1.12 CONDICIONES ECONÓMICAS DE LA CONCESIÓN
1.12.2 CONSIDERACIÓN DE NUEVAS INVERSIONES
Despite a poor knowledge of the etiology of disease, an imperfect and crude understanding of infection and contagion, and little appre- ciation for the pharmacological actions of the drugs they prescribed— other than an empirical (albeit keen) appreciation for dose-response relationships—surgeons had a wide and varied armamentarium at their disposal. The United States Pharmacopoeia (fourth decennial revision adopted in 1860 and made official [i.e., published] in 1863) listed a total of 871 different substances, of which 587 (or 67 percent) were botanicals.12Confronting such a massive materia medica would
be a daunting task were it not for the fact that the U.S. Army pared this down considerably by selecting those thought to be the most es- sential in military practice. The result was the standard supply table. The original table at the beginning of the war was deemed outdated and virtually useless, forcing surgeons and purveyors to improvise as disease and demand dictated. A committee of revision was called to- gether (Edward R. Squibb was among its members) and the official supply table adopted—sans calomel with Hammond’s Circular No. 6 just days before—with Circular No. 7 on May 7, 1863. This circular contained 127 different pharmaceutical substances for hospital use; the supply table for the field service reduced this further to seventy- nine items (see Appendix A). Other substances could be ordered from the medical purveyor’s depot by special requisition, but these were the required substances to be on hand at all times. Perhaps the best way to view and understand these substances as a whole is by a summary. Table 6.1 gives the official pharmacopoeial names of the most commonly used items, their names in English, their properties, and uses.13To avoid excessive length and redundancy, only the prin-
cipal substances are listed in the table; those interested in the entire list, with all the variants, should consult Appendix A.
TABLE 6.1. Selected Items of the Standard Supply Table (As Adopted in Circular No. 7, May 7, 1863)
Name Properties and Uses
1. Acaciæ Pulvis (gum arabic [powdered])
Chiefly a demulcent. Used on inflamed surfaces and catarrhal affection. Can be mixed in water; also used in the formation of pills. 2. Acidum cetum (citric acid) Used in a variety of other preparations (e.g., Ferri et Quiniæ
Citras, etc.). Believed to be of some value in scurvy (though infe- rior to lemon juice).
3. Æther Fortior (strong ether) An anesthetic. Inhaled and also used as a topical anesthetic. 4. Alcohol Fortuis
(strong alcohol)
Regarded as a stimulant. Its uses were many: anodyn, preserva- tive, solvent, suspension medium, etc.
5. Alumen (alum) A powerful astringent used in chronic dysentery, bronchial affec- tions, hemorrhage, opthalmia, and toothache.
6. Ammonæ Liquor (ammonia) Stimulant. Used in chronic catarrh and bronchitis as well as a wide variety of other uses (a wash for ulcers and contusions, etc.).
7. Argenti Nitras (nitrate of silver)
Sometimes referred to as “lunar caustic,” it was given topically and internally. Used externally as a counterirritant; used internally for dyspepsia, diarrhea, croup, cough, tonsillitis, and other affections of the throat, ophthalmic conditions, and even reportedly used for gonorrhea.
8. Arsenitis Potassæ Liquor (tasteless ague drops)
A solution of equal parts arsenic acid and bicarbonate of potassa. Possessed variety of uses, but chiefly for fevers.
9. Asafœtide (asafetida)
Its horrible smell earned it the nickname “devil’s dung.” Used prin- cipally as a moderate stimulant, antispasmotic, expectorant, and mild laxative.
10. Bismuthi subcarbonas (subcarbonate of bismuth)
Considered tonic.
11. Camphora (camphor) Moderate stimulant, anodyne (pain relief), diaphoretic (causing sweating), and used frequently in the treatment of typhoid. 12. Cantharides (Spanish fly) This beetle, when pulverized, produced a poultice that caused
blistering and was considered a counterirritant. Used topically for cutaneous eruptions, obstinate herpes, erysipelas, and other local inflammations.
13. Capsici Pulvis (cayenne pepper powder)
A powerful stimulant used topically for rheumatism and internally for “enfeebled and languid” stomach and palsy or other “lethargic affections.”
14. Chloroformum (chloroform)
Anesthetic 15. Cinchonæ Caliayæ Pulvis
(powdered yellow cinchona)
A tonic febrifuge, especially antiperiodic (see Chapter 7). 16. Collodium
(collodion [a solution of gum in ether and alcohol])
Used chiefly as a vehicle for external medicines, often with can- tharides (cantharidal collodion) or tannic acid (styptic collodion). 17. Copiaba (balsam of copaiba) Considered gentle stimulant, diuretic, laxative, and in large doses
purgative. Also used according to Stillé in “protracted and obsti- nate dysenteries.”
TABLE 6.1(continued)
Name Properties and Uses
18. Creasotum (creasote) Considered similar to carbolic acid. Used topically for hemor- rhages and cutaneous eruptions; used internally as an antiemetic and in some bronchial affections.
19. Cubebæ Oleo resina (oleoresin of cubeb)
Diuretic, stimulant, and carminative (expulsion of flatus). 20. Cupri Sulphas
(sulfate of copper)
Externally it was irritant and mildly escharotic (produced slough- ing); diluted it was used as an astringent and stimulant. 21. Ext. Aconiti Fuidum
(fluidextract of aconite root)
Used in treating rheumatism, gout, and neuralgia. Also used as a basis for other aconite preparations (abstracts, plasters, extracts, liniments, etc.)
22. Ext. Belladonnæ (extract of belladonna)
The active agent is atropine. In neuralgia, it was preferred over opium. Used in cases of whooping cough, scarlet fever, spas- modic asthma, and other instances calling for an antispasmodic. 23. Ext. Buchu Fluidum
(fluidextract of Buchu)
Used in urinary tract and bladder inflammations. 24. Ext. Colchici Seminis Fluidum
(colchicum seed fluid)
Sedative and anodyne. In higher doses, it was emetic and purga- tive. Used in gout and rheumatism.
25. Ext. Colocynthidis Comp. (colocynth compound)
A powerful cathartic. TheUSDcalled this “a favourite preparation with many practitioners” and combined with calomel, extract of jalap, and gamboges, a “safe cathartic.”
26. Ext. Conii (hemlock) Considered a “nervous sedative.” Also sometimes used for whooping cough and asthma.
27. Ext. Ergotæ Fluidum (fluidextract of ergot)
A mold from rye used in internal hemorrhages and reportedly used for whooping cough.
28. Ext. Gentianæ Fluidim (fluidextract of gentian)
A tonic classed along with the “simple bitters.” 29. Ext. Glycerrhizæ
(extract of licorice)
A demulcent (containing a soothing mucilaginous and saccharine nature) used in catarrhal conditions.
30. Ext. Hyoscyami (extract of henbane)
Sedative and anodyne. 31. Ext. Ipecacuanhæ
(extract of ipecac)
A powerful emetic. In smaller doses, it was used as a diaphoretic and expectorant.
32. Ext. Nucis Vomicæ (extract of nux)
The seeds ofStrychnos nux vomicaused in a similar manner as its alkaloid strychnine.
33. Ext. Pruni Virginianæ Fluidum (fluidextract of prunes)
A laxative. 34. Ext. Rhei Fluidum
(fluidextract of rhubarb)
Prescribed in cases of diarrhea. Stillé considered it “a useful pur- gative in the bowel-complaint of summer.”
35. Ext. Senegæ Fluidum (fluidextract of senega root)
The senega root was considered stimulant, expectorant, diuretic, and in larger doses emetic and cathartic. Beasley stated that it was used in “latter stages of pneumonia” and as a stimulant in “low and typhoid fevers.”
36. Ext. Spigeliæ Fluidum (fluidextract of spigelia)
Spigelia mirilandica,native to the South, was used as a powerful anthelmintic (vermifuge or worm expeller).
37. Ext. Valerianæ Fluidum (fluidextract of valerian)
An antispasmodic used in epilepsy, hysteria, dyspepsia, spas- modic cough, and neuralgia.
Name Properties and Uses
38. Ext. Veratri Viridis Fluidum (fluidextract of American hellebore)
An anodyne and used externally as a discutient (an antitumor agent). Stillé reports its use in influenza, jaundice, dysentery, and peritonitis.
39. Ext. Zingiberis Fluidum (fluidextract of ginger)
Ginger was used as a stimulant and carminative, often prescribed for dyspepsia.
40. Ferri Chloridi Tinctura (chloride of iron [tincture])
Used in “pseudo-membranous croup” and in arresting hemor- rhages in the throat and gums. Beasley stated that all iron prepa- rations worked as tonics that “raise the pulse, heighten the com- plexion, and promote the secretions.”
41. Ferri Iodidi Syrupus (iodine of iron [syrup])
Used in scrofula (inflammation of the lymph nodes, especially in the neck). Also used in secondary syphilis.
42. Ferri Oxidum Hydratum (hydrated oxide of iron)
With water, it was used as an antidote for arsenic poisoning. 43. Ferri et Persulphatus Liquor
(solution of subsuphate of iron [Monsels’ solution])
Made by the reaction of sulfate of iron with sulfuric and nitric acids in water. An astringent.
44. Ferri et Quiniæ Citras (citrate of iron and quinine)
A specific tonic that supposedly combined the virtues of iron (a tonic used in chronic diarrhea and dysentery, enlargement of the liver and spleen, anemia, and dyspepsia) and quinine (a tonic feb- rifuge and antiperiodic).
45. Ferri Sulphas (sulfate of iron [green vitriol])
An astringent. 46. Hydrargyri Chloridum Corrosivum
(corrosive sublimate)
Like all the mercurials, mercuric chloride (HgCl2) was regarded as
an alterative. A biliary stimulant and cathartic used in a wide range of ailments (see Chapter 7). It was also supplied as yellow iodide of mercury, red oxide of mercury, and in pill and ointment. Not quite the same as calomel (Hydrargyi Chloridum Mite or mer- curous chloride [HgCl]). Because it was much harsher than calo- mel, corrosive sublimate was used far more judiciously by medical staff.
47. Iodinium (iodine) Considered stimulants. Beasley indicates their use “in simple hypertrophy of any of the organs” and their valuable antiinflamma- tory action, especially in scrofulous disorders. It was used in com- bination with many prescriptions; Beasley alone gives fifty-six. 48. Linum (flaxseed) Used externally as a poultice, it served as an emollient (moisten-
ing and soften agent); internally as a laxative. 49. Magnesia Sulphas
(sulfate of magnesium)
A cathartic laxative often given with senna. 50. Morphiæ Sulphas
(sulfate of morphine)
A powerful anodyne. 51. Olei Menthæ Piperitæ Tinct.
(tincture of oil of peppermint)
An aromatic stimulant. Given for nausea and dyspepsia. A carmi- native and excipient.
52. Oleum Cinnamomi (oil of cinnamon)
Used as a cordial with carminative properties. Often employed with other remedies.
53. Oleum Morrhue (cod liver oil)
An alterative long employed in rheumatic and scrofulous disor- ders. Also reportedly used in phthisis (tuberculosis). 54. Oleum Olivæ
(olive oil)
TABLE 6.1(continued)
Name Properties and Uses
55. Oleum Ricini (castor oil)
A purgative and laxative. Stillé touts its benefits in bowel disorders and asserts that in dysentery “it is generally sufficient for the cure.”
56. Oleum Terebinthinæ (oil of turpentine)
Given internally as an anthelmintic, styptic, and stimulant. Used in certain intestinal fluxes (especially in dysentery) and in low fevers (especially typhoid). Used externally as a rubefacient (producing redness) for rheumatic conditions.
57. Oleum Tiglii (croton oil)
A powerful cathartic and, according to Beasley, “in very obstinate constipation, in dropsy, and in apoplexy or paralysis where a speedy irritant action on the intestines is desired.” Stillé reported its use to expel tapeworms.
58. Opii Pulvis (powdered opium)
Also available in tincture and camphorated. From the opium poppy(Papaver somnifera),a powerful anodyne. Also used in cases of diarrhea.
59. Pilulæ Catharticæ Comp. (compound cathartic pills)
Composed of colocynth, jalap, mild chloride of mercury, and gam- boge. The name fairly well describes its use. Prescribed espe- cially in cases of bilious fever.
60. Plumbi Acetas (acetate of lead)
A powerful astringent and sedative. Used externally for astringent lotions; internally for diarrhea and dysentery.
61. Podophylli resina (mayapple)
A slow-acting but powerful cathartic. It was a favorite of botanic practitioners, who used it as a substitute for calomel. 62. Potasii Iodidum
(iodide of potassium)
Used in secondary and tertiary syphilis. Also, generally used the same as iodine (see number 47).
63. Potassæ Acetas (acetate of potassa)
A powerful caustic and rubefacient. 64. Quiniæ Sulphas
(sulfate of quinine)
During the war this was the most important tonic febrifuge and antiperiodic (see Chapter 7).
65. Scillæ Syrupus (syrup of squills)
From the sea onion(Urginea martima),used as an expectorant, diuretic, and emetic purgative. Its most common use was in the treatment of chronic bronchitis. Beasley gives more than thirty dif- ferent prescriptions.
66. Sodæ Bicarbonas (bicarbonate of soda)
Used as an antacid and in dyspepsia, heartburn, and flatulence. 67. Sodæ [Sodii] Boras
(borate of sodium)
A powerful antiseptic. 68. Sodæ et Potassæ Tartras
(potassio-tartrate of soda [Rochelle salt])
A mild purgative laxative, used much as a Seidlitz powder. Made by combining cream of tartar with a solution of carbonate of soda. 69. Spiritus Frumenti (whisky) Probably the most prescribed “stimulant” of the war. In combina-
tion with quinine, it was commonly given for prophylaxis of malar- ial fevers.
70. Spiritus Lavandulæ (spirit of lavender)
Used as an aromatic.
71. Strychnia (strychnine) Used equivalently to nux vomica. An antispasmodic prescribed in cases of chorea and spasm of the esophagus. Stillé reported its use in epidemic cholera. Calling it “possessed of active and dan- gerous properties,” Beasley gives thirty-six prescriptions for a wide range of conditions.
It can be seen from Table 6.1 that the armamentarium was wide and varied, applying both mineral and vegetable substances to a vari- ety of complaints. These substances had attained their therapeutic status not by experimentation and double-blind study but by empiri- cally established dose-response relationships acquired over time and handed down didactically to each successive generation of practitio- ners. Modern analysis of the supply table suggests that for its day it reflected “a judicious and thoughtful selection of galenicals [botani- cals] as well as good judgment in their quantitative allowances.”14It
should be pointed out that besides the hospital and field service sup- ply tables, portability was achieved with panniers. These medicine chests (88 pounds when full) had been developed by Edward R. Squibb for field use. Designed to be carried by pack animals and hold- ing essential medical materials, panniers were much-used items.15In
addition to the panniers, medical personnel could carry a regulation knapsack to the front. Initially, the knapsack was made of wicker and weighed 18 pounds when full. In 1862 the knapsack was modified by a slight reduction in size and the addition of drawers. Almost 20 pounds when full, it was found to be too cumbersome for its purpose and was abandoned early in 1863, when Medical Inspector R. H. Coolidge developed a smaller field case (or “surgeon’s companion”) that had convenient shoulder and waist straps.16
Nonetheless, the summary of the supply table above does not do justice to pharmaceutical therapeutics as it was actually practiced. Although we know a great deal about the materia medica from vari- ous compendia and texts, we know much less about what the typical
Name Properties and Uses
72. Sulphur (sulfur) Given topically for skin diseases, especially “the itch.” Internally it is used in combination with cream of tartar as a laxative. Also sometimes used as a fumigant.
73. Vinum Xericum (sherry) A stimulant, especially in typhoid fevers. 74. Zinci Acetas (acetate of zinc) An ophthalmic astringent.
75. Zinci Carbonas (carbonate of zinc) A topical for excoriated and inflamed surfaces. 76. Zinci Chloridi Liqour (chloride of zinc) A topical for ulcers and tumors.
77. Zinci Sulphas (sulfate of zinc) A tonic and astringent. Stillé reports it “to have been very efficient in curing epidemic diphtheria.”
physician and surgeon really did, what one able historian has called “the gap which . . . exists between the medicine preached and the medicine generally practiced.”17Here the historian is presented with
a rare opportunity. If the medical corps of both sides did anything, they kept careful notes and records of what they did. The massive
Medical and Surgical History of the War of the Rebellion is a detailed
chronicle of diseases, incidents of diseases, and case-by-case treat- ments. Add to this the published accounts of Civil War surgeons and hospital stewards and the numerous regimental prescription books still extant in archives across the country, and a fairly clear picture of treatment behaviors emerges.
PRESCRIBING AND DISPENSING