (tenia), of which there are three principal varieties, the pork, the beef, and the fish, the last being rare in this country; the round-worm (ascaris lumbricoides); the pin-worm (oxyuris vermicularis); and the hookworm (necator Americanus). Another chronic infection of the intestine is the ameba, the cause of amebic dysentery. Acute infections of the intestines, as occur in typhoid fever, and carriers of pathogenic germs in the intestines, are not cured by anthelmintics. The stools of all patients who have intestinal parasites of any kind should be disinfected.

Tape-worms. The drugs used to eradicate tape-worms are, aspidium, pelletierine tannate, and pumpkin and squash seeds. Pomegranate has also been used for this purpose. Pumpkin and squash seeds are harmless and infusions (not boiled) of ground pumpkin or squash seeds are often very successful in eradicating the worm. A treatment is not successful unless the head of the tape-worm is eliminated. The most used drug is aspidium (male fern), but a drug much in vogue to-day is pelletierine tannate.