Botanical name: 
Mentha x piperita
Erythroxylum coca

Format explanation.
Related entry: Menthol - Coca

Menthol in powder 2.50 | 25 grains
Cocaine Hydrochloride, in powder 0.15 | 1 ½ grains
Ammonium Chloride, in powder 25.00 | 250 grains
Camphor, in fine powder 5.00 | 50 grains
Lycopodium to 100.00 | to 1000 grains

Mix the powders.

The British Pharmaceutical Codex, 1911, was published by direction of the Council of the Pharmaceutical Society of Great Britain.