As above stated, other forms of rheumatism are not as successfully treated with salicylates, with the exception of subacute arthritis. However, in many patients who seem to be rheumatic and who have sciatica or other neuralgic conditions due to some infection or to some uric acid mistake in the metabolism, salicylates, given for a few days, often improve the condition. Of course in every such case the diet should be so regulated as to remove most purins, and frequently meat should be stopped entirely, and patients with acute rheumatism should generally not be allowed meat for several weeks. Although uric acid is not the cause of rheumatism, it may be increased in amount and be retained in rheumatic conditions. Also, these patients are very generally hyper-acid, and are much benefited by alkaline treatment, and are frequently improved by a vegetable protein and carbohydrate diet.

Contraindications to the use of salicylates are cerebral inflammations and disturbances, disease of the ear, deafness, acute cardiac inflammation, and nephritis.

Phenyl Salicylate (Salol).-Phenyl salicylate occurs as a white crystalline powder, has an aromatic odor, is insoluble in water, and the dose is 0.30 Gm. (5 grains).

Phenyl salicylate (salol) should not often be used in rheumatism. Its greatest efficiency is as an antiseptic in the bowels and in the urinary tract. When this drug is given in too frequent or too large doses, poisoning occurs, with black urine and the nervous disturbances caused by its phenol. Occasionally may cause salicylism.

it

Salol is not dissolved in acid media, but breaks up in the intestine into its component parts of phenol and salicylic acid, and, therefore, acts more or less as an antiseptic in the upper part of the intestines and tends to prevent putrefaction and fermentation, and causes constipation. In any acute diarrhea salol is a most efficient remedy, always provided there is no albuminuria or other serious disturbance of the kidneys, as it should not be given when the kidneys are in trouble.

Acute diarrhea is well treated by a purgative, followed by bismuth subcarbonate 1 Gm. (15 grains), and phenyl salicylate 0.30 Gm. (5 grains), one such powder given every two or three

hours for ten doses. Most diarrheas will stop with such treatment.

In typhoid fever salol is frequently given as a bowel antiseptic, and the dose should be 0.25 Gm. (4 grains), in capsule, once in six hours, unless the kidneys are in trouble. It may be given throughout the acute illness, if some other treatment is not preferred. It may prevent the typhoid germs from migrating upwards in the intestine, and the typhoid and colon bacilli from locating in the pelvis of the kidney. There is no question of the antiseptic action of salol in the upper part of the intestines, and also in the kidneys and bladder.

Salol has been much used in infection of the pelvis of the kidney and in infection of the bladder, and also in specific urethritis. Hexamethylenamine has more or less supplanted this drug, but salol is many times a valuable treatment during acute infection of these parts. It has been thought, in specific urethritis that it at times prevents the gonococci from reaching the posterior urethra and bladder.

Salol is not a good treatment in acute rheumatism, as in such a condition the dose must be large and phenol poisoning would be readily caused.

CLASS IX

DRUGS USED TO MODIFY METABOLISM

ARSENIC

Arsenic in sufficient dose is a germicide, and is especially efficient in combating certain germs. In large doses it is a promotor of waste metabolism to the point of destruction of tissue and stoppage of function. In small doses it is stimulant to most functions of the body, and if not too long continued acts as a tonic, and may cause increase of weight. Repeated overdoses or long continued small doses may seriously impair the suprarenal glands.

Arseni Trioxidum (White Arsenic).—Arsenous acid occurs as a white substance, is tasteless but soon irritant, is soluble in water, and the dose is 0.002 Gm. (30 grain). The most used preparation is the Liquor Potassii Arsenitis, (Fowler's Solution),

which is a 1 per cent. solution of arsenous acid, and the dose is 0.2 mil (3 minims).

Arseni Iodidum.-Arsenic iodide occurs as an orange-red crystalline powder, is soluble in water, and the dose is 0.005 Gm. (12 grain).

Sodii Cacodylas (Sodium Dimethylarsenate).-Sodium cacodylate occurs as a white granular powder, is very soluble in water, and the dose is 0.06 Gm. (1 grain).

Sodii Arsenilas (Atoxyl) occurs as white crystals, which are soluble in water, and the dose is 0.02 Gm. ( grain). This drug should not be given by the mouth, as it is likely to be decomposed by the acid of the stomach and cause poisoning. It is intended for hypodermatic administration in the dose above suggested. The dose may be increased, as with any other arsenic treatment, to the point of tolerance. It is best administered every other day, so that it will not be as likely to accumulate in the system.

This preparation has largely been recommended in anemias and in certain diseases of the skin, but, like any other arsenic treatment, it may cause serious symptoms, as destruction of blood corpuscles and optic neuritis.

The arsphenamine preparations are described on page 347. Administration.-When arsenic is given in small doses for its stimulating effect on metabolism, or as a stimulant to the bloodforming organs, it may be given in solid form, as the arsenous acid, and is well given in a soluble tablet, or in a pill or capsule, or in the form of the sodium cacodylate. This latter preparation has, however, no apparent advantage over the older trioxide of arsenic. When it is desired to push an arsenic treatment, it should be administered in solution, and the best solution is the Liquor Potassii Arsenitis (Fowler's Solution). This may be administered in drops, gradually increased to the point of tolerance, and there is no possibility of any accumulation of this soluble form of arsenic in the gastrointestinal canal. If it is deemed best to give the arsenic hypodermatically for systemic effect, the sodium arsenilas is perhaps the best form. For intravenous treatment and for intraspinal treatment, mostly in syphilis, arsphenamine or neoarsphenamine are the preparations to use.

Action. Locally strong preparations of arsenic are escharotic, but arsenic should rarely be used for that purpose; other treatments to destroy tissue are preferable and much less painful.

Arsenic is more or less rapidly absorbed from the stomach and intestines, and many times acts as a stimulant to the organism, increasing the appetite, improving digestion, causing the patient to add weight by the deposition of fat, improving the nutrition of the hair, nails and skin, increasing the exfoliation of the epidermis, and causing a more healthy nutrition of the skin in general. For this purpose arsenic is often used in the scaly, dry skin diseases.

After absorption into the blood, arsenic is found chiefly in the corpuscles rather than in the serum. It is a stimulant to the red bone-marrow, and increases the production of red corpuscles up to a certain point. Therefore it is of advantage in many cases of anemia, and has been used largely in pernicious anemia and in leukemia. However, when the drug is pushed, or has been given for some time, there may occur a rapid destruction of red corpuscles, the arsenic seeming to have a hemolytic effect. Sometimes in such conditions as lymphatic leukemia the white corpuscles are occasionally increased in number by the action of this drug.

Arsenic seems to be a stimulant to all glandular tissues, and probably to the thyroid. It has often been used to reduce the size of enlarged lymphatic glands, especially of the neck. Its success is perhaps largely due to its germicidal effect on whatever organism was causing enlargement of the glands. It is also quite probable that its good effect in pernicious anemia and leukemia is because it acts as a germicide to the infecting organisms that are probably causing these diseases. These diseases are probably due to some focal infection, the germs of which may frequently enter the body by the way of infected areas in the mouth. Arsenic has no special action on the heart or blood-pressure or on the central nervous system, unless poisoning occurs.

Arsenic is chiefly eliminated in the urine, but is found after it has been given for some time in the feces, in the bile, in the perspiration, and in the milk of nursing women. The rapidity

of elimination varies. A single dose may be entirely eliminated in a few hours, or it may not be eliminated for several days, and after many days of treatment the urine may contain arsenic for one or two months, or even longer, after the cessation of the administration.

Over-action. When during the administration of arsenic the limit of tolerance to it has been reached it is evidenced by nausea, vomiting, diarrhea, red eye-lids, puffing under the eyes, skin eruptions, and albuminuria. If any of these symptoms of primary poisoning develop, the arsenic should be stopped, and generally the symptoms quickly disappear.

In some diseases, typically chorea, pernicious anemia, and leukemia, it has been deemed advisable, after the appearance of these symptoms and after their abatement, due to stopping the drug for a few days, to start again with a dose less than the dose that was given when the symptoms were caused and to gradually increase the dose to the point when intolerance is again shown by the above symptoms. After another period of intermittency the drug may be given again to a third point of intolerance. After another intermission the drug may be given for some time at a dose less than that which caused the symptoms at the third point of intolerance. The exact value of the drug given in this manner is questionable. However, some success in causing a remittance of the disease has frequently been recorded in pernicious anemia and leukemia. As above stated, probably these diseases are due to infection and the infection is overcome by the arsenic. Chorea is a selflimited disease, and probably is due to an infection, but it is hardly excusable to use the poison, arsenic, in this disease.

When arsenic is pushed to its full primary toxic effect it may do serious harm in causing multiple neuritis, dermatitis, destruction of red corpuscles, a greatly disturbed digestion, exhaustion, prostration, and fatty degeneration of some organs, i.e., chronic poisoning may develop.

Toxic Action.-The symptoms of a toxic dose of arsenic may appear within a few minutes, or not for an hour or more after such a dose has been taken, depending upon whether, or not, the stomach is empty. There is often pain in the mouth, throat,