Annual and analytical cyclopaedia of practical medicine
Sajous, Charles E. de M. (Charles Eucharist de Medicis), 1852-1929
fM >A'a<6 m m^ m^^^Mm VolJI. Bromide OF ETHYL DIPHTHERIA Ontario College OF Pharmacy ofc..^^»^' RULES REGARDING BOOKS. Each student on taking a book from the Library becomes responsible for the loss or damage of the same. The Librarian shall examine every book returned, and if the same be found marked, or spotted with ink, with leaves turned down, or in any way injured, the borrower shall have the loss deducted from his deposit. Through the day, books must be re- turned on leaving the reading room. From 3.30 to 4 p.m. a book may be obtained for home reading, but must be re- turned by 10 a.m. the following morning. For longer detention a fine of 5 cents per hour will be imposed. Digitized by the Internet Archive in 2010 with funding from University of Toronto http://www.archive.org/details/annualanalytica02sajo ANNUAL AND Analytical Cyclopedia OF Practical Medicine CHARLES E. de M. SAJOUS M.D. ONE HUNDRED ASSOCIATE EDITORS ASSISTED BY CORRESPONDING EDITORS COLLABORATORS AND CORRESPONDENTS Tllustratea will) (KbrottiO'CitDcdrapbs Engravings and maps ^^OLUl^E II Philadelphia Nkw York Chicago THE F. A. DAVIS COMPANY PUBLISHERS 1898 [^bTb m \ b 'ixw. VlBRA.R'^ COPYRIGHT, 1898, THK F. A. J)AVIS COMPANY. [Registered at Stationers' Hall, London, Eng.] Philadelphia, Pa., U. S. A. The Medical Balletin Printing-House, 1916 Cherry Street. EDITORIAL STAFF. ASSOCIATE EDITORS. (l.,st Jicchrd July 1. IS^S.) J. GEORGE ADAMI, U.B., MONTKEAX, P. Q. LEWIS H. ADLER, M.D., PHILADELPHIA. JAMES M. ANDERS, M.U., IA..T)., PHILADELPHIA. G. APOSTOLI, M.D., PARIS, FRANCE. A. D. BLACKADER, M.D., MONTREAL, P. Q. E. D. BONDURANT, M.D., MOBILE, ALA. DAVID BOVAIRD, M.D., NEW YORK CITY. L. BROCQ, M.D., PARIS, FRANCE. WILLIAM BROWNING, M.D., BROOKLYN, N. Y. WILLIAM T. BULL, M.D., NEW YORK CITY. CHARLES W. BURR, M.D., PHILADELPHIA. DUDLEY W. BUXTON, M.D., M.R.C.P., LONDON, ENG. HENRY T. BYFORD, M.D., CHICAGO, ILL. .7. ABBOTT CANTRELL, M.D., PHILADELPHIA. WILLIAM B. COLEY, M.D., NEW YORK CITY. P. S. CONNER, M.D., LL.D., CINCUNNATI, OHIO. FLOYD M. CRANDALL, M.D., NEW YORK CITY. ANDREW F. CURRIER, M.D., NEW YORK CITY. JUDSON DALAND, M.D., PHILADELPHIA. N. S. DAVIS, M.D., CHICAGO, ILL. F. EKLUND, M.D., STOCKHOLM, SWEDEN. AUGUSTUS A. ESHNER, M.D., PHILADELPHIA. J. T. ESKRIDGE, M.D., DENVER, COL. CHRISTIAN FENGER, M.D., CHICAGO, ILL. SIMON FLEXNER. M.D., BALTIMORE, MD. LEONARD FREEMAN, M.D., DENVER, COL. S. G. GANT, M.D., KANSAS CITY, MO. J. McFADDEN GASTON, JI.D., ATLANTA, GA. (iii) IV EDITORIAL STAFF. J. E. GRAHAM, M.D., TOKONTO, ONT. JULES GRAND, JNl.D.. PARIS, FRANCE. EGBERT H. GRAXDIX. M.D., NEW YORK CITY. LANDON CARTER GRAY, M.D., NEW YORK CITY. J. P. CROZER GRIFFITH. M.D., PHILADELPHIA. A. GOUGUENHEIM, INI.D., PARIS, FRANCE. C. M. HAY, M.D., PHILADELPHIA. FREDERICK P. HEXRY, M.D., PHILADELPHIA. EDWARD JACKSOX. M.D., DENVER, COL. XORMAX KERR, M.D., F.L.S., LONDON, ENG. EDWARD L. KEYES, Jr., M.D., NEW YORK CITY. H. KRAUSE, M.D., BERLIN, GERMANY. E. LAXDOLT, M.D., PARIS, FRANCE. ERNEST LAPLACE, M.D., LL.D., PHILADELPHIA. R. LEPIXE, M.D., LYONS, FRANCE. F. LEVISON, M.D., COPENHAGEN, DENMARK. A. LUTAUD, M.D., PARIS, FRANCE. F. MASSEI, M.D., NAPLES, ITALY. E. E. MONTGOMERY, M.D., PHILADELPHIA. JULES MOREL, M.D., GHENT, BELGIUM. HOLGER MYGIXD, M.D., COPENHAGEN, DENMARK. W. P. XORTHRUP, M.D., NEW YORK CITY. H. OBERSTEIXER, M.D., VIENNA, AUSTRIA. CHARLES A. OLIVER, M.D., PHILADELPHIA. WILLIAM OSLER, M.D., BALTIMORE, MD. F. A. PACKARD, M.D., PHILADELPHIA. LEWIS S. PILCHER, M.D.. BROOKLYN, N. Y. WILLIAM CAMPBELL POSEY, M.D. PHILADELPHIA. W. B. PRITCHARD, M.D., NEW YORK CITY. GEORGE H. ROHE, M.D., SYKESVILLE, MD. ALFRED RUBIXO, M.D., NAPLES, ITALY. LEWIS A. SAYRE, M.D., NEW YORK CITY. REGIXALD H. SAYRE, M.D., NEW YORK CITY. SOLOMON SOLIS-COHEX, M.D., PHILADELPHIA. EDITORIAL STAFF. II. W. STELWAGOX, M.D.. IMIILADELPIIIA. D. D. SIEWART, M.l)., rillLADEI.PHIA. HERMAN F. VICKERY, M.D, BOSTON, MASS. RIDGEIA' I?. WARFIELl), .M.D., IJALTIMORE, MD. LEWIS A. STIMSOX, MAX, NEW YORK CITY. F. E. WAX HAM. IM.I)., DENVER, COL. G. ARCHIE STUCKWELL, jNI.D.. NEW YORK CITY. B. J. STOKVIS, M.D., AMSTERDAM, HOLLAND. LOUIS :\IcLAXE TIFFAXY, M.D., BALTIMORE, MD. .T. WILLIAM WHITE, M.D., rriiLADELriiiA. W. NORTOX WHITNEY, M.D. TOKIO, JAPAN. JAMES C. WILSOX, ]\I.D., nilLADELPHIA. CHARLES S. TURXBULL, M.D., PHILADELPHIA. C. SUMNER WITHERSTIXE, M.D., PHILADELPHIA. F. VAX IMSCHOOT, M.D., GHENT, BELGH'M. WALTER WYJIAX, M.D., WASHINGTON, D. C. PREFACE TO THE SECOND VOLUME. The majority of the sections included in the first volume, as stated in the preface of the latter, were prepared under the immediate supervision of the editor and submitted to the various members of the associate staff for revision and cor- rection. Each associate enjoying the privilege of erasing, changing, and adding anytbing he chose, the correctness of the views advanced was insured, while the innovations as to form introduced by the editor could satisfactorily be carried into cITeet. The second volume inaugurates the regular plan of the work as regards elaboration: all tlie articles have been prepared by their I'espeetive editors, and the result sbows the kindly interest taken in the work by all the members of the staff, to whom the editor extends expressions of sincere gratitude. The aim of the editor is not only to facilitate the labor of the practicing l)liysician and to assist investigators and authors in their researches, but he also seeks to elucidate, througli contril)utions from men possessing special knowledge or unusual experience in a particular line, diseases which, owing to their complexity, are not generally understood. This plan has borne frnit, and the readers will have l)efore them, in this volume, exceptionally-valuable articles on a number of ex- acting subjects, namely: ''Cerebral Haemorrhage," by Dr. William Browning, of Brooklyn; "Cirrhosis of the Liver," by Professor Adami, of Montreal; "Cholera," by Professor Enbino, of Naples; "Cholelithiasis," by Professor Graham, of Toronto; "Diabetes," Ijy Professor Lepine, of Lyons, etc. The better-known affections have also been edited by writers of special ability. Among the articles of this kind is tbat on "Diphtheria," l)y Drs. ISTorthrup and Bovaird, of New York, wlio con- tri])ute a masterly review of our present knowledge of this affection from every stand-point. The papers by Professor Eskridge, of Denver, on "Catalepsy"; Pro- fessor Bondurant, of Mobile, on "Chorea"; Dr. Norman Kerr, of London, on "Cocainomania"; Dr. Oliver, of Philadelphia, on "Cataract"; Prof. Nathan S. Davis, of Chicago, on "Constipation"; Dr. Vickery, of Boston, on "Dilatation of the Heart," are, among others, particularly entitled to the readers' special atten- tion. An infirmity bnt little studied by the general practitioner is "Deaf-mutism." A section giving an exhaustive review of the subject has been contributed by Dr. Holger Mygind, of Copenhagen, one of the greatest living authorities upon the pathogenesis of this condition. (vii) ^.jj- PREFACE. The small-ty]>e text, presenting selected excerpts from the literature of the last decade and the recent literature up to May 1, 1898, have, as before, been in- serted by the central editorial staff. The articles on remedies — including only those in general use — were prepared by Dr. G. Archie Stockwell, whose long experience accounts for the many timely criticisms introduced. Repeated inquiries having reached the central department as regards the au- thorship of the fifty-page unsigned article on "Animal Extracts" which appeared in the first volume, the editor wishes to state that he wrote it himself, and that he fully appreciates the kindly expressions relating thereto, and also the many encouraging reviews which the medical press has accorded the first volume. The Editor. 2043 Walnut Street, pliiladelphia, july 1, 1898. Sajous's Annual AND Analytical CvcLOPyEDiA of Practical Medicine. B BROMIDE or ETHYL.— Bromide oi ethyl, or hydrobromic ether, is an anaes- thetic prepared by combining bromine with alcohol in the presence of phos- phorus. It was discovered by Serullas, a French chemist, early in this century. It is an extremely volatile and colorless liquid, sweetish to the taste, and pos- sessing an alliaceous odor. It presents the advantage over ether in not being inflammable. It is quickly eliminated from the system, and its after-effects are slight. Another preparation — bromide of ethylene — is frequently dispensed in- stead of the bromide of ethyl; it causes nausea when inhaled, and in no way pos- sesses the qualities of the latter. Bro- mide of ethyl is, however, frequently found impure in the shops, and to this cause are due many of the untoward re- sults met with. The bromide of ethyl usually em- ployed for anaesthetic purposes is made with phosphorus, bromide, and alcohol, and gives off phosphoretted hydrogen, — a dangerous impurity. The drug pre- pared from sulphuric acid, ethylic ether, and potassium bromide, as in commerce, is purer and, as it contains a larger amount of ethylic ether, is much safer than the other variety. Terrier (Gazette Med. de Paris, May 12, '94). Most of the unfavorable symptoms, such as vomiting, are due, not to the bromide oi ethyl, but to tlie impurities too often associated with it. Bazy (N. Y. Med. Jour., June 9, '94). Bromide of ethyl may be tested as fol- lows: 1. Put it upon the hand. It must evaporate quickly, and absolutely without residue, producing a marked feeling of cold. 2. The filtration with water should be neutral, and should not change on the addition of silver nitrate. 3. The addition of concentrated sul- phuric acid should cause no discolora- tion. If it is colored to brown or yellow, it shows that the ethyl-bromide is un- dergoing decomposition. Merck (Cin- cinnati Lancet-Clinic, Nov. 7, '91). Dose. — Bromide of ethyl cannot be used for prolonged operations, owing to its high volatility. The dose, which varies with the age of the patient, should not exceed 6 drachms. The administra- tion of bromide of ethyl should not be prolonged beyond two minutes. The dose varies Avith the age of the patient: 2 to 10 years, 3 to 4 drachms; over 12 years and adults, 4 to 7 drachms, according to general health, the entire dose being given at once. Cumston (Boston Med. and Surg. Jour., Dec. 20, '94). Ethyl-bromide used in three hundred cases in Billroth's clinic with one death. Its use should be restricted to short operations. Gleich (Deutsche med.-Zeit., Aug., '92). Bromide of ethyl is of great service (1) 15R0311DE OF ETHYL. PHYSIOLOGICAL ACTION. for short operations. Only a pure, per- fectly-limpid product, presenting no garlicky odor, should be used. Ladreit de LacharriCne (La France MM., May 24, '95). The operation may usually be begun twenty seconds after the first inhalation. Physiological Action and Untoward Effects. — Bromide of ethyl causes death Ijy arresting the heart's action, and the cases should be watched as if chloroform were being administered, — respiration and pulse simultaneously. The prelimi- nary preparations for its administration are the same, and the recumbent posi- tion obligatory under all circumstances. Arrest of the heart may be caused, how- ever, through vasomotor influence origi- nating in an intoxication by compounds formed in the system. Case of death from acute yellow atrophy of the liver, which occurred in a healthy male. The operation was brief, the anaesthesia marked by some asphyx- idl symptoms, and followed by severe vomiting for three days. A marked alliaceous smell persisted up to the time of his death. Reiss (Gazette des Hopi- taux. May 15, '94). Case of death from ethyl-bromide. The patient, aged 31, took 2 fluidrachms from a handkerchief and complained of feeling suffocated. The respiration grew stertorous, and after a slight convulsion entirely ceased and the heart failed. Death occurred in ten seconds, with cyanosis, turgescence of the veins, widely-dilated pupils, and upturned eyes. The horizontal posture was adopted. Analysis of the drug proved its purity. Laborde regards the death as a reflex syncope from irritation of the nasal mucous membrane by the vapor. Anony- mous (Bull, de I'Acad. de Med. de Paris, June 19, '94). Experiments on animals indicating that the principal anaesthetics do not act simply by causing vasomotor anaemia and hyperaemia, but principally by form- ing chemical compounds with the proto- plasm of the cells of the cerebral cor- tex and other centres. Hogges (Orvosi Hetilap, No. 2, '89). Case of death from bromide of ethyl after the extraction of a tooth. As- phyxia— due to pulmonary congestion — shown to have been the cause at the autopsy. Heart found fatty. Eschau- zier (Annual, '89). The injurious eflfects of ethyl-bromide inhalation are due to the fact that it undergoes decomposition, resulting in the formation of compounds having a more toxic effect than the ethyl-bromide itself. Hennicke (Archiv f. exp. Path, und Phar., B. 36, H. 3 and 4). Case in which bromide of ethyl caused death. The patient suddenly became cyanotic, and the pulse and respiration failed altogether. The post-mortem showed no hyperaemia of the brain, but fatty degeneration was found in the heart, kidneys, and viscera generally. Gleich (Deut. med.-Zeit., Aug., '92). Tendency to arterial haemorrhage un- der its use, and extreme muscular rigid- ity, amounting, in some cases, almost to tetanic spasm. Brinton (Ther. Gaz., Apr. 15, '92). Therapeutics. — Bromide of ethyl — as it causes muscular rigidity — should not be used in operations in which relaxa- tion of the muscles would be of assist- ance. It also increases the chances of hfemorrhage. Ethyl-bromide used in two hundred cases of minor surgery. Contra-indica- tions are: cases of reduction of dislo- cation or fracture, as it does not pro- duce muscular relaxation; habitual drinking; cardiac, pulmonary, or renal disease. Roman von Baracz (Zeit. fiir Therapie, July 15, '92). In parturition bromide of ethyl is su- perior to ether or chloroform. A few inhalations are given at the commence- ment of a pain, and the patient, while losing consciousness of suffering, is nevertheless able to follow the instruc- tions of the obstetrician. Also found very efficient and safe in five hundred minor operations. Montgomery (Thera- peutic Gazette, June 15, '93). [IMany observers, after careful trial. BRO^IIDES, BROMATES, ETC. speak \\cll of it for brief operations, but caution against its use in prolonged cases. The inlialer, once removed, should never be reapplied. Dudley Buxton, Assoc. Ed., Annual, '96.] Literature of '96 and '97. Case, afterward found to be addicted to alcohol, in which the bromide, having been administered for sixty seconds with- out any signs of anaesthesia supervening, seemed suddenly to take effect, and great rigidity, rapid breathing, and some lividity were produced, which, however, rapidly passed off. In several other cases in which the bromide of ethyl was used the respiration was, as a rule, regular, and the pulse somewhat quickened. The recumbent posture, in all cases, was the one adopted. The patients' ages varied from 7 to 40. The younger ones took it most readily. All the cases felt well enough to depart within ten minutes of the administration, though some hys- terical symptoms appeared in two while recovering. H. Kelson (Brit. Med. Jour., Dec 12, '96). BROMIDROSIS. See Hyperidrosis. BROMINE AND ITS DERIVATIVES (BROMIDES, BROMATES, ETC.).— Bromine is a dark-reddisli-brown, vola- tile fluid, emitting pungent and acrid fumes, caustic in action and taste. It is sparingly soluble in water (1 to 33), very soluble in chloroform, and likewise in ether and alcohol, both of which, however, it gradually decomposes. It combines freely with bases to form salts. As regards the bromates, the small proportion of bromine contained entitles them to consideration only in connection with their respective bases. The list of bromides is somewhat extended, there being no less than seventeen salts, and these, with half a dozen bromates and a number of other compounds, bring the total of bromine derivatives up to thirty- one. Some, however, are to be regarded as chemicals purely, or chemical curiosi- ties, rather than medicaments, and a few are so rare or expensive as to inhibit gen- eral employment. Bromide of ammonium is a white, granular salt that may, however, with exposure to light and air take on a more or less yellowish hue. Its action is prac- tically the same as that of the potassium,, sodium, calcium, lithium, and strontium salts, at least as regards the nervous sys- tem. It also, in small doses, is, to some extent, an alterative and hepatic stimu- lant; but in this particular is no better than, and perhaps not so active as, potas- sium bromide. It is the least palatable of the bromine salts, has a pungent, saline flavor (bromine taste), and is odorless. Calcium bromide is capable of evolv- ing 80 per cent, of bromine: a propor- tion greater than obtains to any other bromide; hence it has been lauded as a succedaneum for all the salts of alkaline base. It is had as a white, deliquescent salt, possessed of the usual pungent saline taste. Lithium bromide presents much the same physical properties as the fore- going; is sharp and bitter to the taste, white, granular, odorless, and the most difficult of all the salts to keep, owing to its deliquescent character. Potassium bromide appears as color- less, odorless, cubical, translucent, non- hygroscopic crystals of bitter, pungent, saline taste, and contains an average of 67 per cent, of bromine. Sodium bromide exhibits a consider- ably larger percentage (77.5) of bromine than its potassic congener, and, though it has characteristic bromine taste, it is most palatable of all the salts, and the best borne by the stomach, though this latter claim has been disputed in favor of strontium bromide. It is a white, odorless salt, fairly permanent under all BROMIDES, 13KUMATES, ETC. PKEPAKATIOXS AND DOSES. ordinary conditions of the atmosphere, and is found in the shops in two forms: as a granular powder and as small, mono- clinic crystals. Strontium bromide is a comparatively recent addition to the materia medica, and occurs in colorless, odorless crystals, only less deliquescent than lithium bro- mide, and possessed of the usual bitter, saline flavor; it contains Go per cent, of bromine. Bromal, tribromaldehyde, or tribro- macetyl-oxide, is a limpid, colorless, oily liquid possessed of a peculiar, sharp odor and irritating taste, obtained through the decomposition of alcohol by bro- mine; it is soluble in water, alcohol, and ether, but is not employed medic- inally. Its derivative, bromalhydrate, however, was introduced with a view of affording an analogue of, and substitute for, chloral-hydrate, but has failed to secure the favor of medical men so con- fidently expected. It is a crystalline solid with the taste of bromal. Bromalin, or bromethylformamide, contains only about half as much bro- mine as potassium bromide, — i.e., about 2-i or 25 per cent., — and offers no ad- vantages over the common bromide salts; hence requires little attention. It must not be confounded with hronielin: a preparation representing the digestive principle embodied in the pine-apple. Bromamide is a synthetic body ob- tained l)y the union of bromine and formamide, and occurs in colorless, odor- less, needle-shaped crystals insoluble in hot, but slightly soluble in cold, water, freely so in hot alcohol, and also in ether. Bromol, or tribromphonol, like the preceding, is a synthetic product, had by the action of bromine on an aqueous solution of carbolic (phenic) acid; it is precipitated as silky crystals that are in- soluble in water, but readily soluble in alcohol, chloroform, ether, glycerin, and fats. The bromates can hardly properly be considered in connection with bromine and the bromides, since their therapeu- tic relations are markedly those that ob- tain to their base, hydrobromic acid excepted. The proportions of bromine are comparatively small as compared with bromides, though it must be ad- mitted that their action as salts is, in considerable measure, different from that of their alkaloidal derivatives. Preparations and Doses. — Bromine, external use only. Bromide of ammonium. 10 to 60 grains. Bromide of arsenic (Clemens's solu- tion), 1 to 5 minims. Bromide of barium, V^g to 1 grain. Bromide of cadmium, ^/g to ^/^ grain. Bromide of calcium, 30 to 90 grains. Bromide of camphor (monobromated camphor; camphor monobromide), 2 to 10 grains. See Camphor. Bromide of ethyl (inhalation only). See Beomide of Ethyl. Bromide of gold, ^/g to ^/^ grain. See Gold. Bromide of iron, 3 to 10 grains. See Iron. Bromide of lithium, 20 to 150 grains. Bromide of mercury, ^/^ to 1 grain. See Mercury. Bromide of nickel, 2 to 10 grains. See Nickel. Bromide of potassium, 10 to 120 grains. Bromide of silver, V^ to 1 grain. See Silver. Bromide of sodium, 20 to 150 grains. Bromide of strontium, 30 to 150 grains. Bromide of zinc, 1 to 3 grains. See Zixc. BROMIDES, BROMATES, ETC. UNTOWARD EFFECTS. Bromal, 1 to 2 grains. Broiualhydrate, V2 to 5 grains. Bromalin, 10 to 120 grains. Bromamide, 10 to 15 grains. Bromoform, anaesthetic and topical ap- plication only. Broniol, Vio to ^/^ grain. Bromohydric acid, dilute, 2 to 120 minims. See Hydrobromic x\cid. Bromohydrate of caffeine, 1 to 6 grains. See Coffee. Bromohydrate of conine, Vso to Vio grain. See Coxium. Bromohydrate of quinine, 1 to 20 grains. See Quixixe. Bromohydrate of scopolamine, V2G0 to Vioo grain. See Scopolamixe. Bromohydrate of strychnine, ^/qq to V20 grain. See Strtchxixe. TJntoward Effects and Physiological Action. — Bromine, per se, cannot be ad- ministered internally because of its poi- sonous and powerfully corrosive prop- erties. When brought in contact with organic matters it rapidly oxidizes and destroys them; hence its chief use is as a disinfectant (1 to 500); it also, some- times, for like reason, finds employment as a topical application in hospital gangrene, phagedenic ulcers, sloughing chancroids, and like morbidities. The common bromine salts are in a general way identical in action, the chief difference being intensity and palata- bility, which, of course, are determined by the amount of bromine each contains, and the character of its base. Potassium bromide is, perhaps, the salt best known and most generally employed, and a general description of its physiological properties may be considered as typical of the ammonium, calcium, lithium, sodium, and strontium salts. Originally potassium bromide was in- troduced as an alterative and resolvent, and substitute for the iodide salt, and in small doses it often answers these purposes. But no sooner was its seda- tive action on the nervous system made apparent than its earlier uses were lost sight of, and to a degree that has prac- tically buried all other properties in oblivion. It depresses the brain and spinal cord in medium doses, rendering the same markedly ansemic if pushed or exhibited in larger doses. If the doses are still further increased and continued, anaesthesia of mucous membranes of eye, throat, and nose is observed, which, doubtless, extends to the entire digestive and intestinal tract, though the evi- dences thereof are not markedly ap- parent in the rectum. Bromides di- minish sexual desire, and, when pushed to the extreme of bromism, may destroy the same, or at least place in abeyance for a considerable period; at the same time the contractility of muscular fibre is diminished, and capillary circulation retarded. First of all the sensory col- umns of the spinal cord are depressed by bromides, next the sensory nerves; next the brain and motor columns of the cord: finally the motor nerves. While small doses do not seem to appreciably disturb the heart's action, larger ones depress, and, pushed to ultimate toxicity, death occurs with arrest in diastole. Brominism is the first definite meas- ure of toxicity, and, unfortunately, bromide of potassium and most of its congeners are eliminated very slowly; hence cumulative action. The cerebral symptoms are: a sense of mental weak- ness, heaviness of the intellect, and fail- ure of memory; partial aphasia; great somnolence and depression of spirits (H. C. Wood). With these there may be decided impairment of sensibility of the skin, to a degree that considerable heat applied elicits no complaint (Peeche). There is usuallv violent frontal head- 6 BKOillDES, BEOMATES, ETC. UNTOWARD EFFECTS. ache; but this often occurs ere the stage of brominism is reached; and bronchial catarrh and cough sometimes supervene. "Where brominism assumes a chronic character, there is a nauseous, fretid breath, congestion and oedema of uvula and fauces, disturbances of sensa- tion as regards vision and audition, loss of appetite, and hallucinations either with or without mania. Eoutine prac- tice in prescribing bromides may lead to mania. The pernicious system of prescribing bromides recklessly for epilepsy and other nervous disorders may lead to severe mental diseases. Such routinism in many instances causes patients to become wild and maniacal. In many of the asylums this condition is well recognized under the title of "bromomania." In former times the same class of persons continued along about the same from year to year and did not require to be sent from home; but with routine treatment, at the dis- pensaries and out-patient departments, much damage is often done by engorging the unfortunates with bromides. For many of these patients go from one dis- pensary to another and thus get loaded with an amount of bromide preparations that is far in excess of the intent, knowl- edge, or conjecture of the respective pre- scribers. AVhen, therefore, a practitioner finds that any of his epileptics give indi- cations of increased excitability or vio- lence, it will be well to investigate the amount of their drug njnsumption, for it may be the invasion of bromomania. Even doses of 15 and 20 grains fre- quently repeated and persisted in may induce unfortunate and deplorable re- sults, including delusions, melancholia, and suicidal tendencies. Editorial (Lan- cet, London, '89). A condition of the brain may be pro- duced similar to that occasioned by ex- cessive haemorrhage; i.e., an increased tendency to convulsive action (Clark, Gowers, Eosenbach). The action is not only on the cerebral circulation, but also in the cells of the gray matter of the cord. In epileptics phthisis is common, and may be rather produced by the drug than by the disease for which the bro- mide is given. Peculiar mental disturb- ances may be met with from its con- tinued administration. The discharge of nerve-force is mental rather than motor, and there ensues a convulsion of ideas rather than a convulsion of mus- cles. Baker (Med. Regicter, Dec. 8, '88). By the continued use of bromides a well-recognized form of bromomania may be induced; and epileptics who, fifty years ago, passed easily through life have now to be put under restraint. Thompson (Lancet, London, May 11-25, '89). In a quantitative examination of the organs of a child who had for years taken large quantities of potassium bro- mide, the drug was found principally de- posited in the brain. Doyon (Jour, de Med. de Paris, Nov., '89). Paresis is often induced, with in- ability to walk, sometimes more marked on one side of the body than on the other and simulating hemiplegia; there may be failure of memory, going on to partial paresis, with involuntary move- ments of bowels and bladder. In a case of Jacksonian epilepsy, in a child, a drachm of potassium bromide was given daily. The father, a druggist, reasoned that, if this amount kept the disease in check, 2 or 3 drachms during the same period ought to work a cure. But the child speedily sank after the larger doses were instilled and became an imbecile. Also two children were taking bromide; one lost all memory of words and the other all idea of time. Case of a lady who took 60 grains daily of potassium bromide for four years, and as a result suicidal tendencies and melancholia developed at each men- strual period, which, however, disap- BROMIDES, BEOMATES, ETC. UNTOWARD EFFECTS. peared when the drug was withdrawn. S. Weir Mitchell (Proc. Assoc. Amer. Phys., '95). Yoisin, Stark, Kiernan, Moyer, Kock- well, Seguin, Spitzka, Alexander, and others have reported cases of convulsions arising from traumatic epilepsy that, under the influence of bromides, were replaced by furor. Case of powerful, good-humored man, liable to frequent attacks cf grand maJ, in whom even the post-epileptic state was that of stupor. Bromides rendered him unmanageable, violent, homicidal, querulous, irritable, and suspicious. A second case was the exact prototype of the foregoing. A third was that of a semidemented patient, who became talk- ative, querulous, and suspicious under bromides. Bannister (Jour. Xerv. and Mental Dis., 81). Case of female, a victim to grand nial suppressed by bromides. In consequence she became irritable, depressed, and sus- picious. Rockwell (Jour. Xerv. and Mental Dis., '81). Literature of '96-'97-'98. Case of petit mal. Bromides induced long-continued attacks of furor, where formerly were but casual seizures of erotico-religious mania and visual and auditory hallucinations. Alexander (Med. Standard, "98). The last author quoted cites several more cases, eight in all. L. "W. Baker, of Baldwinsville, three more. Laborde also observed priapism and sexual ex- citement sometimes amounting to saty- riasis follow the use of bromides. "Win- ters, of New York, has recorded many instances of visual hallucinations. Kier- nan, of Chicago, and Xumro, of Edin- burgh, also observed marked aphrodisia. "That these untoward effects closely simulate the effect produced in epilepsy there can be no doubt, yet the weight of authority, and indeed the weight of evidence, is in favor of the opinion that these phenomena result most often from the suppression of epileptic explosions'' (Bannister and Alexander). ''To give the bromides alone is to postpone the explosions and generally intensify them. The very fact that a sudden suppression of bromide admin- istration is followed by a severe ex- plosion is clear evidence that the drug acts rather like a load keeping down a safety valve." (Spitzka.) Not the least unpleasant sequelae — both as regards patients and medical attendants — that supervene as the result of continuous bromide administration, even in what are often considered very moderate doses, are the manifestations of brominism seen upon the skin. These may range all the way from a simple erythema to a rubeoliform or scarlatini- form rash, up to acne, pemphigus, fu- runcular swellings, and most foul and stubborn ulcerations that, too often, per- haps, are deemed evidences of a syph- ilitic diathesis. These are, for the most part, distinctly traceable to morbid changes in the sebaceous glands, in turn induced by impeded capillary circula- tion and obtunded nerve-fibrillge. Such eruptions, if not recognized, are very annoying to treat, and are practically impossible to relieve until the bromide is suspended and in great measure elim- inated from the system. It is claimed that the simultaneous administration of arsenic tends to inhibit such sequelae; but this is not, by any means, univer- sally true. The late Brown-Sequard was accustomed to combine belladonna with bromides, which frequently proves a most effective measure. Literature of '96 and '97. Case of a robust, well-developed child, 3 years of age, suffering from an ulcer on calf of leg, resembling a boil, covered at the apex with raspberry granulations 8 BROMIDES, BROMATES, ETC. UNTOWARD EFFECTS. batlied in adhesive, sanious pus. In a few days the ulcer was surrounded with aene pustules, whicli coalesced with the original lesion until the latter covered a large part of the gastrocnemius mus- cle; skin tawney or bronze; breath very offensive. The pustules were im- mense, and resembled varicella more than acne. Finally the sores threatened the whole leg below the knee. It was found the child occasionally suffered at- tacks of vertigo, for which a neighboring physician with a reputation for "curing fits" had prescribed large doses of am- monium bromide, under the supposition that he was treating a case cf epilepsy. FuUerton (Memphis Med. Monthly, Oct., '97). {See colored plate.) The evidence is overwhelming that the bromides are not the harmless medic- aments that they are generally assumed to be; also that their present universal and routine employment should be abandoned for more rational and physio- logical methods of procedure. When a patient who has been taking bromides for some time complains of a salty or bitter taste soon after the drug has been ingested, especially if there is increased secretion of saliva, suggestions of foetid breath, or a burning sensation in the mouth, whether accompanied by nausea and eructations or not, such should be regarded as evidence of impending bro- mism, and measures taken accordingly. It must be remembered, moreover, that these evidences may result from the administration of ordinary medicinal doses — 10 to 20 grains in the adult — when frequently repeated, since the emunctories are not able to excrete this amount. Interstitial nephritis is a com- mon sequel to brominism. Of all the bromine salts, that of am- monium is the most apt to induce tox- icity, since the effects upon the sensory portion of the spinal cord are most marked. Bromides of lithium, potas- sium, and calcium rank, respectively, second, third, and fourth as regards poisonous qualities. Collapse under either the ammonium or potassium salt may arise either through the base or the bromine constituent; but the potassium bromide is more apt to be at fault in this respect. It is sometimes a difficult matter to determine where the blame should rest; but withdrawal of the potassium bromide, substituting there- for another salt, — that of sodium, for in- stance,— may lead to definite decision. But the most innocuous (apparently) of bromine salts, when long-continued or pushed to extremes, are apt to induce collapse; and fatal pathological changes in both kidney and liver have been ascribed to their use, with considerable reason and probability. Calcium bro- mide is claimed to be the least depress- ing, but this is not altogether borne out by long experience in its use. Lithium bromide requires to be ad- ministered in larger doses than its con- geners, and often proves the most irri- tating of any to the digestive system. The strontium salt is least disturbing to the stomach when continuously admin- istered for considerable periods, and by many held the least likely to induce bromism; indeed, H. C. Wood believes it stimulates appetite and increases the activity of the digestive organs, which, however true of small and medium doses, at moderate intervals, is not a fact regarding medium doses with brief in- tervals long continued or larger doses. The chief advantage of the salt is that its base is practically non-toxic. Barium bromide may be dismissed with the state- ment that it offers no advantages over the other bromide salts, and it has the marked disadvantage of possessing a very poisonous base. It is also claimed for this salt that it stimulates mucous ' membrane, improves appetite and diges- o r> •>~-^^ j^ 'd! Bromide of Potassium Eruption. ATLAS DE L' M O P I TA L ST. LOUIS, BROMIDES, BROMATES, ETC. UNTOWARD EFFECTS. 9 tion, etc., and though this is, in a meas- ure, true, such are referable to the metallic base rather than the acid source. Sodium bromide is undoubtedly the most convenient, and to considerable degree the most safe of the bromide salts. Suitably diluted, it is no more disagreeable to the palate than the bulk of mineral waters, and it is, moreover, wlien accompanied by abundance of fluid, almost as readily eliminated. It must be remembered, in employing this drug, that it is not only essential, but of paramount importance, that the system be continually saturated, and flushed, so to speak, with water in abundance. Though some doubt its efficacy as compared with the ammo- nium, calcium, and potassium salts, it certainly is least depressing to both cir- culation and nervous system, and less irritating to the emunctories. In epi- lepsy it is questionable if the results desired are not those that accrue to toxicit}' rather than those of purely remedial character, for here free stimu- lation appears to inhibit prevention of paroxysms. But as a nerve-sedative purely, continued experience with so- dium bromide invariably leads to greater and increasing favor on the part of both prescriber and patient, until the verdict ultimately becomes overwhelmingly pos- itive. Bromalhydrate in large doses is a poison of great intensity, death rapidly resulting from paralysis of heart and sometimes of respiration also, preceded by minutely-contracted pupils, marked dyspnoea, and general convulsions. It lowers blood-pressure by powerfully de- pressing the circulation and vasomotor centres; it is equally depressant to the cord, especially the motor columns thereof. "When employed in hypnotic doses, sleep is induced by direct action on the cerebrum, causing brain-anaemia. Larger, but non-toxic, doses induce distinct lowering of body-temperature. Like chloral, to which it was expected it would prove an analogue, it is antisep- tic; and it is likewise markedly and painfully irritant to mucous membranes and raw surface.. It is eliminated by the kidneys but slowly, and in the form of urobromic acid. Bromalin, inasmuch as it contains only about half as much bromine as potassium bromide, requires to be given in large doses, but its effects are sup- posed to be identical with the latter. It is claimed, moreover, that it is less prone to provoke unpleasant sequelse; but clinical experience is not yet suffi- ciently ample to permit of drawing definite deductions. Bromamide evinces its chief activity upon the cerebrum, which it materially depresses; hence its reputation as an hypnotic; nevertheless, it is inferior to many other drugs in this respect. In larger doses it is more markedly de- pressant, exerting its action upon the spinal cord, whereby it becomes an anal- gesic. In medium doses it stimulates the respiratory centres; but here, again, when pushed to the verge of toxicity, an opposite result accrues that may re- sult in total paralysis. In small doses it influences the circulation but little; but in larger depresses the heart, and, if increased, the action of the organ is entirely suspended. Thus it is a remedy far more powerful for evil than good, and furthermore there is little confidence to be placed therein, since, once exposed to air and light, chemical changes take place whereby it develops greater tox- icity. A dose taken from one container to-day that appears harmless, if repeated a week later may prove dangerous. Until more is known of the product, and until 10 BROMIDES, BROMATES, ETC. POISONING BY BROMIDES. its manufacture and preservation can be encompassed by greater safeguards, in- suring stability and uniformity, the drug is best relegated to the list of curious chemicals. Broiiiamids reduces body-temperature without giving rise to the excessive sweating produced by other antiseptics; it is free from unpleasant symptoms as regards the alimentary tract. Caille (Practitioner, London, May, '92). Bromoform is best known for its anaes- thetic properties, but is sometimes ap- plied to relieve the pain accruing to cer- tain morbid ulcers, and here appears to be both an antiseptic and a local anses- thetic. After inhalation it may be de- tected in the form of hydrobromic acid in the urine. It is highly toxic, more- over, and induces symptoms of collapse, accompanied by great weakness, cya- nosis, dilated and fixed pupils, and cold- ness of extremities, but seems to be easily eliminated from the system under the use of stimulants and tepid baths. Bromol has a peculiarly disagreeable, pungent odor, and a sweetish, astringent, but not unpleasant taste, and, as may be imagined from its derivation, is power- fully antiseptic. It is unfortunate it should have secured a designation that is likely to cause it to be confounded with bromal. It has been employed both externally and internally, but definite data are lacking regarding physiological properties when introduced into the liv- ing economy. Bearing in mind its source, it should, for the present at least, be regarded as a drug demanding great caution in its employment. It is said to be excreted by the kidneys as tribrom])lienolsulphuric acid. Poisoning by Bromides. — It has re- peatedly been denied that bromides 'per se ever induce fatalities, but the evidence already deduced is proof sufficient of their dangerous character. Careful ex- amination of literature also reveals the fact that fatalities are, by no means, of infrequent occurrence, and the sus- picion is forced that many deaths that should have been ascribed to the toxic action of bromides have been ignored or mistakenly ascribed to the malady for which the drugs were prescribed. Hameau reports case of a young woman who took four and one-half pounds of bromide during ten months, and while in a condition of cachexia with yellowish skin, copper-colored eruption on forehead, colic, gastralgia, etc., suddenly became greatly prostrated; had delirium with profuse sweats, fol- lowed by death in four days. H. C. Wood ("Principles and Practice of Ther.," '94). Literature of '96 and '97. Case of a woman who took five pounds of potassium bromide in less than a year, and, while having "very pronounced symptoms of brominism, was seized with delirium and suffered frcm hallucina- tions of sight and hearing; declared she was being poisoned. Death followed. Eigner (Wiener med. Presse, Nos. 25-34, '96). A man suffering from neuralgia had been in the habit of taking potassium bromide in 1- and 2-drachm doses. It did not appear to have produced the usual symptoms of bromism, but may have caused the palpitation of heart fre- quently complained of. The night of his death he complained of being very cold, and suddenly, after two deep gasps, expired. The medical practitioner who was sent for at inquest stated that he found the deceased quite dead, his mouth wide open, the eyes half-closed, and the pupils somewhat dilated. A bottle con- taining the drug was on the table, and examination showed it was pure bro- mide of potassium. Death was attrib- uted to failure of the heart's action caused by taking the bromide. This case is interesting for several reasons: It proves, in a marked manner, the BROMIDES, BEOMATES, ETC. TREATMENT OF BROMISM. 11 danger of taking any drug, however harmless it may be, in huge and re- peated doses without the advice of a medical man. As this bromide is con- stantly administered in large and re- peated doses, the action of its basic con- stituent should always be borne in mind, and, if signs of its depressant efTect are observed, its use should be abandoned. Many secret remedies for "fits" contain this drug in large quantities, and it is evidently desirable that the public should be warned that their use is not unattended with danger. Editorial (Lan- cet, London, Apr. 4, '96). A number of deaths can only be ex- plained by the inordinate use of bro- mides. The patients sink into a condi- tion of apathy from which they cannot be roused. Have seen three autopsies and have knowledge of five more wherein the excessive use of bromide salts gave rise to fatality. Janeway (Amer. Medico- Surg. Bull., May iG, '90). Treatment of Bromism. — This con- sists, first of all, in suspending the drug; next in promoting excretion by the emunctories, the kidneys and skin espe- cially, coupled, if need be, with support- ing treatment to heart and general cir- culation, and endeavors to restore to normal the status of the nervous sys- tem. The mercurial salts are often of marked value, especially the iodide as found in combination with arsenic in Donovan's solution. Occasional purges by large doses of calomel are also very effective, and, when given to the amount of 30 to 50 grains at bed-time, this drug is not only without depressing after- effects, but tends to stimulate the kid- neys and emunctories to renewed ac- tivity. Theoretically, pilocarpine, or jabo- randi, would be considered of use; but to an economy already generally de- pressed, with circulation and nervous system suffering from the poison, these might prove boomerangs; atropine and belladonna are much more preferable and reliable. Therapeutics. — Very little that is new has accrued to the use of bromides of late years, except as has already been pointed out in discussing their physio- logical action and relations. Originally introduced as alteratives, their value in this respect seems to have been lost sight of, and they are employed chiefly as anti- spasmodics, hypnotics, anaphrodisiacs, sedatives, and to some slight degree as analgesics. Fever. — By their action on the cir- culation and cord they often prove ex- ceedingly valuable aids in the treatment of febrile maladies, especially of chil- dren, and particularly when employed in conjunction with gelsemium or aco- nite; the same is true, also, in the man- agement of acute brain affections. Epilepsy. — Their greatest employ- ment, however, has been in the manage- ment of epilepsy; but, despite the weight of contrary evidence, the writer has never observed any lasting benefit to accrue to their use in any form of this malady, for, while they may de- crease the number of paroxysms, they positively never afford other relief, and many times the condition resultant upon their use is worse than before treatment began. It might be assumed that the foregoing obtained solely as a matter of coincidence; but, imfortunately for such an hypothesis, this experience is by no means solitary or unique. Again, at least 5 per cent, of epileptics cannot bear any bromide, even in small doses. Use the tliree salts in epilepsy — am- monium, potassium, and sodium — in combination in doses of from 40 to 80 grains morning and evening. In strictly nocturnal seizures one dose at night only. Treatment should be persisted in for at least three years. Arsenic is a valuable adjunct to the bromides. 12 BRO:\IIDES, BEOMATES, ETC. THERAPEUTICS. Eulenberg (Thcv. Monat., Nov., Dec, '92). Large doses of strontium or potassium bromide are demanded in epilepsy. Begin Avith 60 grains daily and increase gradually to four times the amount (240 grains). Large doses are beneficial only when the maximum is reached. Fere (Revue de Med., Mar. 10, '93). When a bromide is given in conjunc- tion with borax the action ia better than with either salt alone. Alexander (Liverpool Medico-Chir. Jour., July, '93). Xothing superior to bromides, alone or in association, has been evolved in the therapeutics of epilepsy. Gray, Pritch- ard, and Shultz (Annual, vol. v, "94). Twelve cases of epilepsy: 8 male and 4 females, of ages ranging from 10 to 50 years; no predisposition, no syphilis. In 4 the fits occurred at least once a week, in the other 8 at intervals varying from 1 to 8 weeks. Bromide of stron- tium, 20 grains, with 5 to 10 grains of bromide of ammonium or sodium, were given night and morning, largely diluted with water. Strontium increased rapidly to GO grains twice dailj', when the smaller doses failed to control the at- tacks. The majority took the latter drug without any depression, but gen- erally with the production of acneic rash on face. Fowler's solution of arsenic added to the mixture controlled the rash and increased appetite. The number of attacks in all cases was materially de- creased, and in 8 there was no return after intervals of from 4 to 16 months. Roche (Med. Press and Circ, Aug. 12, '92). It has been recommended to combine adonis vernalis and codeine with bro- mides in the treatment of epilepsy, bnt careful investigations on the part of many observers are not at all assuring in this direction. Literature of '96 and '97. The cures do not appear to be in any way effected save by the bromides alone, and the combination does not, in any way, prevent tlie complications and dis- agreeable symptoms which arise from the use of bromide salts. Taty (Lyon Med., Dec. 29, '95; ibid., Jan. 5, 12, '96). Chorea. Convulsive axd Paroxys- mal Maladies. — The bromides have also been extensively employed in chorea, bnt without any great measure of success. They are, however, often most eifective in hysterical seizures, asthma, the milder forms of whooping- cough and puerperal eclampsia and in- fantile convulsions; also have been lauded in tetanus, laryngismus stridu- lus, and seizure that sometimes follow thyroidectomy. 