shown that pinching the toes of a frog, or irritating them by acetic acid, prevents the vessels from dilating when the abdomen is struck, or causes them to contract and propel the blood to the heart if dilatation has already taken place. If I may judge from my own experience, persons not unfrequently take unconscious advantage of this effect of pain, and medical students occasionally prevent themselves from fainting, when witnessing an operation, by biting their lips or pinching their fingers. Its beneficial action in shock is very great, and my friend Dr. Fayrer informs me that he has succeeded in recovering a patient from a state of collapse by thrashing his feet and the calves of his legs with switches after other means had failed. Mustard plasters are often applied for a similar purpose. Sometimes the performance of an operation during shock is attended by a marked improvement in the patient's condition, and it seems to me not improbable that this is due to the stimulus thus given to the vasomotor nerves. At other times, however, the additional injury seems to produce an injurious effect either on the heart or vessels, and the patient succumbs. It is possible that the different effects of operations performed during shock may depend to some extent on the greater or less amount of irritation which is occasioned to the nerves of bones as compared with those of the soft parts; for, as we have already mentioned, injuries to bones tend to cause syncope, while irritation of other nerves, unless it be excessive, tends to prevent it by raising the blood-pressure. This, however, is a question which pertains more especially to surgeons, and with them I will leave it. I must not conclude without mentioning another valuable remedy in cases of shock, viz., digitalis. It has, I think, been conclusively proved by Dr. Adolf B. Meyer and myself,' that this drug possesses the power of contracting the arterioles, and I have shown 2 that it greatly strengthens the pulsations of the heart. We would therefore expect it to prove useful in shock, and experience does not disappoint our anticipations. This is well shown by a case of shock following parturition, in which it was employed by Dr. Wilks 3 some years ago. My attention was drawn to this by my friend

1 Journal of Anatomy and Physiology, Nov. 1872, p. 134.
On Digitalis. London, 1868, p. 28.

Medical Times and Gazette, Jan. 16, 1864.

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Dr. Milner Fothergill, and I quote the following from his admirable essay on digitalis. "The patient was apparently in articulo mortis; her limbs were cold, her body in a state of deathly clammy sweat; the face was livid, no pulse could be felt at the wrist, and a mere fluttering was heard when the ear was placed over the region of the heart. Brandy and ether had been tried without any good effect, and as dissolution was imminent, it was determined to try digitalis. Half-drachm doses were given every hour: after four doses a reaction took place, and after seven doses complete recovery occurred." Such a case as this needs no comment, and a consideration of the encouraging results here obtained can hardly fail to gain for digitalis a much more extensive application in cases of shock than it has hitherto received.

1 Digitalis: its Mode of Action and its Use.

London, 1871, p. 63.




A VERY important subject has been suggested for the consideration of the profession by the result of a coroner's inquiry into a death which occurred lately. A gentleman of Ramsgate was affected with delirium tremens, and his medical attendant prescribed a draught containing half an ounce of tincture of digitalis, to be repeated, if necessary, in four hours' time. The chemist to whom the prescription was taken refused to dispense the dose; the patient died, and an inquest was held on the body. The medical man expressed much indignation at the chemist's refusal to dispense the medicine ordered, and intimated his opinion that the deceased might have recovered had it been given to him. The chemist justified his conduct on the ground that the dose was eight times as large as the highest dose The of tincture sanctioned by the British Pharmacopoeia. surgeon stated, however, that half-ounce doses, and even much larger ones, had been given successfully by many practitioners, and that this fact was well known in the profession. The jury returned a verdict of "Death from natural causes, accelerated by drinking," and censured the chemist for not dispensing the prescription ordered.

A great deal of comment and rather angry discussion has arisen about this case; and the medical journals have been somewhat severe in their criticisms of the chemist's conduct. Certainly it does appear that the proper course would have been for the chemist to communicate his doubts about the prescrip

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tion to the prescriber, and ask whether he had really intended to give so large a quantity of digitalis. In so far as he neglected to take this step, he was decidedly wrong. But we think that the profession would be wrong to place the whole blame upon the chemist. The chief fault rests, as it appears to us, with the compilers of the posological list of the Pharmacopoeia, who, by indicating 30 minims as the extreme dose of tincture of digitalis, have been guilty of an unpardonable blunder which might well mislead the dispensing druggist. The medical man who prescribed the medicine justly remarked that the propriety of half-ounce doses was supported by a very large mass of respectable medical evidence; and that it was a great hardship that the patient should lose an important chance of recovery because a chemist thought that such doses would be dangerous. The matter is all the more important because this is by no means a solitary instance of extraordinary ignorance or negligence on the part of the officials who have compiled the list of doses of different drugs published in the British Pharmacopoeia. In fact, the evil is so serious that we propose to call attention to a number of instances in which it is easily apparent to a careful observer.

Let us take first the case of hyoscyamus, of which we find that the Pharmacopoeia recommends the tincture to be given in doses of 15 to 60 minims. The smaller of these quantities is probably completely without effect upon the human organism; and as to 60 minims being the maximum dose, anyone in the least familiar with asylum practice must be aware that as much as half an ounce is frequently required by, and given with good effect to, maniacal patients. In the case of belladonna, the official scale of doses is deficient in both directions: 5 minims is far too large to be assigned as a minimum, and 20 minims is a long way from being the largest dose that may be given with benefit in certain conditions. The official doses of the extract only range from to grain, a still more obvious absurdity to anyone who is familiar with the varied circumstances under which belladonna may be usefully employed.

Take next the instance of conium: what sort of value can be attached to the statement that the succus conii may be given in doses of from 30 to 60 minims? It has certainly been known,

for many years past, that 4 or 5 drachms may often be given. without the production of any marked physiological phenomena; and it is only to-day that a physician of large experience in the treatment of nervous disease reported to us that he had been administering ounce doses of a succus made by one of our very best manufacturing druggists, without producing any recognisable effect whatever.

Again, look at the official dose of potassium iodide-2 to 10: grains what kind of guidance does such a direction afford to the student or the practitioner? Surely it had been discovered long enough before the publication of the last Pharmacopœia, Ό that doses three and four times as large as the highest of those just mentioned might be given, not only with impunity, but with the most remarkable benefit, in many cases of tertiary syphilis and of lead-poisoning. Now these are cases in which a timid and feeble style of administration is very far from being a trifling evil: for the affections in question are often most dangerous, and urgently require to be treated with rapidity and efficiency.

Take next the instance of quinine (we are purposely selecting examples of remedies that are in constant and familiar use): the official dose of the sulphate ranges from 1 to 5 grains. It is unnecessary to remind any well-informed practitioner that in severe intermittent and septicæmic fevers, and also for the specific purpose of reducing pyrexial temperatures, it is idle to talk of a maximum dose of 5 grains: 30 would have been nearer the mark, but even larger quantities than this, in repeated doses, have been recommended by high authorities.

If the examples above given seem to indicate a lamentable timidity on the part of the compilers of the Pharmacopoeia, there are others which show quite a different tendency, in fact an unaccountable rashness in recommending high doses of very powerful poisons. Who could have suggested such a range of doses of tincture of nux vomica as 10 to 30 minims, and of the extract of the same as grain to 1 grain? The person, whoever he was, must have been entirely unfamiliar with the practical use of the drug, or he would have known that much less than 30 minims of the tincture would half tetanise many patients, and that it is very rarely advisable to exceed 10 minims; this is

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