9 AR 77 FORD THE PRACTITIONER. APRIL, 1877. Original Communications. ON THE USE OF WEAK SOLUTIONS OF SALINE DRUGS. BY W. F. WADE, F.R.C.P. Physician to the General Hospital, Birmingham. EVERY practitioner with much experience amongst the upper classes of society must have been struck by excellent results produced in many cases by a course of mineral water taken at its source. Not only are symptoms of long-standing relieved, but the relief, if not permanent, is frequently of long duration. It may readily be granted that alteration of habits, change of, and restriction in, diet, charming scenery, difference of climate, or of altitude, out-door life, exercise, early rising and retiring, with freedom from business or other cares, may actively co-operate in producing the happy result. But, especially in the case of some springs, we cannot ignore the fact that the patient is also taking saline drugs in very sensible quantities; combined with these there is very generally a minute, often most minute, proportion, of other salts and substances. To what extent these are active agents we have no data or facts to determine. But without venturing to offer any opinion on this point, I assume for my present purpose that the favourable changes effected by these mineral waters is due. NO. CVI. R rather to those drugs which are present in sensible, than to those which occur only in insensible quantities. These salts in no way differ from other samples made in the laboratory of the chemist. But the fashion in which they are mixed by nature is very different from that in which we are accustomed to order them to be mixed and taken. For example, if we give a patient two scruples of carbonate of soda, we probably put it into an ounce of water, whereas nature at Vichy puts it into about sixteen ounces. If we give two scruples each of sulphate of soda and sulphate of magnesia, we put them into an ounce or an ounce and a half of water; nature at Friedrichshall puts them into sixteen ounces. Here then is a very material difference between the artificial and the natural prescriptions. In my opinion better results are obtained by the use of the natural prescriptions. Carlsbad salts from the Sprudel spring are now frequently employed in this country; they consist merely of sulphate of soda, carbonate of soda, and chloride of sodium, all drugs of extreme cheapness, a characteristic of all the main ingredients of mineral waters. A small bottle of Sprudel salts costs 3s. 6d. The materials are intrinsically worth about one penny. Why then should not a poor club-patient have the benefit of a course of Carlsbad, Vichy, or Friedrichshall waters, rudely it may be, but, as it seems to me, very efficiently prepared? The disorders attendant upon insufficient action of the liver and kidneys, which are those most notably alleviated by such waters, are by no means limited to the rich. And actually for a few pence a three or four weeks' course of such waters may be obtained. It should be remembered that a want of success cannot be fairly imputed to such a plan unless the treatment has been pursued for as long a period as experience at the springs shows to be necessary. An ounce of a mixture containing the proper amount of salts is to be added to ten or fifteen ounces of water, and drunk either at once or in divided doses before breakfast every morning, or, if the patient be willing, it may be still further diluted. This principle is capable of further development, and in a way which furnishes even more important advantages, in which the rich as well as the poor may participate. The "alkaline-acidulous," the "muriated-alkaline-acidulous," and the "alkaline" springs comprise amongst others the important waters of Vichy, Fachingen, Ems, Carlsbad, and Marienbad. In these waters there is found a varying but considerable quantity of carbonate of soda, but either no, or very inconsiderable quantities of, potassium or lithium. Now we most of us, and not without reason, believe that the salts of these metals are more potential in the classes of disorders for which these waters are used than the salts of sodium. The "muriated water" of Baden-Baden contains a fair quantity of lithium, but so little that it is there customary to add lithia salts for the treatment of those persons whose stomachs will not stand an efficient dose of the native water. Again, the "Bitter waters" are active purgatives from the quantity of sulphate of soda they contain, as well as, in some instances, sulphate of magnesia, but they contain a very small proportion of sulphate of potash. Thus Püllna water has 123 grains of sulphate of soda and 93 grains of sulphate of magnesia to a little less than 5 grains of sulphate of potash. Now sulphate of potash is, as regards the other two salts, much superior as a cholagogue, though inferior as a purgative. Nevertheless, many patients whose livers are sluggish are not in need of any eccoprotic, in fact, in some cases, the bowels are relaxed. It is true that in some persons the action of a saline purgative seems to extend to the liver and to promote its action. But this is by no means invariably the case, even as regards plethoric people. While writing this, two gouty patients have consulted me, one of whom had been in the habit of taking Friedrichshall, and the other Hunyadi Janos water for torpor of the liver, and they both spontaneously mentioned that these waters respectively acted freely on the bowels, and yet did not relieve the liver. Most of the waters alluded to act to some extent as diuretics, and in many of the cases which they benefit it would appear that a diuretic action is that which we should expect to be of use. It is quite true that in other cases where great benefit is obtained there is no diuresis, and, according to some observations, no increase of urinary solids is produced. It is quite conceivable that irregularities of blood-distribution may be insensibly removed. Yet none of them contain iodide of potassium, which in small doses, i.e. one and a half or two grains, is a powerful adjuvant to diuretic salts. It seems to me then that we can make, if rude, yet very effective imitations of some of the most potent mineral waters, and, secondly, that we can compose even better mineral waters than those which nature has provided. If, for example, we wish to act only on the liver we can use sulphate of potash by itself, whereas if it is necessary or appears desirable to conjoin purgation we may add a suitable quantity of sulphate of soda or magnesia as we think best. If we wish to act only on the kidneys we can use carbonate of potash with citrate of lithia, combined with small doses of iodide of potassium or any other potash salt which we may prefer, and, indeed, if we desire to do so, the soda-salts likewise, and we add, if required, a purgative salt. If, as is perhaps most often the case, we think proper to act upon both liver and kidneys, we can combine any of the abovementioned drugs. Nor is it difficult to utilise salts of iron and manganese, though I have not yet done so. The addition of chloride of sodium, a prominent constituent of so many natural waters, makes the mixture to most persons less unpalatable. I generally order the dose to be taken in warm water, as this mixture is, in the absence of carbonic acid, better tolerated by most stomachs, but cold water may be more agreeable to some, and, indeed, there is no reason why an aërated water, as, for example, Apollinaris, should not be employed as a vehicle. Most people are nowadays accustomed to bitter and other mineral waters, and to them the bulk of the dose is not startling. It is, even by persons not previously so accustomed, and more especially by men of business, found very agreeable to have done with medicine for the day when once the morning dosage has been disposed of. I have found the plan here recommended very useful in a number of cases. In one a large and unsuspected renal calculus was passed by a woman at the end of three weeks. I must again repeat that a course of this kind should be continued for three to four weeks, or, in some instances, even longer, to have a fair chance of success. ON DIPHTHERITIC PARALYSIS. BY THOMAS STRETCH DOWSE, M.D., F.R.C.P.E., (Continued from page 182.) DR. BARR and Dr. Hector Cameron also give instances of this form of paralysis in the British Medical Journal for August 21, 1875. 3rd, 4th, 6th of the ocular muscles; I have usually found the 6th to be more involved than the others, and the patients to have an internal squint. Ptosis is by no means common, yet there is a heaviness of the eye-lids, showing that the 3rd nerve is not quite free. 5th, This nerve is usually involved, both in reference to its motor and sensory supply-the jaw in some cases is depressed with the greatest difficulty, and there is also almost complete absence of sensation of the face. 7th, Both the portio dura and mollis are in like manner affected, and owing to the paralysis of the facial muscles, conjoined with those of the neck, the chin falls forward upon the chest. The patients present a very remarkable appearance. The paralysis of the muscles of the neck is sometimes so great that the head can be impelled from one side to the other in the most ludicrous manner. There is want of voluntary power to blow, whistle, or eject saliva. 8th, The greatest point of interest and importance is attached to the glosso-pharyngeal, pneumogastric, and spinal accessory nerves. 1st with regard to the glosso-pharyngeal. We not infrequently find both dysphagia and dysphonia, as well as com |