NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland pU MS B – 110 20 SEP '45 Notes on Lectures delivered [*] by Prof John A. McCorkle at the Long Island College Hospital At Regular Term of 1882 Books recommended Bartnote. Ririger. Nuring Farquharson. One of the first thing, We learn is the prescription wri tings. Now what are medicines They are simply substances used for the cure of disease All medicines are relative in their action. Medicines in one dose, if given in a larger dose may be poisonou 2 or in less doses may be useless; the step between a remedial agent and poison blends together. Do not think because the dose of a remedy is so and so, that you must always give that as a dose. Every physician should be well acquainted with Hygiene. What is Materia Medica? It is the study of certain medicines. Therapeutics is the last branch in the course of medicine; work up your chemical knowledge as early as possible; much of our Knowledge comes by Therapeutic Chemistry. A stimulant and sedative should never be given together, as the result 3 is a neutral. Therapeutics is the application of medicine to the cure of disease. There are two forms, a general and a special application. Keep this in mind. In taking up medicines we must discuss its source, to know something of its action. Most medicines are derived from vegetables; minerals and animals. Most from vegetables; many from minerals; and the least from animals. The medicines gathered from vegetables, must be gathered at a certain season of the year, usually the medicinal agent abounds in the plant when at maturity. Medicinal agents 377830 4 4 obtained from the animal, are generally obtained at the rutting time. Most of our medicinal agents are obtained from the Torrid Zone. We cannot grow Opium properly in this country. The mineral agents as a rule have to pass through the hands of the Chemist before we can use them. Instinct originated from the animals. We notice this often in animals; the cravings of nature will guide them in their choice of food or medicine. If you take from a fever patient “water” you take from him all that is left to appease nature, our older teachers observed the 5 way in which nature cures herself. Three fourths of all diseases will cure themselves; nature gets up what is called a critical discharge. In regard to the laws of cure, or natures cure, the principles of Therapeutics are not well established. You have first the uncertain action of the remedies; the invalid man, certain deformities, certain influences of climate or occupation, certain modes of living, then you have a pathological condition of the organs; no two persons condition are exactly alike; so that you deal with an uncertain drug, and an uncertain 6 condition. Now as to cure. This word comes from the Latin word “to take care of”. Just remember that in every human organism, there is a tendency to return to the normal condition. We can restrain nature if she becomes violent or errs. If nature will heal external wounds, will she not heal internal wounds? Acute diseases are always attended with well marked symptoms. First, that of pain, more or less developed, and almost always we loose all appetite; accompanied also with more or less debility. We have incurable diseases, remember 7 you cannot cure every disease; many incurable diseases can be made bearable by judicious treatment. If a patient have cancer of the stomach, you can teach them to become Opium eaters. Then we have the long list of chronic diseases. Let me call your attention to the modifying effect of medicines. The mode of preparing medicines has much to do with its efficacy; the forms of medicine are essential; as a rule the best way to give medicines is in solution. The impression is with some, that Iron is as good in one form as another. It is not so. 8 The Chalybete Waters are more readily taken up, because of their better division of the Iron. The next best way is in powders it is then more readily acted upon by the gastric juice. No medicine is a rule can find its way into the blood except it be in solution. Then again, the dose has a modifying influence upon medicines. Ipecac in minute doses is a tonic; just short of its emetic effect it becomes an expectorant and in another dose it becomes an emetic. Tartar Emetic in one dose slows the circulation and acts as a sedative; in another dose it is an expectorant 9 in another dose it is an emetic, and in another dose it is a rank poison. Now how about Opium? In small doses it sustains the system and is merely a stimulant; in another dose we give it to produce sleep. In giving Opium give your patient enough to put him to sleep if sleep be the object desired. Small doses of Aconite act as a sedative. If you want to get the continual effect of the medicine give it in small doses continually. gr x of Calomel is a cathartic, if you want to get the specific effect divide the ten grains into ten or more powders 10 and you will then get the specific effects. I want to call your attention to the cumulative action of drugs. Digitalis is claimed to possess this property, but I have never found it to be so. Explanation. First the action of the medicine has been prevented; sometimes in some diseases the stomach becomes so dry, that no medicine will be absorbed; and if you keep putting in medicine, it may be that all at once it becomes absorbed, the cumulative action of the remedy is simply an effect of the disease. Now I want to 11 present to you the diversities of the patient. Remember that no two persons are alike. In some diseases the susceptibility to the action of the medicine is increased. First – age influences the action of the medicine; and on this I wish to dwell at the greatest length. First we have the period of growth; second; the period of maintained integrity; thirdly the period of decay. – Read, Beck’s Infant Therapeutics, and Sharko and Lukes on old age. Now let me call your attention to the different ages; infancy and childhood is the period of growth, an infant is the most helpless thing in creation, note the development of the nervous system; from a little idiot apparently in about five years it has learned one or two languages; do you wonder at convulsions with a brain so active as that. In infancy you look for gastro-intestinal diseases; the functional activity of the organ predisposes it to disease. There is something so intimate with the nervous system of the child and the digestive organs of the body. Recuperation is best shown in the growing infant. I call your attention to the brain and nervous system. 13 Almost any disease in highly nervous children may be ushered in by convulsions. Now let us compare childhood with age. I want to follow the case which dies of old age; the changes of age are so insidious that they are part of the man, if you notice the appetite of the old person they go back to childhood. Old persons suffer from what is called Senile Bronchitis, this is not Bronchitis at all; the breath of old persons is often foul because of derangement of the gastric organs; we find the skin of old persons cold because the blood is used up internally by the circulatory 14 apparatus. In old age the thoughts come slower, and the most vivid impressions upon the mind of the old, is that of their youth. About the sleep of old people. The waking hours of an old person are less than the sleeping hours; they are also very susceptible to cold. In old age you cannot give violent medicines. Another condition in old age is, that people have pneumonia and you may not find a single condition to point you to the lungs, in old people every organ seems to act independently of each other. Remember in your treatment of old persons 15 and children, be careful of blisters; in a child you may get a convulsion and in an old person an ulcer. In regard to sex we generally give smaller doses to women than to men, but remember that there are effeminate men and masculine women. Be careful in giving medicines during lactation, pregnancy and menstruation. Children born with heart disease have the disease almost always situated on the right side of the heart. Note – In chicken pox the vesicles do become umbilicated; Briston claims that they umbilicate at times. 16 In chicken pox the vesicles come out day after day. I must do call your attention to some points which influence the action of medicine upon the patient. Habit has a very modifying effect with the patient who takes medicine continually; habit usually diminishes the susceptibility of the parts to medicine; some people have been known to take an ounce of Opium daily. A few doses of Mercury will so impress the system, that you cannot increase the dose, on the contrary you have to diminish it; - that is an exception, exceptions are generally active corrosive poisons; then there 17 There is Arsenic, beyond a certain amount you cannot go, because beyond a certain amount it will destroy the mucus surfaces. I call your attention to Tartar Emetic; just as soon as the stomach becomes irritated you must stop the dose. Then in regard to the use of medicines, always be careful of your first dose; increase the dose gradually and withdraw gradually. Another condition that influences the action of medicines; that is the idiosyncrasies of the patient. Some people can eat of all kinds of fruit, all kinds of meat; there is the smell 18 of Epicac will produce asthmatic spasms of the bronchial tubes in some. Some people cannot take Opium in any form. Medicines acting well in warm climates will not act as well in cold climates We use alcohol in fevers as a fuel; in fevers we have increased burning, and alcohol is thus burned in the place of the tissues. In warm climates cathartics are not used so freely as in cold climates, the liver acting more freely in the warm climate. People living in warmer climates usually have two or three evacuations daily, in colder climates there is 19 less secretion of the bile. In regard to the time of day to administer medicines; some medicines act better by giving them at night; others in the morning. If you want to have a slow easy action of the bowels; give it at bed time. If you give a saline cathartic give it in the morning; and give it fasting and well diluted as they generally act within an hour or so. If you want to cause the patient to sweat give it at night when nature will aid you in the action; if you give a diaphoretic in the morning, it will act as a diuretic. If you want to 20 act upon the patient’s kidneys you would not give the diuretic at night, but give it in the morning and keep him in a cool room; let the skin be cool so as to divert the action of the medicines from the skin to the kidneys. If you want a patient to sleep, do not think of giving an anodyne in the morning, it is perfect folly unless you give an overdose to produce special results. Now as to disease; this has a marked influence upon the action of medicine; the susceptibility to the effects of the medicine is both annulled and intensified by 21 disease. When the tongue is dry and brown, the stomach is also dry and brown; how then can your medicine be absorbed if given then, your medicine will lie and accumulate until being suddenly absorbed it acts all at once. In these cases consider the secretions first, you cannot get medicines through a dry membrane. The mode of living also has a certain effect; it is more easy to treat the rich than the poor. Too much nitrogenous food loads the blood with effete matter. In summer time children die of cholera 22 infantum. Why is it? Simply because their mothers nursing them have been living upon poor diet, which the child of course takes into its system. Another action is to be the effect of medicine, is the mental action. In the first place you want the confidence of your patient, this you must have; a man who can inspire the most confidence is going to be the best physician. Let me call your attention to that mental action. If you are going to give to your patient a sleeping draught be careful about your conversation to the nurse in relation to its effect, when 23 in the presince of nervous patients, as it has a mental influence. A man that dwells upon the disease only makes it worse. If you really and truly feel that certain medicines will have certain effects, you have a right to endeavor to impress that upon your patient. There are of course certain diseases which are not influenced by it, as for instance, chronic diseases. Read Took’s work on the influence of the mind over the body. Today I want to take up the subject of medicine more especially on the primary and secondary actions. If you give 24 a cathartic, the primary action is an evacuation of the bowels, the secondary action is probably a relief from headache symptoms. Almost all medicines act through the blood, a few act locally. Almost all nerve medicines act through the blood. Headland’s first proposition is; that medicine’s must obtain an entrance into the blood before they can attain their efficiency. The great majority of medicines are at once taken up from the stomach. By the internal fluids we motion the chyme, lymph, chyle and so on. All medicines will dissappear 25 as a general rule where it is applied, then they reappear in the secretions. The circulation is so rapid that it is made to account for any phenomena; in about thirty nine seconds the blood makes the complete circulation. Inhalations of Ammonia will excite the action of the heart. Headland’s second proposition is; that the greater majority of medicines are capable of being absorbed by either the Gastric or Intestinal juices, and passing without material change by a process of absorption through the coats of the stomach and intestines to enter the capillaries 26 of the Portal vein. Now how do these medicines enter? If you place medicine in the stomach, it is taken up by the Gastric juice; then we have the endosmotic action of fluids; medicine first passes through the mucus membrane of the stomach and the membranes of the Portal veins. This is by osmosis the passing of fluids through an animal membrane. The first condition which modifies the influence of medicine is its density. If we have water on one side of a membrane and alcohol on the other, the water will pass through first; this is due to the affinity of 27 the water for the alcohol. As a rule the density of the blood is greater than the contents of the stomach. Almost all medicines have a special affinity for the membranes of the stomach and hence they pass through without much difficulty. Between the contents of the stomach on the one side, and the blood vessels on the other we have a strong affinity. motion of fluids. In the stomach we have a fluid comparatively at rest, and externally we have a fluid in a state of motion, the secretions are thus carried rapidly away, which amounts almost to a 28 continuous current. We have another modifying influence on osmosis, and that is pressure on one side. If you place anything in the stomach you start a peristaltic action of the stomach, which tends to press the secretion through the walls of the stomach and it is thus carried rapidly away. Now what is true of food or water is true of medicine; if you want medicine to act quickly, give it at the temperature of the body. What medicines are absorbed by the stomach? All medicines soluble in water; all albuminous substances are digested in the stomach; whatever 29 is soluble in an acid secretion will be digested in the stomach, all vegetable and animal medicines. Rosins; alkaline or fatty medicines are absorbed by the intestinal canal or tract. If you give Cod Liver Oil before a meal you do harm; if you give an alkaline matter, give it after the digestion has commenced. Headland’s third proposition is, that those medicines which are completely insoluble in water, the gastric, and intestinal juices cannot enter the circulation. We use charcoal sometimes and also Sub nitrate of Bismuth. Now why do 30 We use it? We want to cover the tender mucus membrane, and thus the irritating matters pass over and do no harm; this gives the intestinal tract a chance to heal. Sulphates are soluble, but they are soluble in the Chlorides. You take the Sub Carbonate of Bismuth, it is I believe absorbed to certain extent. If you give a drachm of Bismuth it has only a local effect. Headland’s fourth proposition is that some remedial agents act locally upon the mucus surfaces, either before absorption or after being absorbed at all; they are chiefly as follows; 31 Irritant Emetics. Irritant Cathartics. Superficial Stimulants. Sedatives and Astringents. If we give a poison in an overdose, we give antidote to neutralize its effect, or we give an emetic at once. We give Arsenic in Sesquioxide of Iron and then we feel a little better if the patient vomits. We know that Albumen will neutralize the corrosive action of poisons. If you give to a patient Tartar Emetic it will produce its specific effect just the same. An irritating emetic acts either by being vomited or thrown off through the evacuations. Take cathartics; as 32 a rule they act upon the mucus membrane of the intestinal tract, and are thus eliminated through the glands. Irritating Emetics, and Irritating Cathartics are different in their action, one acts upon the nerves, and the other is eliminated by the glands. In relation to this fourth proposition, we know that certain medicines as soon as they reach the mucus membrane of the stomach are absorbed, and that action may continue even after the absorption into the blood. We have what are called muco stimulants; then we have muco astringents, and muco sedatives. We 33 give carminatives to tone up the stomach; muco stimulants come under this class. When we find the stomach in an irritated state, we give muco sedatives. Hydrocianic Acid is a sedative. If you want to act directly upon the stomach give your medicine by way of the stomach in order to get its specific effect. Then we have the muco astringents; and give the Acetate of Lead first if it is local, or treat it by way of the blood. Then we use to check the secretion, muco astringents. Headlands fifth proposition is; that while in the blood 34 the medicines may undergo a change, and others may not affect its influence. That is, changes may be of construction, reconstruction, and combination. Certain secretions of the alimentary tract are acid and some alkaline. We know that if we give an Alkali on an acid stomach, it is speedily neutralized. Many of the medicines we put in the stomach are neutralized before they are eliminated. Two influences are at work; first the chemical action, that is modified by vital action. If we give to the patient Benzoic Acid 35 it appears in the urine as Uric Acid. Then we have the changes of combination; as soon as the medicine goes into the stomach, the Carbonate of Potash becomes something else; then there are certain chemical laws which govern it. Take two soluble salts and mix them, and we get four salts. We will now discuss the avenues; how medicines gain entrance into the body. There are two: the skin and the mucus membrane, that is external and internal. How do we introduce medicine through the skin? Some medicines are just laid upon 36 the skin; this is called the Enepidermic method, then between the medicine and the blood is a dense layer of tissue. The blood is Alkaline, and acids and alkalines attract each other. If you want to use a medicine on the skin, as a rule use acid medicines. The Epidermic method is to rub the medicine into the skin, you can use this method in children. Then we have the Endermic method this is to apply the medicine on the raw surface of the integument, you having previously removed the cuticle with a blister. An 37 inflammatory surface is not a good absorbing surface, the effort of the blood on the inflammatory surface has a tendency to throw off, not to take anything in. Why do we use it? Very often we want a counter-irritant and obtain it in this way and then find a little of the medicine is absorbed. All these methods are superseded to a certain extent by the Hypodermic Syringe. Now in regard to the Syringe be sure you know the exact ____ quantity your Syringe will hold; this you must attend _________ to. The advantage of the 38 Hypodermic Syringe is first; rapidity of action, then certainty of action, and you can avoid the cumulative effect. We would use this injection in acute pain, it is an excellent thing in colic. In chronic painful affections do not use the syringe, give medicine by way of the stomach, give them opium pills as in a case of peritonitis. The danger is, that often if you allow the patients to use the syringe themselves; they are almost sure to form the opium habit. You will of course use soluble medicines in the syringe, for if you introduce a solid 39 under the skin it will form an ulcer; be sure your solution is not remarkably alkaline or acid, for acid will coagulate, and an alkaline will irritate. Then be careful about having your injection too strong; if you use too strong a solution you are not absolutely certain of the amount that goes into the tissue. Do not carry a solution in your pocket too long, as they will not keep long. Always be careful of your first dose to a new patient. Do not leave the patient immediately after you have given a hypodermic injection, as it is apt to produce a little faintness. 40 The best way is to give an injection deeply, put it in the deep tissues; you can inject it into the body wherever you find an accumulation of muscular tissues, there is no necessity to give it over the seat of pain. Now as to the internal administration of medicine. We have the nasal douche, also the spray. The douche should be used with great care, and let the liquid be a mild solution. Then we have inhalation; this is used very much in diseases of the mouth and nose, but be careful of its use. Now the stomach is the chief avenue for the entrance of 41 medicines, we can use the skin when the stomach fails. In the stomach we have certain difficulties. If we give medicine on a full stomach we may wait a long time for its effects; we sometimes find the stomach dry we sometimes find the liver engorged; the pressure is then outward instead of inward. Then again sometimes the patient can not swallow, or they will not swallow; sometimes the medicines are vomited and again the medicines are not absorbed The normal condition of the mucus membrane; free circulation of blood; and freedom from disease in the anexed 42 organs, will aid the stomach in the absorption of medicines. If we want a medicine to act quickly and it is a nonirritating, we give it on an empty stomach; we give Iron on a full stomach; we give medicines which we want to act slowly, on a full stomach. Then if you want medicine for the blood, give them on a full stomach. Another avenue I want to dwell upon is the rectum. The rectum was made for excretion. The reaction of the rectum is alkaline, so therefore give your nutritious material slightly acid. I have no doubt that 43 patients can be kept alive for weeks by feeding by the rectum. You can almost make a person drunk by keeping their feet in hot rum and water, if they are in a weak state. If you give your medicines by the rectum, give them in solution. The membranes of the bladder absorb less than any other membrane. Note Enemas. If you give an enema and leave it to the nurse; give them full directions. Be careful about giving an injection. If you have a case demanding grave attention; give the injection yourself; let the patient lie on the back or on the side. 44 If you want to use large injections use a large catheter. If you want to introduce a nutritious enema, get it up as far as you can; it must however be small in quantity at the time; if you want to give a nutritious enema get it up beyond the large bowel. Do not wash out the bowel with oily substances, as oil prevents absorption; if the bowel be irritable put a little Opium in your injection. The dose of medicine by the rectum should usually be larger than by the stomach; in Strychnia give less by the rectum, and morphia also. In a Suppository 45 you will have to give a little larger dose. We use the rectum when want to give the stomach a rest, or if the disease is near the rectum, you use suppositories at longer interval because of their slow absorption. All anodynes; Morphia. Atropia. Hydrate of Chloral &.c. can be used by way of the rectum. Whenever you want to use your medicines for a long time, coat them with gelatinous substances, or you can use cream. You can administer medicines to children by way of the rectum, or coat them with cream and administer by the stomach. 46 We will now take up the art of prescribing; how to prescribe; when; and what to prescribe. In the treatment of the different stages of disease you may need different medicines. At the outset of an acute disease we ought to use sedatives, then there is a period when we use neither sedatives or stimulants; then their is a period when we want to use stimulants. Remember that all diuretics will act better together than one single one; in all cough medicines, combination is good. Note Warburgs Tincture which contains nearly forty different bitters. Diaphoretics. Expectorants 47. and Cathartics are desirable in combination. Then you take the Diver Powder which contains Sulphate of Potash. Ipecac. and Opium. If you combine a little Morphia with Quinine you do not get the unpleasant effects, Hydrobromic Acid will also produce the same result. Now as to incompatibles: We have them both chemically and physiologically; medicines that are chemically incompatible, may be physiologically compatible and visa versa. you can hardly combine Sulphuric Acid with any salt, as it forms a simple sulphate. 48 you must remember that almost all acids are better given alone, or with their bases. Be careful in the use of oxides on an oxidizing agent; in starchy materials never combine it so as to become explosive. If you give any nitrates give them with their acids. Note. Drop doses in urgent cases of vomiting are excellent; always make your medicines as palatable as possible. The physical states of medicines are, solids, liquids, and gases. We will first take up powders. Homeopaths use Sugar of Milk to triturate their medicines in, the most perfect powders however 49 are produced by precipitation; it is said that the ordinary dose of Calomel is ten grains; yet by triturating it one grain will effect almost as much as ten grains not triturated; by trituration the Calomel will become yellow; Calomel should always be carefully triturated. If you want to give medicines in a powder, do not give very unpleasant medicines in this form as it hangs around the mouth. Heavy substances are not well given in solution as they sink to the bottom. What about Pills? They should generally weigh about four grains; if you want to 50 give a larger dose than four grains, give it in a capsule, this is speaking of vegetable medicines. The minerals you can give up to eight grains in a pill. Children cannot very well take pills. Consult your patient’s wishes as far as possible, as to how they would like best to take their medicine. What are the objections against the use of pills? First old pills will loose their virtue; again many pills will leave the body as they went into it, without effecting any result whatever. Now old Opium pills will be disolved in the intestinal tract, and what is there very 51 valuable, is in most pills very objectionable. Now Quinine Pills will frequently pass from the body in the same condition as when administered; be careful in giving pills in diarrhea as they will not be absorbed. Quinine must be disolved in the stomach or it is not disolved at all. What kind of medicines are usually given in pills. First, medicines that are given in small bulk; many of the extract can be given in pills, and it is a very good way to give solid extracts; secondly; medicines that are offensive can be given in pills; Turpentine can be given in pills mixed 52 with some inert matter and flavored with Cinnamon. We often give medicines in pills when we wish them to act along the bowel, then the older the pill, the better. What are Lozenges? They are another form of pill used generally for throat trouble, and diseases of the mouth. Dry Lozenges by the air, not by artificial heat. Liquid medicines are the best form of medicines. What are Mixtures? They are powders held in solution. You must always be careful to put “shake well before using” on the bottle; I do not however like to see this direction on 53 a bottle. Give your medicines a good appearance. What is an Emulsion. An Emulsion is an oil held in suspension. You will find it is better to give Cod Liver Oil pure, not in emulsion. If you want to give it in emulsion, make the emulsion yourself and get the oil from fresh livers. What are Extracts? They are simply the active principle of the drug extracted by water or alcohol. When you are treating Kidney disease you do not care to use any alcohol, then use an infusion. An infusion is made with water just below the boiling point. 54 You must however make an infusion of Wild Cherry with cold water. Decoctions are _________ made with boiling water. Tinctures are simply Alcoholic Extracts; we can use these unless we do not wish to use the Alcohol. We have also Syrups; then we have Poutices, Ointments and Blisters. Now for Prescription Writing. One is official and the other is non-official. Every prescription is made up of five different parts. 1st Heading. 2nd name of ingredients. 3rd directions to the druggist. 4th directions to the patient. 5th date and signature. Do not abbreviate your 55 prescriptions too much. In a prescription always put your active drug first. Always write directions for your medicines, don’t write on the bottle take as directed and tell your _____ patient how to take it. In a gargle be careful to write your prescriptions plain and in full. Now as to the domestic measure. If you give medicine to a child give it in a Minion Glass. Tea spoons do not always hold the same. Always be sure you put “poison” _____ on the bottle if so needed; to insure yourself against accident. Do not give medicine in drops if it can be avoided. 56 A nutrient enema should be about two ounces; wash out the rectum before injecting. If you give a patient a drug that will be dangerous to repeat put on the prescription “not to be repeated”. We will now take up the subject of food in general use. The Nitrogenous and non- nitrogenous; tissue building food, and heat producing food. The amount of nitrogenous food, needed in the adult is not great; this includes lean meats, white of eggs &c. Nitrogenous food is a stimulus to the nervous system. In nitrogenous food we 57 have liberation of force, the nitrogenous food is digested in the stomach. In the liver, albumen is broken up and converted into waste material and Glycogen; the waste is disposed of by way of the Kidneys; if there is a large amount of waste it leads to great activity of the kidneys, this leads to hyperemia, and this leads to chronic Bright’s disease. In fevers; especially in the latter stages we find waste material increases. Glycogen goes in the form of respiratory food; we burn the Carbo Hydrates in the system to get the animal 58 heat. The fever patient in the latter stages of the fever feeds upon his own flesh; the Hydro Carbons furnish the heat and are the respiratory food. The albumen in the white of an egg is very complex compound. Oxygen gives us life and it also destroys life. The growing plant takes up on the under side of its leaf the Carbonic Acid. The Carbon is woven in by the plant and the Oxygen is given off to the air. A man can live ten days without food, and in a warmer climate still longer; in a cold climate a man needs more Carbo Hydrates; every 59 time you move a muscle; oxydation takes place. The physiological action of nitrogenous should warn us of their use in sickness. As in the degeneration of Albuminoids their stimulating properties are not reduced. The following is a table of retrograde metamorphosis. C H N SO + O = (----------) \ 72 112 18 22 \ (Albumen) \ (------------) + O . . . . . . . =. . . (----------) \ (---------) \ (------------) + O . . . . . . . =. . . (----------) \ (--------) \ (------------) + O . . . . . . . =. . . (----------) \ Oxidation (--------) \ (------------) + O . . . . . . . = C H N O \ > C H N O + O = C H N O + H N O / 5 5 5 3. 5 4 4 3 / Complete (Guanin) (Hypoxanthin) / C H N O + O = C H N O / 5 4 4 5 4 4 2 / (Hypoxanthin) (Xanthin) / C H N O + O = C H N O / 5 4 4 2 5 4 4 3 / (Xanthin) (Uric Acid) / C H N O + H O = 2C H N O + 3 C O / 5 4 4 3 2 3 4 2 2 (Uric Acid) (Urea) C H N O + 2H O = (N H ) G O 4 2 2 4 2 3 Urea Ammonia Carbonate C H N O + 3 H O + 2 O = 2 C H N O + H C O + C O \ 5 4 4 3 2 4 2 2 2 4 2 \ (Uric Acid) (Urea) (Oxalic Acid) \ Oxidation H C O + O = H O + 2 C O \ 2 6 4 2 2 \ (Oxalic Acid) \ ___.___ \ 2 C H O + 216 O = 55 H C O + 4 C O \ 57 110 6 2 2 4 2 \ (Stearin) (Oxalic Acid) Incomplete \ 2C H O + 326.O = 114 C O + 110 H O > 57 110 6 2 2 / (Stearin) Complete / ___.___ / C H O + 9.O = 3 H C O + 2 H O / 6 10 5 2 2 4 2 / (Glycogen) Incomplete / C H O + 12.O = C C O + 5 H O Complete / 6 10 5 2 2 / Incomplete ___.___ Our Knowledge of Guarin. Hypoxanthin and Xanthin is too meagre to be of material aid in Therapeutics. 61 Now in relation to meals. It is said that if a man can sleep well, and eat a good breakfast he is in the best state of health. A little fat in the morning is excellent; for dinner you require another hearty meal; just after a hearty meal do not commence to work. Now as to Phospirorous and Nitrogen. Phosphorous is called brain food, but there is a great deal of nonsense about that; these are both stimulants to the nerves. What is the result if a man eats too much meat? He simply becomes loaded up with nitrogenous and effete 62 matter; over stimulation leads to convulsions, coma, and death. If we eat too little meat we feel languid. When you come to treat Bright’s Diseases you will have a constant fight with your patient, they will want to eat meat when you do not want them to eat it; remember this in gouty kidney. If you take too much Hydro Carbons the system becomes loaded with fat; if a man eats too little fat he becomes scrofulous and tuberculous; remember this in consumptive families. We will now speak of Hydro Carbons In cases of fleshly persons make 63 use of food that has but very little nitrogenous matter, but give them enough food to fill the stomach; the best kind of food is a mixed diet. In Diabetes be careful of your diet, remember that sugar is irritating to the to the Kidneys. I want to call your attention to another disease, “Indigestion. It is not every case of indigestion that must be treated; for this disease stands between many a man and the grave, as some men would eat themselves to death. If any organ does not appropriate its normal amount of nourishment, it becomes so much waste product 64 in the body; great eaters usually suffer from Hepatic diseases, excessive wear leads to disease. Now in regard to drink. The first and best is milk; it contains mineral ingredients, nitrogenous matters and respiratory food; in regard to stimulants you can give your milk punch or rum punch. Beef tea as a food ranks very low, and yet in a sick room it is absolutely essential; it contains a little salt, a little albumen, and some other materials which go in the direction of waste. The whole tendency of stimulants is to unlock the reserve fund. The best time to use 65 beef tea, is when you begin to use your stimulants; do not depend upon it as a stimulant. At the outset of a fever you do not want to use stimulants; alcohol is a better stimulant than beef tea; do not stimulate a robust healthy man who is suddenly taken sick, carry this idea to the bed side with you. Now in regard to tea and coffee. I am partial to these as a drink. I want to call your attention to the active principle of tea, “ Thein”. It contains a large amount of Gannin and in the treatment of children with Gannin, I do not know 66 anything better than equal parts of tea and milk, this is specially applicable in the latter stages of diarrhea. The active principle of tea and coffee is about the same in cases where you cannot use alcohol, you are perfectly safe in using tea or coffee; these have the power of diminishing waste; in exhaustive diseases I do not discourage their use. In the treatment of diarrheas in children I use tea. I want to call your attention to astringents; these are medicines which are used in emergencies, they are however of the least importance 67 of any of our medicines. They are medicines which have the power of contracting living tissue and also dead tissue as in tanning leather. These are vegetable and mineral; every vegetable possesses this power in some form; astringents pucker the mouth and produce roughness; in dead tissue they coagulate the albumen; they prevent secretion of the gastric juice and thereby impair digestion. If they enter the blood they pass out by the excrementary organs and thus these become constringed, their local effect is to tighten up, they are used to stop hemorrhages &c. 68 The effect upon the nervous tissue is but slight, and is only secondary through the muscular structure; upon the lungs it has the same effect as upon the excretory organs, it has also just the same effect upon the urinary organs. If we have profuse diuresis we give Uva Ursi, this acts upon the kidneys. Many of the astringents are not digested in the stomach. Now what are the indications for their use? First to check morbid discharges. Second to obviate morbid relaxations; and third to check inflammation in its early stage, the latter locally 69 First then we have excessive secretions; second, hemorrhages. We have morbid discharges of various kinds from almost every mucus membrane; but every morbid discharge does not need astringent treatment. Very often we have a morbid discharge to which the system has become accustomed, in this case you will do harm to check it; if you check this all at once you get excrementitious plethora; you must always be careful then in this direction, as in fistula for instance. Now in some cases bleeding from the rectum is not dangerous, but if the 70 bleeding is excessive you must interfere. Then we use astringents in menorrhagia, do not be very anxious to relieve hemorrhage from the lungs, but when it is excessive you must employ astringents freely. Take for example in a diarrhea, in nine cases out of ten a diarrhea is beneficial; suppose you give astringents at the outset of this diarrhea you merely make it worse; the best treatment is to give a little Castor Oil or Rhubarb, in Rhubarb the cathartic acts first and the astringent second. If you have a diarrhea which becomes chronic 71 you would not then want to give a cathartic to clear the intestinal tract, you would then use astringents; when the bowels have lost their elasticity, tighten them up. In dropsy remember that the swollen condition of the limbs is simply a counterpart of the intestinal tract; if you have a watery discharge from the bowels, it is the best thing you can have in this case. Now what is true of diarrhea is true of dysentery. In Typhoid Fever we have sometimes a relaxed condition of the bowel after the disease has left; be sure your tract is clear 72 from morbid secretions then give your astringents; you would not use an astringent in plethora, you want every organ to act freely. In a hemorrhage be careful of the use of astringents; remember that where you have a hemorrhage you have a condition of congestion unless in the bursting or wounding of a blood vessel; in passive hemorrhages you can usually use astringents with good effects. A Styptic is anything which will stop morbid relaxations, you use it in leucorrhea, gonorrhea, in the mouth, 73 nasal passages and throat. If you want to use an astringent in the early stages of inflammation, you must use it very early just before the blood vessels begin to pour out any exudate, you must not use an astringent when the blood vessels are engorged The following is a good gargle In sore throat. Rx. Tannic Acid ℈ij. Acidi Carbol gr viii Glycerine et Aquae ℥i āā. Sig ʒi in half tumbler of water and gargle. Note dose of Gallic Acid from 5 – 10 grs. Tannic Acid “ 3 – 10 grs. Never give Tannic Acid with Iron. Copper. Silver or Lead. 74 Now as to the efficiency of the two acids. If you want local effects use Tannic Acid; if you want an interval effect use the Gallic Acid. What are the indications for their use? They are useful in Gastric Catarrh this disease is often owing to the relaxed condition of the stomach. In hemorrhage from the stomach we find that Tannic Acid in 5 or 10 gr doses is the best, but if you have a hemorrhage from the lungs, use Gallic Acid as it has to enter through the circulation, we use them in dysentery after the discharge has somewhat abated. 75 Tannic Acid is common to all vegetable astringents. When you are called to see a case don’t begin to think what shall I give this patient; first make your diagnosis then observe the tendency to death, always observe the old rule; “obviate the tendency to death”. Now for vegetable astringents; Kino is often used among children it is good in the diarrheas of children and females, where you want a little tonic action also. In Catechu we have an excellent astringent for the mouth it is good for spongy gums, the dose of these remedies is about the same, from 76 ʒi - ʒij. We use Rhatarry as an injection in the rectum about ʒiss. Logwood among children for a diarrhea is excellent, in adults it is too weak for any special action. Black Berry Root is usually given in the form of a decoction this is excellent for a relaxed condition of the mucus membrane of the stomach. Uva Ursi is used a great deal, for its special action upon the bladder and urinary tract, this has a tendency to pass out by way of the kidneys. Witch Hazel is an astringent and slightly tonic. Whenever you want to check a morbid 77 secretion of the stomach you can use your mineral acids. You can use your Tannic Acid in the form of a pill or suppository, but if you want to use it locally you had better use it in solution. Note chief mineral astringents; Acetate of Lead, Alum, Iron Zinc, Copper, and their salts Sulphate of Iron, Sulphate of Zinc and Copper, every one of them will coagulate Albumen; each of them in large doses becomes a poison; the mineral astringents act chemically. If you give too large a dose, the chemical action will overcome the vital 78 action and destroy the tissues, keep these minerals substances well within their chemical action. Now what is the action of Sulphuric acid? It puckers the mouth if too strong, it is rapidly taken up by the stomach and cannot be held in the blood; Sulphuric Acid has a special affinity for the glands of the skin, it therefore stops night sweats; remember that every medicine that you put into the stomach and that is foreign to the blood must be eliminated from the blood; Nitric Acid promotes secretion; Hydro Chloric Acid promotes digestion 79 Acids have a tendency to check acid secretions, and also have the power to constringe; we use them largely in Typhoid fever to check morbid discharges. Sulphur Acid is used to counteract the effects of Lead, it unites with the Lead and forms a Sulphate of Lead and thus renders it inert. Now as to Alum; the dose is from 5 grs to a tea-spoonfull, it is an excellent remedy in the vomiting of croup, Alum is a universal astringent; it is used in chronic Gastric Catarrh, it is not a harmful remedy, it is excellent in hemorrhage in the 80 Gastric Hemorrhages it is excellent. A hot solution of Alum is stronger than a cold one; in leech bites you may use alum and if this fails to check the hemorrhage you may know a blood- vessel has been injured. Alum is a very good laxative, as in females who have been accustomed to allow themselves to go for a week or ten days without an evacuation, we then give Alum to tone up the muscular fibres of the bowel. Give a good free dose of alum in lead colic, you must try and overcome the paralysis produced by the lead, and 81 thus you empty the bowels. Then we have another astringent in the Acetate of the Sugar of Lead; it will take at least an ounce of this to produce death so that acute poisoning by this substance is very rare; the dose is from 3iss to 3v the antidote for this poison is Sulphuric Acid. Acetate of Lead has two effects, it is first astringent and then sedative, it lowers fever and reduces the pulse. If you want to use any astringent in inflamatory stages, use lead; when it enters the blood slowly it produces chronic lead poisoning. How does lead get into the system? 82 We find it in lead workers and painters, some people are very susceptible to lead poisoning. Now what are the symptoms? First you will notice his haggard appearance, the patient is emaciated, the color is often of a jaundiced hue, there is loss of appetite, metalic taste in the mouth, furred tongue loss of sleep, irritability, you may find a blue line along the gums, pain in the stomach and abdomen, pain is relieved by pressure showing it to be neuralgic, there is pain in the Recti muscles, also obstinate constipation is present the muscles of the bowel are 83 paralyzed by the lead, there is a kind of rheumatism in the joints due to the deposit of urates. We use Lead in morbid fluxes of all kinds, we can use this astringent where we can use no other. As to its physiological effects, it leaves a sweetish taste in the mouth; long continued doses will produce constipation. What are the sources of lead poisoning ? It may come through the water; all lead pipes should be zinc lined; a frequent cause is the use of hair dyes; diminished secretion always attend lead poisoning, the liver becomes diminished in 84 size, there is elevation of temperature, lead specially prevents oxidation of nitrogenous materials; if your patient with lead poisoning could eat he would kill himself, then we have a large deposit of lead in the nerves, which paralyzes them; The muscles of the intestinal tract correspond with the muscles of the forearm to it is said and hence we get wrist drop. We find on Post Mortem a large deposit of lead in the brain, also in the liver, we find it in the muscles wherever there is paralysis. Rember that the abdomen is flat and falls 85 back to the spinal column; death usually takes place from inanition, from failure of nutrition; in rapidly fatal cases the poison falls upon the brain and the patient dies of Lead Encephalica; the patient dies in coma; lead is very fatal to foetal life, whatever interferes with the nutrition of the mother will interfere with the nutrition of the foetus. How will we treat this difficulty? This is prophylactic; first avoid the cause, if the patient cannot leave his work give him a Sulphuric Acid lemonade. Once in the system how do 86 We get rid of it? Disolve it by the aid of Iodide of Potash, give this largely diluted, the hygiene must be of the best; as the lead diminishes use tonics. What are the indications of lead therapeutically? We use it in Gastric Catarrh, in this disease use it for a short time only; use it in chronic diarrhea; the lead and opium pill is an excellent combination; in the summer complaint of children it is coming more and more into use not in the acute stages but in the latter stages remember. In the diarrhea of consumption one grain of lead and one of 87 Opium is excellent in pill form. In the third week of Typhoid fever we use it; be careful of its use and look out for the symptoms of Lead poisoning. In hemorrhage we use lead to diminish the force of blood and as an astringent. If a man is fainting from loss of blood do not give him stimulants; let him faint, it will prevent the hemorrhage. External use of Lead. A solution of Lead is used in extensive burns, paint the parts with Carbonate of Lead, ʒii in a pint of water; in sore nipples paint them with Lead. Alum and Lead are the chief minerals as medicines. 88 Now as to tonics. These are used too much. Tonics are medicines which materially and somewhat durably excite vital action. Tonics usually increase secretion; increase nutrition generally when the patient is below par; they are usefu until he gets up or almost up to par. Astringents have the power of constringing tissues. We have Tonic Astringents. Astringents act quickly; Tonics act slowly. Tonics act generally; Astringents act locally. The action of Astringents is transient, the action of tonics is permanent. Astringents increase the 89 coagulability of the blood; Tonics increase the nutrient qualities of the blood; Astringents increase the muscular action; tonics act organically. Note. Astringents. Tonics and Stimulants. Strength is the capacity to act; if you increase the strength of an organ you increase its capacity to act but you may increase action without increasing strength; note this in fevers the action is then out of all capacity. Now when every function is doing its action let them alone. If you increase the function of an organ, you increase its tendency to disease 90 do not try to go beyond the ordinary plane of life; never give a patient a tonic who is in perfect health and never let them take one up to a standard of perfect health. I would like to call your attention to excitability. When you come to treat drunkards the excitability is almost dead in these cases; now if you over stimulate an organ you simply crowd it into disease. Tonics are always indicated in depressed conditions, just enough to stimulate the appetite, not more; this increases the quality of the blood. So long as debility remains your tonics are indicated. 91 Rember there is no such thing as a permanent stimulant. Give tonics only when the patient is below par, in gangrene we have to give stimulants to sustain the depressed nervous system. In the stage of convalescence use your tonics, but remember they are indicated in cases of debility where the cause has entirely ceased; sometimes the system gets in the habit of living below par; you must tone them up or they will be chronic invalids you must bring them up to par. Tonics will help to sustain the system in fevers, gangrene, or suppurations of any length of time. Tonics 92 are useful in the failure of a particular organ. The first effect of a tonic in the stomach is to increase the appetite and increase the quality of the blood; the vessels of the body feel the effects of good blood; any organ that may be weakened simply measures the power of the man. In debility tonics may be useful or harmful. I will give you a few points where they are not indicated. They are not indicated where we have worn out excitability; they are not indicated when such cause is irremovable; in cases of cancer they simply do no harm; tonics are not indicated where there 93 is apparent prostration from congestion or inflammation of the lungs; in acute inflamations they are not indicated. “Tonics are chronic remedies for chronic conditions.” Tonics materially and somewhat durably excite the vital functions. Remember when a disease becomes chronic your tonics are indicated. Tonics are not indicated in rapidly failing cases, in such cases you must use stimulants. You do not want to use tonics in debility from excrementitious plethora; in this case the appetite fails because the system is replete with nitrogenous 94 matter; in this difficulty you want purgations and fasting. Where debility is, the functions are depressed below the normal. In apparent debility one organ is stimulated above normal, and others below normal. In pneumonia the excess of blood in the lungs must be depleted. Loss of muscular power means principally loss of power in the involuntary muscle. Now note a case of real debility in a woman from long continued lactation. Now place beside that a case of a strong man who thinks himself sick he has a loss of appetite & has a thumping head ache; this is 95 due to too much blood which is rich in excrementitious matter. This man’s tongue is heavily loaded his pulse full, hard, and strong just the opposite to the woman just spoken of. Treat this man with a little Calomel or saline cathartic; just wash him out and he will be cured of his difficulty; his was apparent debility. When the tongue is flabby and quivering, tonics are indicated. The action of tonics is never rapidly manifested. Now always take with you to the bedside the element of hope. We have animal, vegetable, and mineral tonics. 96 I place Cod Liver Oil under the head of animal tonics. Iron takes first place in Mineral Tonics. Cod Liver Oil is a food and a medicine; it contains Iodine, Bromine, Billiary salts and certain organic properties. If a child does not like fat that child needs oil in some form. Cod Liver Oil promotes digestion by increasing the appetite this is its secondary effect, it is usually taken up by the lacteals of the intestines; it is more readily taken up on account of its Biliary salts the effect of Cod Liver Oil upon the nervous system is caused by its secondary effect. 97 Note its physiological effect. The best cure for neuralgia associated with debility; is Cod Liver Oil and Iron; whereever you want improved nutrition, your Cod Liver Oil and Iron are useful. Cod Liver Oil is readily taken up by the system, it produces its effect very quickly. What is true of this oil is true of other oils in a less degree. Whenever you use oil externally you must use friction. For external use I use Cocoa Nut Oil I have used this in the treatment of Scarlet Fever. If you want to use Cod Liver Oil externally 98 the patient a bath previous rubbing in the oil, then rub in as much as the skin will absorb. Children will take pure Cold Liver Oil rather than in emulsion. Cod Liver Oil prevents the deposit of tubercles. In children who have abcesses and discharges of pus I give Cold Liver Oil; but never give it to a child in a high fever. In Phthisis in a high fever do not give your Cod Liver Oil, but give it in the chronic forms of Phthisis; we use it sometimes in the chroni forms of diarrhea combined with some astringent tonic Note. Tonics of vegetable origin 99 We have three classes. We have the simple or pure bitter, this contains simply a bitter principle and that only. Then we have peculiar bitters, they contain a bitter principle and a peculiar principle. Then we have the aromatic bitters, they contain an aromatic oil. Simple Bitters improve the appetite; improve the secretions, and improve the blood by acting upon the stomach. A Simple Bitter can do no harm except wearing out excitability. Now for the antagonists. Anything that will exhaust the system as Iodide of Potash. 100 The Simple Bitter is slightly irritant in the stomach. We can combine tonics with laxatives. Whenever you have a condition below par, use the mild tonics. In diarrhea we can use our Astringent Tonics, these we can use with a little Opium. Columbo or Quasi can be used with Iron very often where the stomach is irritable. Some people as soon as the food is taken into the stomach desire to go to stool; a little Opium and Colombo is I believe the best thing you can use here. In the intestinal tract Pin worms infest the lower bowel, 101 a simple infusion of Quassia is very good, about ℥iss can be thrown into the rectum after the child is asleep. The condition which gave rise to the worms may however exist, this is an atonic condition of the bowel, you must then treat it by the blood. Note remedy for flatulence. Combination of Columbo. Ginger and Sennae, this is excellent in flatulent colic or flatulent dyspepsia. In convalescence of chronic malarial poisoning we often use the tonics, the Dogwood is employed very much in the West. There 102 they use a mixture something like this. Dogwood. Wild Cherry. Poplar bark. Columbo ℥vi aa. flavored with Sassafras, to this is sometimes added Gentian. Cayenne Pepper. Boneset. This is put in half a gallon of Whiskey and a wine glass of it taken three times a day to break up the malaria. Note peculiar bitters. Quinine is a type of this class. Note doses of Bitters. A teaspoonful of the Tincture; a tablespoon ful of the infusion; ten to thirty M of the Fluid Extracts. One gr of Quinine is a tonic dose. Quinine 103 represents the virtues of the Cinchona bark. Sometimes we find a combination of bitters, is better than any one bitter alone. Now in Warburg’s Tincture each fluid ounce contains gr ix ss of Quinine; the action of that ℥ i is better than any gr ix ss of Quinine that you can employ. Note; history of Quinine, the bark is gathered by the Indians of Peru. It is said if you were to make an estimate of the usefulness of medicines; that Opium would stand first, and Quinine second. We have antagonists to Quinine 104 Alkalies are incompatible with Quinine. Quinine of itself is an irritant along the bowel in large doses; in fevers much passes out by the bowel. Incompatibles are all those which tend to promote waste. Note Mercury; this has a specific action upon the morbid condition of the blood, and to build up the body. The best bitter is the Compound Tincture of Cinchona; we therefore combine Mercury with Cinchona. If we use Mercury and Iodide of Potassium this gives us a bad precipitate in solution. Here a receipe was given for Syphilis as follows 105 Rx Hydrang Bichloridi gr i ss Potass Iodidi ʒiv “Chlorat gr x Aquae 7t Sol or Tinc Cinchon Comp ℥ iij Sig ʒ i three times day after meals. Now what is the action of Quinine upon the nervous system? The first action in small doses is to stimulate, it sustains the nervous system in small doses. In large doses it overstimulates, and we get a whole lot of unpleasant symptoms of the brain. Some say this is due to hyperemia of the brain, and some to anaemia. Upon the 106 spinal cord in small doses it stimulates; in large doses it diminishes reflex irritability; in large doses it increases contractility of the uterus, the malarial poison itself however is enough to secure abortion. Note effect of Quinine upon the vascular system; small tonic doses increase cerebral circulation; it increases the whole vascular supply; it increases the hearts action. In large doses Quinine diminishes the action of the heart; lessens force of the circulation; lessens arterial tension this produces anaemia I should judge. Now note 107 the effect upon the white corpuscles of the blood it prevents their migration and is used in the earlier stages of inflammatory diseases such as pneumonia; pericarditis; it must however be used in the early stages or your Quinine is of no use whatever. In the early stages of Tonsilitis give about gr x of Quinine. On the red corpuscles of the blood Quinine has a peculiar effect; it prevents them from giving up their Oxygen too rapidly; we then find the tissues are imperfectly burned and hence we use Quinine in fevers. Upon the respiratory organs 108 Quinine has but little effect. In the normal health it will not diminish the temperature; it is eliminated by the kidneys, a gland that eliminates medicine is usually stimulated, and it is claimed that Urea is decreased by the action of Quinine. Now Quinine as an antiseptic. It has a special effect upon the low organisms, it prevents putrefaction; it will destroy low forms of vegetable growth; we sometimes use a solution of Quinine to wash out old burrowing ulcers. In diphtheria oftentimes a solution of Quinine painted over the 109 surface destroys the low organisms which give us the diphtheria. You will find Quinine recognized in every Desk Book as an antiseptic in diphtheria. The low forms of animal life feed upon the white blood corpuscles. What is the condition of the blood in diphtheria? A patient often dies from failure of the heart and nervous system, use small doses of Quinine in these cases. We use Quinine in malarial fevers: the vegetable poison in this disease depends upon the minute vegetable growth. Age, sex, and condition of life modify the action of Quinine. Quinine as a 110 tonic can be born by all classes of people. In large doses it is an absolute sedative. Opium intensifies the action of Quinine and modifies its unpleasant effect. Quinine I believe causes a little anaemia of the brain; a little Opium stimulates the brain and this causes the unpleasant effect of the Quinine to pass off. The maximum effect of Quinine is reached in about five hours. If we were to collect the Quinine that is eliminated by the kidneys, and give it the second time it would have no effect whatever. This is called Quini sine; you may give a hundred 111 grains of this, and you will not get any ringing in the ears and yet its tonic effect is the same. Quinine does not remain in the system; some of it is used up in the organism. Now what are some of the disadvantages of Quinine? Its bitter taste; its unpleasant effect upon the brain; its unpleasant effect upon the spinal cord; and upon the skin when the kidneys do not do their work properly then the skin tries to eliminate it. Note its therapy. In Summer Catarrh paint inside the nares with a gr 1/1 solution, you must use this in the early stages of the disease; in sore mouth 112 of children I find this useful. In dyspepsia there you use it as a bitter tonic, in yeast like vomiting we use it in gr III - IV doses this will cure this malady by destroying the vegetable growths; sometimes in Cholera Infantum you can use Quinine; this also depends upon these minute organisms, you can thus use it as a tonic and antiseptic. In acute rheumatism I do not use it. Use large doses of Quinine in exhaustive fevers; in Typhoid fever you have an exhausted nervous system, large doses of Quinine there will simply overwhelm the nervous 113 system. In Typhoid states generally the heart is weak and feeble; depress that with Quinine and you have a heart ready to stop in its action; you may give two or three grs two or three times a day but do not give large doses there; the stomach cannot absorb them it only irritates the bowel more and causes profuse diarrhea. I give Quinine when there is no failure in the nervous or circulatory system. Now here is an exception in Typho Malarial Fever, this is a malarial fever with a Typhoid condition; malarial fever must be treated at the outset 114 with large doses of Quinine, but just as the Typhoid element comes to the front, just so must your Quinine be dropped; as the Typhoid element diminishes, you can give your Quinine; give it with a cardiac stimulant such as Digitalis or Stychnia. Quinine is used first and last in all septic diseases. In certain low forms of septic diseases, use Quinine, Oil of Turpentine and Oil of Cinnamon. Quinine is the antiseptic and Turpentine is a special stimulant to the sympathetic system. This will close up the minute openings in the blood vessels, and thus 115 holds the white blood corpuscles in their place Malarial Typhoid fever usually starts as an ordinary malarial fever; the temperature runs up to 100 104, 105 but in the Typho Malarial fever the temperature does not come down to normal; as the disease runs along the pulse becomes weaker and the patient shows exhaustion, and shows signs of nervousness; then lessen your Quinine and give stimulants. Now just as soon as your Typhoid symptoms begin to diminish, your malarial symptoms may again appear; then give your Quinine with Turpentine or Digitalis. Then as to the subsequent treatment, be careful of your tonics, the best treatment is one of the mineral acids; if there is a little tendency to malaria again give a little Chinoidine with a little Arsenious Acid; remember the stomach of your patient and give the proper and requisite food. Note in erruptive diseases. Dr. Hood says that if he can obtain charge of a case of Scarlet Fever at the outset he rarely looses a single case, using Quinine in just sufficient doses to sustain the action of the heart. Children suffering 117 from Scarlet Fever have an intense itching of the skin, that must be relieved, and the best application is Cocoa Nut Oil Note prescription for external application of Quinine in children. Rx Quin Sulph gr xx Chlorof m xx Vaseline ʒij In cerebral diseases Quinine has attained quite a reputation; in large doses remember it produces a state of anaemia of the brain. In Cerebro Spinal Meningitis combine the Quinine with Opium, and your child will often recover under this treatment, when 118 they will not under anything else. An old man often becomes hypochrondriacal; now often by the use of Quinine you will rejuvenate that old man. In that difficulty called horrors after drinking, small doses of Quinine; mix Vomica and Cayenne Pepper will produce the most satisfactory results. In chronic bronchitis Quinine is excellent. Quinine and Iron in Erysipelas cannot be surpassed. If you are called upon to treat a patient suffering from stricture, and you have to pass the catheter; always give him the gr v of Quinine 119 before passing the catheter, or you will produce a urethral chill. In the treatment of Intermittent Fever, Quinine is almost a specific; this is when the fever comes down to normal and then recurs. We use Quinine as a prophy lactic. In visiting marshy districts it is well to use a little. When you find a failure to cure by Quinine, always examine into the cause, as the Quinine may not be absorbed. If you have a patient suffering from biliousness, the reaction of the bile is alkaline; and Quinine is not soluble in Alkalies, 120 you must therefore prepare your patient for the Quinine Give a cathartic at night and then give a saline in the morning. What are the conditions to the rapid cure of Intermittent Fever? First it must be an acute attack; the chronic malaria will not come under the action of Quinine readily, as the liver and portal circulation are Jammed up. If I am called to treat a case where a man has a fever, chill, and sweat; I will probably give him directions something like this: I will give him a dose of Hydrargyrum to night; follow 121 that in the morning with a saline. Now what is the condition of the liver and portal circulation, is it ready for absorption immediately after that fever, sweat, and chill? No not at all! but just follow out the treatment as stated, and you get your stomach thoroughly washed; if you give your Quinine in that condition you have it absorbed rapidly. Give your Quinine then in gr v doses wh y . 8 and 9 oclock in the morning, give this for two days. Subsequently put him on a little Chinoidine and Arsenic, and let him go 122 along on that until the 6th day, these fevers have a tendency to return every 7th day. So I would suggest that the man take his Quinine on the 6th and 7th day again; that would probably be the end of his attack. Remittent Fever. There the temperature never comes down to normal; it is the same poison but with a different manifestation, there is congestion and anaemia. There are here two plans of treatment. Prepare your patient as in Intermittent fever, or give your Quinine at once. If it is a mild case, prepare 123 your patient; if a severe case, give your Quinine at once if the stomach will bear it. If you have a stomach in remit tent fever that is a little dry, give your patient minute doses of Ipecac, not enough to vomit them, but just enough to make the mouth water, this makes the stomach water and thus your Quinine is taken up. If you do not break the fever it may take on a Typhoid type and possibly destroy your patients life. Give your Quinine at the outset in large doses. If you give Quinine by the rectum, you must give it slightly acid. 124 Now we have the pernicious form of fever with the congestive chill. Now here do not stop for anything, give your Quinine by the mouth; bowel, or hypodermically. In the treatment of chronic malaria, the best treatment is by a compound tincture of Iodine. But if you have an acute attack remember, there is nothing will take the place of Quinine. The compound tincture of Iodine hastens absorption; we use it in enlarged liver and spleen. Quinine will reduce the liver and spleen in acute malaria; but let that 125 enlargement continue for weeks, and your Quinine will not act; but your compound tinct- of Iodine will cure. We often find that malaria will lease a condition of anaemia, in such a case combine your anti- periodics with Iron; be careful about the bowel. If the pulse be weak and feeble, give Iron and Digitalis; if you want an antiperiodic give one sixth of a Gr of Arsenic with the Iron. Very often Chinoidine comes in in chronic malaria, and if you have a little constipation put this prescription in use. Rx Arsenic gr 1/30 tn Ferri gr 1/1 Ag Ex Aloes gr 1/1 Chinoidini gr 1/1 -1/1 ss – 11/11 Nucis Vomici gr ¼ Always give this after meals. Note. I would like you to bear this in mind, that no man can be a specialist until he has been a practitioner for about 10 years. I speak of this now, because the effects of malarial poison will fall upon one or the other of the organs. It may be the liver; lungs &c, or it may result in a persistent headache. Often in female diseases it causes an increased flow from the uterus. The woman gives you her history and it may simply 127 be a case of marked malaria. Take another illustration that of hematuria which is caused by malaria. You must remember that every organ bears some relation to the other. Now let me call your attention to the periodical, diseases of malarial origin. These are difficult to treat, if you use Quinine you must use it in large doses; in trifacial neuralgia and nervous affection use your Quinine; find out whether the disease arises from some specific origin. If it is from anaemia treat it with Iron and Cod Liver Oil; if it 128 is due to malaria, treat it with Quinine, if it is due to other causes find them out and treat them accordingly. If anaemia be present in neuralgia give Arsenic and Iron; if anaemia be absent give Arsenic and Quinine. Sometimes we find that diarrheas depend upon malarial poisoning; this is caused by the water being driven in upon the bowels; now just treat this with Quinine and the same way with dysentery. How does dysentery occur? If you have a liver engorged with blood, what will be the condition of the intestinal 129 circulation? It will be simply loaded with blood, and the intestines sweat out their watery contents with little blood. Now note this in Jaundice and Hematuria, and remember that Quinine is the second remedy in the Material Medica, but do not think that Quinine is a harmless remedy. The next subject that I intend to run over, will be the Peculiar Bitters. The first will be Wild Cherry bark; this possesses Tannic Acid; Prussic Acid and a Bitter Principle. We can use it as a tonic; in a cough mixture, or as an astringent; never use a hot 130 preparation of Wild Cherry bark as you simply drive off your Hydrocianic Acid. In Phthisis we use it to check the cough, as a tonic and astringent. In chronic Bronchial difficulties Wild Cherry is a very excellent tonic. In debility I do not believe Wild Cherry is used as much as it should be; you take it where the system has run down as in Typhoid fever &c, there a cold infusion of Wild Cherry is excellent; it promotes digestion and enriches the blood. Often after a fever a patient will complain of night sweats, just give to that patient Wild 131 Cherry and a little Aromatic Sulphuric Acid. Another remedy we have in Sage Tea, it is one of the best remedies for checking night sweats; it is a bitter tonic; one ounce of Sage to a pint of water; let this stand and then strain and take a wine glass of this at 6 Pm and 9 Pm; in each dose put the 1/100 of a grain of Atrophia. We will now pass to the Aromatic Tonics; they differ from the Bitter Tonics in this; that they possess a peculiar Volatile Oil. The Aromatic Bitters act transiently; the Peculiar Bitters act more or 132 less permanently. We use aromatic bitters as condiments, in the mouth almost all of them have a hot pungent taste; the same is felt by the skin to a certain degree. Note Minthaul in the cure of superficial neuralgia, this is a combination of aromatic oils and which acts by deadening the sensibility of the nerve for the time being. In large doses aromatic oils become caustic. What are the chief uses of aromatics? We often give them with bitters, they give pungency to the medicine; we use them to stimulate the intestines; we often use them 133 to overcome colic as it stimulates the intestines; we use them to disguise taste. We have an old fashioned remedy in Chamomile Tea; the oil of Chamomiles is very expensive. For flatulent colic I know of nothing better than Chamomile tea, for females especially so. If you want to intensify the Bitter I gave you before; Gentian, Columbo &c. put in a little Chamomile. Boneset is an excellent diapho retic, this should be taken hot in case of colds. Then we have Serpentaria (Virginian Snake Root), this is a stimulant and a stimulant expectorant 134 when you use this, use the tincture; it is a most excellent remedy in Bronchitis when you want a stimulant action, in capillary Bronchitis in children it is good. In Pneumonia where you use Carbonate of Amonia, combine it with Serpentaria, this is the best stimulant I know of in the exhaustive stage of Pneumonia. Note, Simple Aromatics. Cinnamon, Cardamon, Cloves Ginger, Orange, Canella. Note Eucaliptus this is used in capsules from M v to ʒ ss. One to five drops of the oil is all you want to 135 use at one time, it is not however poisonous. This tree is grown in California; it is an Aromatic; it increases the secretions of the mouth, stomach and intestines, it gives us softer and easier stools. The effect of a Volatile Oil is to increase the action of the heart and increase the supply of blood in the brain. In the anaemic it produces sleep; in the plethoric it produces wakefulness; in the latter case you had better combine it with Bromide of Potash, it is eliminated mainly by the kidneys. It is useful in the treatment of diseases in 136 the Genito Urinary tract; it increases the flow of water, it acts pleasantly upon the bladder and hence, is used in the chronic form of Cystitis where you want a slight stimulant upon the bladder. It is also eliminated by the lungs, we use it in chronic Bronchitis, it is a stimulant and as it is eliminated by the glands of the bronchial tubes helps to heal. Never give these remedies if there is any inflammation of the stomach; they are sometimes useful at the menopaus, they are sometimes useful in hysteria, often useful in asthma associated 137 with anaemia. If you find a case of asthma that will not yield to Iodide of Potassium or Arsenic just try Eucaliptus; do not use it in the Asthma associated with hyperemia. Hydrastis Canadensis (Golden Seal) This is used largely by Eclectics. It increases glandular secretions; this is also eliminated by the kidneys and the mucus membranes of the bronchial tubes, we use it as an injection in Gonorrhea; I do not know of any safer injection than this combined with a little mucillage. It is often used in throat diseases for its local effect on the tonsils. 138 Now let us review for a moment the different remedies we have gone over. Quinine. Serpentaria associated with Carbonate of Amonia. Wild Cherry; then all aromatics that are used to stimulate the bowel; then Eucaliptus used for chronic effects only. Note Oil of Eucaliptus in Bronchorrea. Note Hierapicra is Canella and Aloes. Note Lint’s Solution Quin Sulph gr 4 Acidi Sulph Dil M C Aquae Font ℥ l/l Solve et add Acid Carbol Loq M v This morning I want to take up ferments. Pepsine is simply 139 the active principle of the Gastric Juice. The action of the Gastric Juice outside of the body is very different from that inside of the body. Secreted under the most favorable conditions, it produces a ferment which will give the greatest possible results with the least possible material. We have different preparations of Pepsine. Saccharated Pep sine. Aromatized Pepsine this is simply made up of Aromatics. They act transiently and not permanently. It is often a great temptation to give the Wine of Pepsine, but it is not a good remedy 140 as the Alcohol will precipitate the Pepsine. All Pepsines contain more or less Hydro Chorlic Acid. We have the Glycero Pepsine the dose of which is about 1/3 of a tea spoonful. Let me warn you in the diarrheas of children, there is a preparation used compound of Pepsine, Bicarbonate of Soda, and Bismuth. You get only in this mixture the effects of the Bismuth; Pepsine must be given in an Acid solution. The above three remedies are incompatible. The dose of Pepsine is from 10 to 20 grains. We now come to Pancreatine. This is simply the different 141 elements of the Pancreatic Juice, it is not any single element. We use this where there is a deficiency in the digestion of food. Liquor Pancreaticus should be given after meals, from half an hour to two hours after the meal. Pepsine must be given directly ______ after the meal. Then we have Ingluvin; this is used very often in the vomiting of pregnancy. Now anything that will check the secretions will antagonize the Pepsine. There is a general Therapeutic law that Acids applied to the orifices of glands, secreting alkaline 142 fluids, will increase that secretion, and “visa versa”. If you put an alkaline solution in the stomach, it will increase the secretion. What are some of the medicines that will act with Pepsine? Hydrochloric Acid; Lactic Acid and so on. Pepsine simply dissolves the Albuminous matters, and thus renders that part of the food ready for admission into the blood. We use Pepsine when we have a lack of Gastric Juice in the stomach; if you give this before meals it will have a tendency to check the acid secretion. In an atonic 143 dyspepsia it is the one remedy we use more than any other, we can give it with Iron, also in the lack of Gastric Juice in infants; and this I believe is where Pepsine has its greatest effects. Where the child vomits immediately after eating, you can give your Pepsine with excellent results; you must try and prevent the undigested food from passing into the bowel. The secretion of the intestinal tract is alkaline, so when you want to use an enema you should use your pepsine, put in half a tea spoonful of Pepsine into the enema, a little while before 144 injecting it. Pepsine is used hypodermically in the digestion of tumors; this however is rather theoretical. Lactic Acid is another remedy we often use in digesting preparations; the remedies that will go with it are Pepsine, Acids, Bitter Tonics &c. Let me call your attention to this preparation Lactic Acid and Lactate of Iron, the average dose is M xv; it aids digestion and promotes the appetite; you must give this with the meals. Lactic Acid is supposed to be the common element in the production of rheumatism; it has been found that diabetic 145 cases treated with Lactic Acid, will often show signs of rheumatism. It will also dissolve false membranes, hence it has been used as a local remedy in diphtheric. It enters into many of the preparations of Pepsine. It is a most excellent remedy in acidity of the stomach but give it before meals. The best treatment for Water Brash is an acid before meals and the best acid is either Lactic or Hydrochloric; note this in an acid dyspepsia. Wherever you find a condition of oxalates in the urine; use acids. In Diabetes Mellitus Lactic Acid is used quite largely. We 146 also have another remedy for this disease, which is the alkaloid of Opium called Codia. Now let us discuss Mineral Acids in general. We have in common use, Hydrochloric. Phosphoric. Sulphuric. Nitric Acid &c; we use these diluted. Always write for these acids diluted, especially the Nitro Muriatic Acid. The acid should be diluted at the time of filling the prescription, otherwise the Chlorine is lost. Now the general dose of all Mineral Acids is M xv diluted. Incompatibles with acids are all alkalies. Sulphuric Acid 147 should only be used with its sulphate; it is the strongest Acid we have. Acids should be given alone or in combination with their bases. Every acid is an escharotic in a greater or less degree. If we want to use any acid as an escharotic we use Nitric Acid as being better under control. If a patient has taken a poisonous dose of Sulphuric Acid, the tongue will be black. Remember that each one of the Mineral Acids is corrosive poison in an over dose. The antidotes for acid poisoning, are both chemical and mechanical. We use oil or white of egg mechanically; 148 Magnesia or Soda are chemical. In Acid poisoning I would not advise you to try to vomit your patient, as the acid acts quickly; it is well enough to induce vomiting in Narcotic poisoning. In acid poisoning you should try to soothe the parts. You must urge the heart by way of the bowel, for when the stomach is all burned up, you cannot use it; you can however use the skin; now do not loose sight of the irritability of the stomach. Acids promote osmosis. Now What is the effect of an acid upon the mouth? Note how quickly it starts secretion! 149 Why? Because the reaction is alkaline. When you are treating a case of Typhora fever why do you use acids? The patient suffers from intense thirst because his mouth is so dry, now you simply acidu late a glass of water for the patient, and it increases the secretions of the mouth; so you use your acid drink mainly upon the mouth. Here is a formula for an acid drink in the Typhoid fever. Aromatic Sulph Acid. Quant Suf Little peice of Orange Peel it add Glycerince M xx. This will allay that intense thirst, and often induce a 150 fever patient to pass off into a comfortable sleep. In night sweats sponging with vinegar is often an effective remedy. Now as to the relative value of Acids. If you want to promote digestion, use Hydrochloric Acid. If you want to promote hepatic secretion, use Nitric Acid. If you have hepatic and gastric indigestion, use the two. If you want to prevent secretions from the bowels or skin, use Sulphuric Acid. Note Therapy of Acids. External use. Sometimes we bathe the skin with an Acid solution in that disease known as Hives, this will stop it better than 151 anything else. Hives is due to the circulation in the blood of unburned effete matter; this comes to the surface and meets the Oxygen and is then burned; now if you use an acid application it will close the pores and the Oxygen has no chance to get at the blood. You treat this disease internally with alkalines, advising also out door exercise. Sometimes in torpor of the skin where the skin becomes relaxed we use a mineral acid bath; Nitric Acid in the best: oftentimes night sweats are due to a relaxed condition of the skin, often you have to deal with growths upon the 152 skin, as warts for instance, the best cure for these is equal parts of water and Chromic Acid; just trim the dead parts off before applying this. We use Nitric Acid as a test for Albumen in solution; albumen in solution always exists with a base, and when you put in the acid it takes up the base and leaves the Albumen. Your mineral acid is an astringent to the bowel, just remember the many uses of acids in fevers; and in the hepatic diseases we have the nitric acid. There is another thing I would like to call your attention to: in fevers 153 the secretions dry up; if you want to use meat juice, use it in connection with Hydrochloric Acid, very often this makes a good food for invalids. We will now take up the Third Remedy; which is Iron. We have Reduced Iron, dose one to three grs. Muriate Tincture of Iron &c. Now when you have tried all the various preparations of Iron, and do not secure the expected result; just fall back upon the Muriate Tincture. In Iron you cannot do much harm by an over dose; but if you get a small dose you will get as good an effect as a large 154 dose if administered judiciously The trouble with us is, we give too much Iron. The dose of the Sulphate of Iron is from 5 to 30 drops; when you give Iron in solution you want to give the Iron Solution; give dry Sulphate in pill form. Then we have the Syrup of the Iodide of Iron, the combined action of Iron is an alternative. Then we have Citrate of Iron and Quinine, this is a good combination in malarial diseases; then also we have Potassa Tartrate of Iron where we want an alternative action. When do we use the stronger preparations of Iron? The general rule is that the 155 Chlorate, Sulphate or Nitrate in combination with bases make stronger compounds, they give us more effects. If you want an astringent however, give the Sulphate; we use the Sub Sulphate of Iron for its astringent effect. If you want a mild effect, you can use the Reduced Iron, but the Hydrogen will be transformed into Sulphurated Hydrogen often blackening the teeth and tongue; the faeces are often colored black by the combination of Hydrogen and Tannic Acid. Of the Phosphate of Iron, the Pyrophosphates is the best preparation; 156 in Rachitic children the Phosphates of Iron and of Lime is a most excellent combination. We use Iron as a tonic; if you have an atonic affection of the stomach give Sulphate of Iron; if it is not well born in the stomach give it in connection with Hyosciamus. Whenever you give Iron always remember it is apt to produce a condition of constipation; then always associate it with some laxative or give the Sulphate of Magnesia and the Sulphate of Iron or a few minims of Sulphuric Acid and a little Chloroform. Magnesia and Iron are apt to be cold upon 157 upon the stomach, we therefore warm the stomach with a little Chloroform and the transudation of the medicine into the blood is far more rapid; or if you want a little alterative you can combine it with a little Aloes. The Syrup of the Iodide of Iron we also use when we want the combination of the Iron and an Alterative. We use it in Scrofula, we use it in chronic pleurisy this is an exception; you can give this in ʒi doses, give it in capsules and give it after meals you will need to give this for some time in order to secure the desired result. 158 There is also another combination, the Syrup of the Iodide of Manganese; equal parts of the Iodide of Manganese and Iron; I think it is better than the Iron alone or you can change them around. Now in almost all solid preparations of Iron you can average the dose from one to three grs; there is one exception in the Arsenite of Iron, the dose of this is from 1/6 to 1/10 of a gr. In Chorea you can give the Arsenious preparations, until it produces puffyness of the eye lids. The dose of the liquid Iron is from 10 to 30 drops. A word here in relation to Styptic Cotton 159 this after it has been made up for a long time is useless, the Iron simply eats up and destroys the fabric of the cotton you can note this by hanging a cloth on a rusty nail, the Iron converts the Oxygen into Ozone. Now in the stomac what is the action of Iron? It is that of a tonic! It is used to increase the appetite and promote digestion, if you give the soluble preparations of Iron they are precipitated Iron enters the blood as an albuminate. If you give Iron in the solid form it is simply dissolved and thus enters the blood. Now of you give Iron 160 hypodermically it will blacken the faeces; now let us follow that. What is the action of a medicine upon the glands that secrete it? It astringes it. Iron causes constipation. Iron is not foreign to the organism, it is really a food and supplies something needed when given under the proper conditions. We find Iron in every color tissue of the body; beef steak is a good way to give Iron; every plant contains Iron the coloring matter of plants is due to this; plants will not grow in a soil devoid of Iron. Iron exists mainly in the haemaglobin, in the red 161. corpuscles of the blood, we note this specially in anaemia. The temperature of the anaemic person is never above normal it is often below, the brain becomes sluggish and they want to sleep; now if that patient gets below the anaemic point they cannot sleep and they then become nervous and neuralgic. The astringent properties of Iron are tonic in the true sense of the word, they specially supply to the blood the element wanting. Now what kind of a tonic is it? It is a restorative tonic, it is a reconstructive tonic, it builds up the blood. Now what is the 162 effect of Iron upon the nervous system? Its effect is indirect it supplies the nervous system with better blood; it increases the force of the heart, it increases the action of the nervous system when given under proper conditions. Now there are indications for the use of Iron which it is necessary for you to remember. Now let me just briefly review the action of Tonics. They improve the appetite by their local effect; in anaemia we have a relaxed condition of the bowel and the stomach. An astringent preparation is the best preparation there, and 163 hence Sulphate of Iron is often us in an atonic dyspepsia with Nux Vomica, Aloes and Quinine. The celebrated pill R contains gr l/l Sulphate of Iron, gr l/l of Sulphate of Quinine, gr ¼ each of Nux Vomica and Belladona. Aloes you can give gr ss or ¼ as you find your patient. The effect of Iron upon the circulation is what I want to call your attention to, as it is often used in heart disease. If you have a murmur in the any of the valves of the heart, you are apt to have that difficulty increased by anaemia; in fact we often have a blowing murmur in 164 the heart due to anaemia; the best treatment then is Iron. If you have an organic lesion with anaemia, use your Iron largely; hence we give that incompatible known as Digitalis and Iron. When you prescribe Iron always give it in food remember that every medicine that has its counterpart in the organism you can always continue; in rachitis we can give lime for a long time. In scrofula give the Syrup of the Hypophosphites. Iron upon the respiration simply increases the quality of the blood; upon the urine it has but little effect. 165 Let me call your attention to the treatment of urinary diseases in the use of Iron. If you have to treat Bright’s disease use the Potosso Tartrate; you use this for two reasons, the Potasso salt is easily associated with the Urea this forms a very non irritating salt, you can often increase its action by using a little more Potasso Tartrate with the Iron. Now let us take up the relations of some of the Irons to each other If you have to deal with excessive anaemia always use the stronger preparations; to overcome their astringent effects 166 use some mild laxative; the ordinary forms of Anaemia do better by by treating them with the mild Irons as Potasso Tartrate. When you are preserving iron; unless in chronic cases of pleurisy do not give very large doses, ten drops of the Muriate Tincture is a medium dose, this will accomplish all that you desire. In gastric irritation combine your Iron with Hyosciamus, but always give your Iron after meals unless there is some decided indication to give it before. I call your attention to the effect of common salt upon 167 Iron. If you take much salt much of the Iron will remain in the blood; if you give it with much Chloride of Potassium, much of the Iron will be eliminated from the blood. I think by this it is much better to give it with meals. If you have to give Iron for any length of time, just omit it for a few days or a week now and then; omit it until the stools become natural. Now remember that mutch can be learned from observations of the stools; purgatives always intensify the actions of Iron hence we associate Sulphate of Magnesia with Iron. 168 Keep the portal circulation free and you will have better effects. Never give your patient Iron if he be suffering from constipation until you have removed the same; you can often remove that constipation by giving your Iron with a laxative; a certain amount of Iron is necessary for proper secretion. Then we have Iron acting to a certain point, but if you enrich the blood beyond that point, you get plethora. Stop your Iron when the functions of the body have become normal, or even a little before. Now note the 169 contra indications for the use of Iron. All inflammatory affections with one or two exceptions as for instance Erysipelas; do not give it in congestions of various kinds as congestion of the lungs, liver, or stomach; relieve your congestion before you give Iron; plethora will contra indicate Iron, the languine temperament in general will not need Iron such cases as a rule need depleting agents, not restoratives. Now as to the Therapy of Iron. You will find the Tincture of Iron in almost every house. In cases of nose bleed that cannot be controled by 170 ice, it can often be controled by a weak solution of Iron, snuffing it up the nose. In hemorrhage of the stomach where there is a constant oozing from the ulcer or carcinoma of the stomach; give most any of the astringent forms of Iron but give but a few drops in ice water about every 20 or 30 minutes; almost always you can stop that oozing; in hemorrhoids just wash them over with a weak solution of iron ʒi to a pint of water. If you have debility associated with anaemia, your best treatment is Iron altogether. It has often been 171 noticed by physicians; “this is empirical”; that a patient who takes Iron and it does not improve his appetite, the remedy will have little or no effect. Your Iron must be backed by food or they will loose under the treatment. Note Iron in Chlorosis; the result will be that the appetite will increase and your patient will sleep better; that chlorotic girl will begin to suffer from pain in the stomach, pain in the head &c. you will hardly ever find the pain on both sides she will have pelvic neuralgia, she will either suffer from 172 menorrhagia or amenorrhea, the blood vessels in these cases are weak and feeble so where nature makes a little effort to bleed the system, the effort is extremely painful and they do not recover their normal condition and there is no checking it only by the use of Iron. Now how will you treat a case of that kind! You must begin with a mild solution of Iron, you must just saturate that patient with Iron, do not give it up because it disagrees with them for the first few days if they cannot take the preparations of Iron give them mineral waters. 173 In neuralagia with anaemia give Iron. We often give the preparations of Iron in rheumatism; whenever you have a patient suffering from rheumatism with anaemia always give Muriatic Tincture or Iron and give it liberally; whenever you have to treat a patient with rheumatism with plethora give your Salicylic Acid. If you have a case of incipient consumption be careful of the use of Iron. Whenever you have a patient come to you with a cough, and a family history of consumption; do not give that patient Iron or give it very 174 sparingly and stop it the moment the anaemia dissapears. Now if there is a little tendency to congestion in the lungs, the use of Iron will cause a congestion at that point. In the latter stages of consumption you cannot use Iron too mutch. But let the young patient take Cod Liver Oil or the Syrup of the Hypophosphites. Take care that you do not make the crippled lung do more work, but rather prevent it from doing that work; if you make that lung do more work you will only hasten the end. In Erysipelas Iron is an 175 excellent remedy, give it in large doses, here we use the Chloride of Iron. In Diphtheria Iron is the standard treatment of to day; associate it with Chloride of Potash, but do not give the latter in large doses or you will get up a diphtheretic nephritis. In the passive forms of hemmorrhage we use the Muriate Tincture of Iron; in menorrhagia also for its astringent as well as its tonic effects. The use of Iron in obstetrics Prof Jewett will tell you about. In spermatorrhea, if nocturnal emissions are associated with anaemia use Iron. 176 Now in incontinence of urine in children wherever you have a pale anaemic child, just give that child Iron. Never allow parents to punish a child for incontinence of urine, it only intensifies it, if the child is plethoric just give it Belladona. I now want to call your attention to the action of Stimulants. We now take up a class known as acute remedies; they are indicated in acute conditions; the seat of stimulants is in the nervous system; as compared with tonics they act rapidly; their action is transient as compared 177 tonics; a tonic medicine such as Iron, enters the blood and adds something to the blood. A stimulant as Alcohol, enters the blood and must be eliminated from it. Stimulants are indicated in passive weaknesses; tonics are durable and suitable for chronic conditions. Stimulants are practically nerve medicines, they enter the blood and act upon the nerves. We have then nerve force; and vital force. Nerve force is the power; vital force the machinery. Now the machinery may be all perfect or nearly so, and yet 178 if you have not power to run it, what is the use of it? If you have not a supply of nerve force, your machinery is of no use. Or you may have the machinery wrong and the nerve force all right. If you want to correct the condition of the machinery give Tonics; if you want to intensify the power give nerve medicines, but of course no stimulant will take the place of nourishing diet. We have then Tonics to strengthen vital action; and Stimulants to increase nerve force; now if you have failure in the two together, give Tonics 179 And Stimulants. Remember stimulants cannot take the place of food, and food and tonics cannot take the place of stimulants. Tonics develope the neutritive apparatus. The question has been under discussion for a long time whether stimulants can create nerve force. We give them to quiet and sustain the nervous system. My opinion is this; - that stimulants help nature to unlock her reserve funds. The nervous system must be kept up; stimulants will liberate enough nerve force to keep the machinery up, hence we give 180 Alcohol, non-Alcohol does not generate nerve force, but it helps nature. Now remember at the bedside the difference between the failure of nerve force and vital force; wherever you find a low nervous exhausted condition you will need stimulants. Now note in Typhoid fever, in a week or ten days the patient develops nervous symptoms, there is undue restlessness because there is trouble in the nervous system but remember this is associated with exhaustion; now day by day the life forces are becoming weakened, and to all 181 appearances the nerve force is above par, but it is a perverted action. Now if you have failure in the vital energy; by that I mean true exhaustion; where the whole organization is depressed in the primary assimilation, in the heart, failure of circulation and innanition; now in that case stimulants will do no good whatever, you want food that is the best tonic in this condition. Stimulants will merely help to unlock the reserve fund, it is this reserve fund which helps to sustain us in acute diseases. The stimulant which you give helps nature to use this 182 material; now every time you use a stimulant you convert just so much reserve force into nerve force, and unless you back it up with nutriment your patient will die, you must keep up the life forces. Now let me call your attention to another condition. We sometimes have as an indication for stimulants; sudden failure of nerve force, without any failure in the vital forces, take for instance syncope and for the time being, the circulation is way down and if it stays there long enough the patient dies; then stimulants are indicated, they simply rouse 183 the nerve force and start the machinery again; we find that condition sometimes in the latter stages of a Typhoid fever, the organic forces are sinking as well as the nerve forces but not so rapidly you may in some instances use tonics, stimulants and seda- tives. What are some of the symptoms? here we have failure of the heart, tremor, como vigil, and restlessness; your stimulants then act as sedatives just so far as you can bring the system to a standard of health, just so far can you use stimulants; in order to rase perfect action you must 184 have all the functions act together Now what is the effect of stimulants in acute diseases take for example Typhoid fever. Now there is always failure upon the side of the nervous system, if the nerve forces go below a certain point they abandon the life forces and the patient dies. If you supply the nerve forces you supply force sufficient to keep the machinery running long enough for nature to heal the local lesion, and thus give a margin of time. In Typhoid fever or Pneumonia the tendency is to cure itself if you can keep the patient alive long enough; in Typhoid 185 fever you cannot eliminate that poison, nature must do that; but you can prolong life by giving nature time to heal the local lesion, now do not think that you eliminated that poison, you may have been instrumental in prolonging life, and thus giving nature time to eliminate the poison. Now if you know the history of a disease you anticipate the coming difficulty, and obviate it if possible. Where there is a real debility where every organ is debilitated, then use your tonics. We have stimulant tonics, and tonic 186 stimulants, and the judicious physician will use them according as they are indicated. Now in the cure of acute disease remember that time is an essential element; you cannot cure Pneumonia inside of six days do the best you can; you cannot cure a Typhoid fever in 20 days, it must run its course, and just as soon as you recognize that fact you will understand the uses of stimulants and tonics. Then in some cases we may have loss of nerve power as the chief thing, the patient may die in the Typhoid fever because of failure of the nerve forces; the loss 187 of nerve power in exhaustive diseases is often the element of danger. In fevers of low type this nervous condition into which the patient gets, will exhaust him; why how can he exist in that constant state of watchfulness and wakefulness; he is in a perfect state of perturbation all the time and it will wear him out. Just quiet that by alcohol it will give him rest and sleep. We must ever be on our guard in exhausting diseases, do not wait until the difficulty comes but anticipate it; in the use of stimulants you must have judgement or you 188 will fail. You do not want to give a wine glass of brandy three times a day, although the amount required may be twice that, but if you give a tea spoonful every one or two hours you will get all the good effects without the depression. Now I want to speak of stimulation and recoil. Many say that a corresponding degree of depression will follow a corresponding elevation; now I want to discuss for a moment the effect of stimulants in disease; we will take a line which will represent the condition of health. Now in fever we have an exalted condition 189 it is above the health line, then you give sedatives; but in certain forms of fevers we have it below the health line, then give your stimulants and keep it as near as possible up to the health line; a rapid and feeble pulse shows there is lack of nerve supply, then give your patient stimulants. Now there is Therapeutic law; - the nearer you can get your patient to the standard of health, the more likely he is to remain there. Now if you carry your patient way up beyond the health line, a corresponding depression will follow, and he will fall back 190 again to below the health line. Now if you use your Aconite do not bring him down below par; the organism is in no condition to stand these extreme elevations. Alcohol is a food in a certain way, Stimulants are used in prostration, sudden and acute, in syncope, in the loss of blood in profuse hemorrhages after the hemorrhage has stopped, not before. Give your stimulants because they act quickly, they add nothing to the blood. Now in acute fevers you must anticipate the coming debility, of either nervous or vital forces. Now in regard to inflammations, 191 you say in that you must not use stimulants: not necessary so: every inflammation is not sthenic in character; very often you have an inflammation that is asthaenic in character; very often you have an inflammation that is asthaenic and followed by a Typhoid state. You may have at first to use depleting agents and after that to use stimulants in the typhoid element; it is dangerous to suppose that every element must be treated with sedatives Now we may use tonics to give better blood; cups to deplete the blood, and stimulants to 192 sustain the system. Then again the inflammation may have been the original disease, which may have passed over and left a typhoid condition, the weakness is then manifested in the nervous system. In the inflammation of old drunkards, do not stop to think what you are going to give, but know at once what you are going to give, give them Alcohol to start on, no matter how severe the malady just give them Alcohol or they will die of delirium tremens. They have been living on stimulants and if you take them away, the system is completely broken up; the 195 nervous system must be braced up. This lack of nerve power is very dangerous in disease. Now do not think because it takes two men to hold a patient in bed, that he is going to get well; in Typhoid fever you have something more than loss of strength, that man is the strongest who can rest well. In Typhoid fever there is a clouding of the faculties, there is a failure in every function of the body, when you find this associated with a nervous trembling condition stimulants are the only remedies which will tide that patient over: There is another condition of pure exhaustion 194 from loss of blood; or loss of sleep, stimulants are then the only things which will start them up, Alcohol and Opium together are excellent. In conditions of shock to the nervous system, it is wonderful the amount of stimulants a man can stand. In that extreme weariness which follows post partem hemorrhage, after the hemorrhage has stopped your patient cannot sleep, there is not enough blood in the body; you want to give that patient stimulants and rouse the dormant nerve forces, they will in turn take care of the life forces. 195 In general weakness of the body we have three forms of weakness; we have exhaustion, then we have depression, then we have a condition known as oppression This is known as excrementitious plethora; the first two are real weakness, the last is but apparent weakness. This whole subject of stimulants and the use of stimulants is a subject of practical importance Your stimulants are needed just where a man must exercise good judgement as in oppression and depression. This condition of oppression usually occurs in the circulatory system and needs just the opposite 196 treatment to depression, now if you were to begin to stimulate a man with a good Tonsilitis u would do harm, in this case you would want to use eliminatives, salines; local applications or anything to take the pressure off the circulatory apparatus; in a case of acute bronchitis how often you feel dull and languid and yet you are just as strong as you were the day before, this is apparent debility. The need of stimulants is indicated when the nerve force is depressed without any marked depression of the vital forces. Now 197 let me call your attention to some of the uses of stimulants, how we must use them: Just remember that there come a period in every disease when every moment is valuable. I want you to remember right here that the power of medicine is relative, not positive. You must have something for your medicine to work upon or your patient will die; then in all diseases it is well for you to watch carefully the workings of the great vital powers, you cannot watch too closely the avenues of death, look well to the digestion, assimilation, 198 respiration, circulation and nervous system. By the harmony of the action of the main organs do we prolong life. When the body is tending towards disintegration, you may as well give up your medicines, as there is nothing for the medicines to work upon; so you must anticipate the coming debility. I want you to bear this in mind, - it is a common error to treat diseases by name, here you will run a risk; by doing this we are apt to loose sight of the failure of the nervous, vital or digestive system; now if you fail to unite these 199 you are going to fail in your practice; you must be on the look out for other conditions besides that condition of the disease of the patient; you may carry this with you as a general rule that in an organic affection that organic affection is likely to suffer less just in proportion as the system is kept near the health standard; and your patient will make a better recovery. Remember that an organic affection will cast its shadow over every other organ; then no matter what be the name or character of the disease, treat the general 200 indications. Remember that the longer a disease exists in an organ, the less likely is it to be restored to its normal condition. Shorten every disease by every means known, if you do not you run the risk of chronic conditions, which will last the patient a life time. Now I want to call your attention to stimulants proper. I will just run over the names of them; we have different divisions of stimulants. We have Cerebral Stimulants, Spinal Stimulants and Arterial Stimulants. Cerebral Stimulants act specially upon the Cerebrum. Spinal 200 199a Stimulants act specially upon the spinal cord. Arterial Stimulants as Digitalis, increase the action of the heart. Of the Cerebral Stimulants we have three great classes; first the inebriate of which Alcohol is the type. Second, Sophorifics of which Opium is the type. Third, Deliriants of which Belladona is the type. Now the mode of action of stimulants. Moderate stimulation will always excite; excessive stimulation depresses. Now what are the general indications for the use of stimulants? First to support the powers of life, we use Alcohol very 201 generally for this purpose, especially in failure of the nervous system, we use then Opium to relieve pain and Opium to produce sleep; we can support the powers of life, relieve pain, and produce sleep. We will take up now the first of this class, this is Alcohol. We may give this in Brandy. Whiskey Beer and all the malt liquors. Remember that in Brandy and Whiskey the Alcohol is about 35%. Now as to the physiological action of Alcohol. Pure Alcohol on the skin produces a little hardness of the skin; it will 202 coagulate-Albumen; in the mouth it produces an Astringent effect; in the stomach first it produces a sense of warmth and increases for the time being the flow of Gastric Juice; increases the flow of blood to the brain and increases the functional activity of the stomach; that is the effect of the occasional use of alcohol. Carry that now to the habitual use; for a time this has the same effect, it however renders the habitual secretion pathological; we get an increase of mucus and hence the morning vomiting of drunkards. We 203 then have thickening of the interstitial tissues of the stomach that means pressur upon the Peptic glands and less Gastric Juice, the mucus glands however are increased in activity; then we have the dyspepsia and all the evils which follow in this disease. One step further and what about the Pepsine; the wine of pepsine is as I told you a useless preparation; the only good effect produced by it is by the Alcohol; now Alcohol is extremely diffusive; the blood of the stomach is carried directly to the liver, causing 204 an extra amount of bile to be poured out; bye and bye the liver is enlarged, then the condition of the liver becomes similar to that of the stomach, we get what we might call scar tissue there; its first effect upon the liver is hyperplasia and then atrophy. The effect of a small dose of Alcohol upon the heart, is to increase the circulation; it tends to dilate the cutaneous capillaries. Alcohol acts as a febrifuge by increasing the action of the heart, and dilating these capillaries, the result is the blood becomes cooled by the 205 external air; remember that the capillaries constitute a cooling area and thus Alcohol acts as a febrifuge. The effect of Alcohol upon respiration and temperature. Reespiration is not materially affected. The Temperature in health is slightly diminished as Alcohol has a tendency to hold the Oxygen in the red blood corpuscles; it diminishes the destructive metamorphosis of tissue. A great many people when they want to withstand cold, take Alcohol; that is all wrong. For the time being you feel warmer because 206 the external cutaneous nerves are bathed in a warm fluid, but bye and bye you begin to feel chilly and cold, because much of the heat of the internal organs has been dissipated by the capillaries. If you want to take Alcohol to secure warmth, take it after you have been exposed to the cold. Effect of Alcohol upon the nervous system; the first effect is to simply stimulate it, possibly two elements enter in here in the increased circulation of the brain the cerebral cells can probably appropriate more blood by its action, then we find that 207 the use Alcohol is increased activity of the brain, Alcohol in itself will produce increased circulation. Now what is the effect of an intoxicating dose of Alcohol, the first effect is the action upon the brain, the thoughts flow freely; now this is followed by depression. Alcohol causes hope to be rekindled, it gives courage, and dispells despair; this is the first effect of Alcohol in intoxication. As the first stage gives place to the second the impressions become blurred, the tongue becomes muddled, the better element of the man becomes submerged 208 under the animal element, then courage becomes recklessness, then hope becomes a disfiguring conceit of the man, and at last locomotion is completely destroyed, and the man lies down in the gutter. Now is there anything so disgusting as such a condition, he lies there like a brute. Now I do not say that for temperance as that is the next thing to drunkeness, but simply that Alcohol should not become the master of the man nor the man the slave of Alcohol. If you want the sophorific effect of 209 Alcohol, rum is best, for the diuretic effect Whiskey is best or gin; for cerebral effect use brandy. Note the interstitial tissues of the liver is specially affected by Alcohol. The first effect of Alcohol upon the brain is to increase the amount of blood in the brain, shortly after this increase we find the peripheral vessels dilated, and the blood is drawn away from the brain, first we have stimulation then we have an anaemic condition. In using stimulants for the nervous system, keep within the range of stimulation or your remedy is worse than useless. 210 If you give a small dose of Alcohol its stimulating effect is long continued; if you give a large dose of Alcohol you get the period of stimulation short, and the period of depression long. Now the effect upon the brain itself; the effect of Alcohol upon the intra cranial organs. The effect is to increase the connective tissue, not only in the brain but in the nerves everywhere, and the result is contraction of the tissues and wherever you have the contraction you will have impairment of intellect; in effects not only the brain 211 but the spinal cord and the spinal nerves. You note the shambling gait of the drunkard it is tottering and weak even when not intoxicated, the functions are impaired all through the body, such a man walks better under stimulation. I do not care how gigantic a mind may be it will succumb at last under the influence of alcohol. Then again, the gray matter of the brain undergoes a fatty degeneration as it were, upon the spinal cord the same result is produced. Then the long use may lead to delirium tremens 212 which means simply an exhausted nervous condition. Now as to the treatment of a case of delirium tremens. If you were called to a case well marked, the first thing to do is to get your patient to sleep if possible; if it is in a young strong robust man and there is no danger to the cerebral vessels, opium is very good; if there is danger there use Hydrate of Chloral and Bromide. If you find a man with a hard pulse and eyes starting out give that man a good injection; the best that I know of is Turpentine, Castor Oil and soap suds; you must unload 213 the Portal circulation in these cases. What is the effect of Alcohol upon an empty stomach? As I said, Alcohol is quite diffusible and is readily taken up by its seat of action. Now as long as a man that is drinking, eats well; he is going to carry the Alcohol well. It is just as well to recognize in a drinking man, that he is going under when his stomach fails. At dinner parties the effect of Alcohol is largely obviated by the use of Coffee. The day after taking a large quantity of Alcohol the man’s secretions are locked up, there is thirst and the bowels may 214 be constipated. Now the individual that uses Alcohol night and day becomes a physiological bankrupt; under these conditions a man is very likely to succumb to slight attacks of disease, as his reserve fund cannot be called out. Now in an acute and severe illness if you find your patient does not emaciate well, he is in danger. Note this in Typhoid fever or Pneumonia. Whenever a patient emaciates under a fever, he will in nine cases out of ten recover, you supplement the case with stimulants and that will force nature to bring out her 215 reserve force. Now the lesson taught by this is, that it must bear a direct relation to the forces of the system. You do not want to give Alcohol in every kind of sickness. If the individual has been a drinking man give stimulants from the start; if a young man not used to stimulants; stimulate only in the latter part of the disease. Alcohol is to call out latent energy. In the early stages of labor especially in the poorer class, you will find the friends of the woman will give her Alcohol in the first stage; this simply exhausts the 216 woman when given in this stage, as it unlocks the reserve fund too soon, and the reserve forces cannot be used at the last where it is required. If you use stimulants remember that they are only adjuvants to something else; they help where other things alone might fail. Your food and your drink is enough for the ordinary wear and tear of life but when you have some difficulty to go through, you may perhaps need as stimulant to help you. Now stop the Alcoholic stimulant as soon as the obstacle is overcome, never use a stimulant. 217 beyond the necessities of the case, remember that the stimulant is the third horse to the car. Sometimes there comes a stage in an acute disease in which it means death if you do not sustain the system; in some of these cases you must use your stimulants as much as the stomach can sustain, anything to give a margin of time. Sustain your patient in every way you know of to secure this margin. Now when it come to stimulate the value of Alcohol, we must estimate it for its effect upon the nervous system and as a 218 food; as food it is easily burned and protects the tissues, and then it helps by its stimulant effects to digest other food. It helps first by the heart, then by the stomach, and then by the nutritive system. If you give Alcohol with Strychnia it will never induce drunkeness, so that you can give it safely in this form, and you know exactly the amount of Alcohol that is taken. I was asked a day or two ago as to the diagnosis of acute drunkeness; now I may as well tell you that I cannot give any definite rule. Now in Opium narcosis the pupil as a rule 219 is contracted, but again some times it is not. In appoplexy as a rule the pulse if full and strong, and yet some times it is weak and feeble. Then again you may get apoplexy and drunkeness together. You cannot always tell when you pick a man up on the street, whether he is drunk or dying: Now if you want to sober a man up give the Spirits of Ammonia, but if the man be weak and feeble be careful; if you can get them to take a glass of milk it may direct the blood somewhere else. Now the Therapy of Alcohol. In temporary loss of heart 220 power as in syncope, in acute cases always give your alcohol hot do not forget that; if you want a rapid action give it with Ammonia or Capsicum. Remember that not a particle of anything will go into the blood until it is heated to the temperature of the blood. Whenever there is failure in the nervous system no matter what the disease, we can give it with excellent results. If in the nervous and vital forces as well give it backed up with food. Wherever margin of time is necessary to effort a cure then bring in your stimulants. 221 Administer your Alcohol in small frequent doses, give it so that the stimulating effect of one dose will overlap that of the other, and you will thus avoid fluctuations. In fevers always give your Brandy ice cold, give iced milk with Brandy for there you do not care for a sudden absorption, let it absorb enough of the heat from the system to bring it to the temperature of the blood. Now you can see that Alcohol is doing good, when it improves the appetite and secretions, increasing the pulse and nervous action; it does harm when 222 it frets the pulse and locks up the secretions; then it may do harm in fevers by upsetting the stomach, then you must give it by the bowel. Always be careful of Alcohol in convalescence, do not give it longer than is absolutely required. The morning is the best time to give Alcohol in convalescence, in the form of wine. Very often in a convalescent patient the brain cells become weary, and the result is that when the brain is fatigued the patient is gloomy, and when they go to sleep, their sleep is restless and unrefreshing; they want 223 a dose of Alcohol before they go to sleep. Now there is nothing will benefit old people so much as Alcohol especially at bed time; they are apt to suffer from cold feet and hands and they will be awake a long time. You give a dose of Alcohol and bye and bye the blood is called from the brain into the cutaneous surfaces, and they fall asleep. I would like to impress upon you the fact, that there are diseases where stimulants are absolutely indispensable. There is no time where the effects of Alcohol is so marked and pleasant as in convalescence, so 224 be careful of its use. Do not use Alcohol in every acute case, do not use it in the majority of cases; but wherever your patient is likely to die from failure of the nervous system, you have no remedy that will take its place, and back that up with Quinine and Iron if so indicated. In convalescence give your Alcohol at meal times as it helps digestion, you can also give it at bed time. In old persons the danger of the Alcohol habit is reduced to a minimum. Now I want to dwell upon the hypnotic qualities of Alcohol. It will 225 usually put a patient to sleep when he is suffering from an exhausted condition of the cerebral cells associated with anaemia; it gives food to the tired nerve cell. You take a person suffering from a severe hemorrhage, they will suffer from wakefulness because the brain is so anaemic, it is below the sleep point. Now if you give Bromide here you only intensify the anaemic condition of the brain; now in this case give alcohol in the form of a milk punch or egg nog; if you give Bromide or Chloral your patient will not get a wink of sleep all night. 226 For old people remember there is no hypnotic like Alcohol. The reason of old people being so wakeful is, that their capillary circulation is so poor driving the blood internally, and we have as it were a congested condition of the brain; now in old people that condition means that they are worn out; in convalescents it is much the same the system is run down. We will now take up the Arterial Stimulants. Digitalis is an arterial stimulant but I will take it up in connection with the heart. Arterial Stimulants are 227 those which act more especially upon the heart and blood vessels; they are like Cerebral Stimulants, they are very diffusible; they are readily taken up and they are readily given off; their action is transient and not permanent. The primary action is upon the heart, and secondly upon the brain and general functional activity of the body. Now indications for their use. Failure in the circulatory apparatus; they have more or less of a burning property. Now their counter indications. In acute inflammations, 128 and general Gastric Catarrh. The first I call your attention to is Capsicum; this is used in the South very largely as a food; the first effect is to produce a sense of burning, it will produce an increased flow of saliva in the mouth, it increases the Gastric secretion and increases the force of the circulation. Its action upon the heart is to stimulate it, upon the bowels and stomach it stimulates. It is eliminated oftentimes by the kidneys and will oftentimes give a burning sensation on micturition; much of it is also eliminated by the bowel. 129 When a patient is taking Capsicum, you had better explain these points. Now as to the Therapy. First in an atonic dyspepsia and in the dyspepsia produced by the excessive use of alcohol: The Tincture of Capsicum, Tinct of Nux Vomica and Tinct of Columbo is an excellent combination to give to an old drunkard to finish off with. In colic especially wind colic where there is a distension of the bowels, sometimes Tinc of Capsicum acts very nicely. In fevers where you want to give beef tea season it with Cayenne Pepper. It helps digestion by increasing the flow 230 of Gastric Juice. Be careful of its use in Typhoid fever, for if it goes down into the bowel and gets up a colic; the dose of Capsicum is about 10 M. In intermittent fever by giving Capsicum in the first stage, you will lessen the cold stage; in some parts of the country they use red and black pepper to break up the paroxysm; never give it where you have any inflammation of the stomach or bowels. In intermittent fever sometimes you can increase the action of the Quinine by giving a gr or two of Capsicum. You can give this in a capsule. 231 Capsicum plaster is just a mild irritant. Now the Oil of Turpentine; this is useful in certain cases and I hope you will use it in your practice The dose is from 5 M to half an ounce but always associate a large dose with a cathartic. Sometimes we make a Turpentine Liniment. Turpentine upon the brain is a little intoxicating; on the circulation it acts as a stimulant to the heart. It acts specially upon the vasomotor nerves. It diminishes the size of the arterioles, it closes up the little orifices where the white blood corpuscles would go out. On the 232 stomach Turpentine acts as a mild stimulant, it gives a very slight burning sensation. On the respiration, it increases it slightly and helps to oxidize the blood; it raises the blood pressure by tightening up the arterioles. It stimulates the kidneys in small doses; in large doses it over stimulates and leads to bloody urine, and albuminous urine and sometimes to suppression of urine. It always gives to the urine a violet odor. A portion is eliminated by the bronchial glands and a portion by the kidneys; we sometimes use Turpentine in 233 chronic bronchitis, but not in the acute form, and not in the acute form of kidney disease. Turpentine as also an antiseptic as are all the productions of Pine. We use it internally then when we want to use an anti septic. Benzoline, Turpentine and Boracie Acid are all anti septic, and we use them internally for this purpose. Now when do we use Turpentine? It is the best thing we can use in Colic, 10 M on a piece of sugar is an excellent remedy; in intestinal catarrh it is good, then we use it as an enema. We use it in tape worm, 234 the old dose for this used to be half an ounce of Turpentine one ounce of Castor Oil; and a little Oil of Male Fern; this is a horrible mixture and we have other remedies as good or better than that and not so unpleasant. Now in passive hemorrhages note the peculiar action of Turpentine, we have no better remedy in this difficulty, it just closes up the little capillaries. In active hemorrhages it does harm, it increases the force of the heart and pumps the blood out. In passive hemorrhage we give Turpentine and Digitalis, or Turpentine and Ergot. Never give Turpentine 235 in plethora. In typhoid fever in about the third week, when the ulcers begin to bleed, when there is beginning to be flatulence, and where the heart is beginning to fail, you have no remedy that will take the place of Turpentine. Now when the tongue becomes red and blazed, and you have tympanitic distension with heart failure, give your Turpentine. You can give it in emulsion if you so desire. You can if you like give Turpentine, Quinine and Cinnamon. Just remember Turpentine in this stage of typhoid fever, and if you have diarrhea 236 at this stage, you can give a little Opium with it. The external uses of Turpentine. The Turpentine stoop, take a pail full of hot water and pour on the top a table spoonful of Turpentine, now take your flannel and press down below the Turpentine, and draw it up through the Turpentine and you then have it evenly and will spread upon the flannel; this is a most excellent remedy in flatulence, tympanites or any affection of the stomach, especially where there is a distension of the bowels; we often use Turpentine in Pelvic Peritonitis 237 or cellulitis. Now Ammonia; we have the Carbonate and Chloride of Ammonia, dose from 10 to 15 grs and the Aqua Ammonia, dose from 5 to 20 M. Always give Chloride of Ammonia in ice water; if you want to gets its action upon the liver give it in Fld Ex Taraxacum. Then we have Aromatic Spirits of Ammonia, dose from 5 M to a tea spoonful; in failure of heart action you can combine it with a little Brandy. Give your Ammonia with the Bromides or Iodides. If you have a case of poisoning by Ammonia 238 it will produce an erosion of the Pharynx and Larynx. The Therapeutical antagonists Veratrum Viride, Aconite, cold and so forth. If you want to intensify the action of the Bromides and Iodides give them with Carbonate of Ammonia. Give about one gr of Ammonia to ten grs of Iodide. Locally Ammonia will burn the skin. Rember this in fainting not to use too much Ammonia. The Chloride of Ammonia has a cooling effect in lotions. Upon the brain and nervous system the effect of Ammonia is secondary; it first 239 affects the circulation. It affects the Sympathetic System rather than the brain. Do not use Ammonia as an emetic Its action is extremely transient and hence you must give your doses at short intervals of about half an hour apart, or your Ammonia will have dissapeared this is especially the case in pneumonia. Ammonia externally is a good counter irritant, we usually apply the Liquor Ammonia; then we have The Ammonia Oil and the Ammonia Liniment. Its use is not wide ranged but in sudden failure of the 240 heart or a prolonged faint, there is nothing better than Ammonia given with a little hot Brandy. Inhalation is probably a better way to use it in faints, in the purely functional derangement it is always best. In adynamic fevers where there is a general failure of heart, you do not want to give Ammonia; in typhus scarlet fever, and diphtheria it must not be used except in emergency; there you should depend upon Alcohol which is a stimulant and food. Wherever you have a poison in the blood that must be 241 eliminated quickly, as snake bite or Aconite poisoning or Veratrum Veride; you have nothing better than Ammonia. In the poisoning bites of animals you often get an acid condition of the blood; there Ammonia acts in two ways first stimulating the heart and then neutralizing the acid. In failure of the heart from anasthaesia your Ammonia should always be at hand. Now the Nitrate of Amyl. If the patient can get just one breath of this it will start the circulation, as it is absorbed very rapidly. In the collapse of the pernicious 242 fevers of the intermittent type, if this is given with Brandy it will shorten the chill, or you can use the Spirits of Chloroform and Aromatic Spirits of Ammonia with hot Liquor and a little Capsicum. Now here you have a condition of the skin in which there is not a particle of blood, and if you can get this into the stomach you will simply relax the blood vessels of the skin and shorten the cold stage. Now what is true of the pernicious form of fever is true of the severe form in the mild stage. In pneumonia we often use the 243 Carbonate of Ammonia for two purposes· first for its effect upon the heart, wherever you have a solid lung you know you have obstruction to the right side of the heart, now if the lung is blocked up you may have failure of the heart from the extra work imposed upon it, thus when you find the heart beginning to fail give Carbonate of Ammonia as a cardiac stimulant and as an expectorant; it stimulates the bronchial glands and helps to raise the liquid from the lungs. Remember in pneumonia the failure is on the right side of the heart, in this 244 disease they often die merely from failure of the heart; there is another condition in pneumonia which Carbonate of Ammonia helps to obviate; that is heart clot; we find this on the right side. Now you want to liquify tha clot to a certain extent and Ammonia will do that. Never loose sight of the failure of the heart in pneumonia; Digitalis can be used as an energizer to the heart muscles; Nux Vomica as a stimulant for the nervous system, let their action be in common but do not give them together. In Gastric Catarrh we often use Chloride 245 of Ammonia, this may be given in 10. 15 or 20 drop doses or half tea spoonful doses in cold water. Give this upon an empty stomach, it has a special action upon the gland cells of the liver; it is one of the best cholagogues we possess; whenever you have Gastric Catarrh, Gastro Duodenal Catarrh give this about an hour before breakfast on an empty stomach. Chloride of Ammonia has the nearest specific action upon the liver, of any medicine we have. You can always increase the action of Ammonia by the use of the 246 Liquor Ammonia Acetalis. Now Ammonia should not be used in the continued fever, do not use it in Typhoid fever or the Typhoid states; when a pneumonia has become typhoid, the period for the use of Ammonia has passed in Typhoid conditions the blood already contains an excessive amount of Ammonia you do not want to add any more to the already poisonous condition of the blood; in typhoid states you want Alcohol, you can give Opium and Alcohol together, but never give Ammonia unless as I have said it be to tide 247 over a sudden failure of heart in these conditions. Note the effect upon the urine. Wherever you have any disease of the kidneys avoid Ammonia; you can use Soda or Potassa this with the Uric Acid forms a solid. We will now take up Opium; this is a Cerebral Stimulant and is the remedy of the Materia Medica, this is the juice of the unripe Poppy. Now as to the preparations; We have the Opium pill this contains one gr of crude Opium then there is the Tinc of Opium the dose of which is about 13 M this represents about the 248 strength of one gr of crude Opium, then we have the Deodorized Tinc of Opium, dose about 20 M this is good for children; then we have the Camphorated Tincture of Opium there is one gr of Opium in half an ounce of this it is also excellent for children and nervous females; then we have the Compound Soap pill, and the Dovers powder the dose of the latter is 10 grs, this contains one gr of Opium, one gr of Ipecac and 8 grs of Sulphate of Potash. We often use the dry old Opium pill in Peritonitis, as we desire the effect of the Opium locally as well 249 as its constitutional effect. Now as to the incompatibles of Opium. Almost all the minerals are incompatible with Opium. Fowler’s Solution, Lead, Zinc &c; these are therapeutically incompatible not chemically. Now the effect of a small dose of Opium is to slightly stimulate the heart, wherever you find a remedy that stimulates the heart in a slight degree, we get a slight stimulation of the brain. Opium has a peculiar effect upon the secretions, it diminishes the peristaltic action of the bowel, it may possibly stimulate 250 the respiration organs; this is the first stage of Opium. Now the second stage; this is a depression of the function lessened cerebral stimulation and lessens heart action. Now the awakening. The patient may awaken in a perfectly normal state. Some under the influence of Opium may have bad dreams, others will be perfectly calm and quiet; this is owing to the condition of the cerebral cells at the time of taking the Opium. The effect of Opium is to increase the activity of the skin, if it does not do this it is apt to 251 increase the secretion of urine. Now in large or poisonous doses the stage of excitement is extremely short, and the stage of depression long varyinig from ten to fifteen hours the first stage here then is just a little excitement and then off sound asleep. By the time you have reached a patient who has taken a poisonous dose, you will find the respiration about 8- or 10 to the minute, pulse slow, the breathing may be quiet or stertorius; as the fatal point approaches the heart may be rapid or feeble. We find then abolition of 252 of all intelectual faculties, the pupil of the eye is brought to a pin point, the patient may either be very pale or very flushed; every other secretion but that of the skin may be more or less dried up; you of course get the fumes of Opium from the breath; the condition of sleep quickly passes into that of coma. Sleep in arterial anaemia of the brain, coma is venous congestion. In Opium narcosis we have venous congestion of the brain. Now how will you treat a case of that kind? You will first wash out his stomach; 253 if he has taken Laudanum fill it up again and again and wash it out thoroughly. If you cannot do that, use your emetics, one of the best is Alo Morphia you can inject this under the skin, this has a special affinity for the stomach; if the patient is conscious give him Sulphate of Copper or Zinc. If he is unconscious never give an irritant emetic remember this particularly; for if you allow the Sulphate of Copper to remain in the stomach, it will destroy the coat of the stomach. You can give Ipecac or Sulphate 254 of Copper and Ipecac together or you can give a tea spoonful of mustard in a cup of warm water. If the patient is a young man let him have a little Carbonate of Soda, then give him a little Acid after it. Use warm water in washing out the stomach. You can use the irritant emetics if the patient is conscious. Now the physiological antagonists to Opium. Belladona is antagonistic up to a certain point, but beyond that point they act together. Now Belladona produces delirium and relieves pain; it dilates the 255 pupil, it increases the hearts action, and is a cardiac stimulant. In Opium narcocis we have a weak heart action, if we give Belladona it stimulates the heart and respiratory organs. Opium produces pallor of the face. Belladona flushes it. Belladona increases the peristaltic action of the bowel, it relaxes the bowel; the action of the skin and kidneys are both diminished by Belladona, especially that of the skin. Now in the latter stages of Opium poisoning the pupils are widely dilated. (Extra not: post yourself well up on the 256 doses of Opium, Quinine. Chloral and Alcohol.) Now we use Opium in fevers and exhaustive diseases to sustain the powers of life, but we use it in small doses in order to get the stage of stimulation long; the stimulating effect of a small dose of Opium will last from 3 to 5 hours. Now Opium upon the sensory nerves; it lessens the power to carry pain, it also has the power of lessening the receptive power of the cerebral cells. Now the reflex function; the first effect is to increase the reflex action of the nerves in a 257 large dose it lessens the ir- ritability of the nerves, later on in the difficulty the heart is increased in its action. Upon the respiratory centres it has its sedative action diminishing the respirations until they get down to 4 or 5 per minute, and until perhaps they stop altogether. As a patient comes under the influence of a large dose of Opium, we find the blood is imperfectly oxidized, it is not forced through the respiratory apparatus sufficient to oxi- dize it in a proper manner. Opium upon the stomach. It removes the sensibility of 258 the stomach therefore we are careful of what emetics we give; now a small dose will dry up the secretions especially the biliary secretions; most people after taking Opium have pale looking stools, it also renders the faeces hard. Now what is the action of Opium to produce sleep? The normal condition of the brain in sleep is anaemia; wherever you get venous congestion of the brain, you get coma. Opium produces its effect by obtunding, it diminishes the receptive power of the brain and lessens the power of the nerves to carry sensation. 259 In some cases you give Opium to relieve pain and yet it does not induce sleep; in this case you have not given enough, you should have given a larger dose in order to bring the brain to a point of anaemia; that is you will need to give enough Opium to quiet the cerebral action. Now you must remember in inflammations that the Opium allays the pain, slows the vigor of the heart, and thus allays the inflammation. Now as to some of the circumstances which modify the effects of Opium. Remember that the extremes of life 260 bear Opium badly; you cannot give much to a little child as the reflex irritability is so great; a child once under the influence of Opium may be a long time before it recovers from its influence; in a nursing woman be careful about giving such a woman Opium, as enough Opium has been taken in the milk by the child to destroy its life. Nervous women do not bear Opium as well as men, some how- ever will bear enormous doses; you will find some patients very susceptible to the action of Opium, it makes them 261 nervous and wakeful, and the dose requires to put such persons to sleep is a dangerous dose. Then pain has a modi- fying effect upon Opium; some- times you will have to give five grs of Opium, in peritonitis you may have to give from 2 to 4 grs at a dose; hypoder- mically you may have to give less. Be careful of the use of Opium in acute pain that is likely to end suddenly, as in renal colic; now re- member that for as soon as the stone has passed into the bladder the pain is gone, and you may then get Opium narcocis. Now 262 an opium eater’s word is worth nothing, they do not lie in- tentionally but they see every thing magnified, but their period of depression is extremely long, and the demand for Opium is so imperative that he must repeat its use; you will be surprised when you get into practice how many Opium eaters you will find in the cities. Now there is nothing will put a child to sleep and keep it asleep all day but Opium; and this it is which is used in these so called Soothing Syrups, the mothers of children are ignorant of the action of Opium and 263 are not aware that it is in- juring the child. Now the indications for Opium. We use it to stimulate and support in exhaustive diseases, we use it in a shock or injury oftentimes in fevers we use it to suppress morbid dis- charges, it dries up secretions remember excep. that of the skin; we use it to produce sweats; to produce sleep when in pain, it reduces mucu- lar spasm as in Lead colic; renal colic, hepatic colic. Now note, to ally pain; obviate wakefulness; quiet nervous irritability; and to allay muscular spasm, 264 Opium is the antidote. Now note the uses of Opium outside of its general employment. Mrs. Winslow’s Soothing Syrup, two doses of this caused the death of a child; one ounce of this mixture contains one gr of Morphia with other Opium alkaloids. Godfrey’s Cordial is estimated to contain half a gr of Opium to the ounce, in four years 56 deaths are reported to have resulted from its use. Dalby’s Carminative is composed of 7 essential oils this contains one sixth of gr of Opium to the ounce. Atkinsons Infant Preservative contains one drachm of Opium 265 to the pint. Caves mixture is still more dangerous. Steadmans Powders, each of these contain ¾ of gr Calomel Now any remedy that will stimulate in small doses will also support to a certain extent. Opium is not used to suppress morbid discharges in ulcers or abcessess; when given for the purpose of produ- cing sweating, give it at night with hot drinks; at night the blood leaves the brain and floats out in the cuta- neous surfaces; the spasm of the uterus can be relaxed by the hypodermic use of Opium. Now let me give 266 you the contra indications for the use of Opium; but always remember that the indications of Opium are more to be observed than the contra indications. In plethoric conditions especially where there is a large amount of blood in the brain, Opium is contra indicated, also in congestions generally. Now be careful of the use of Opium in fevers especially if the pupil be contracted, there is probably a little difficulty near the Pons Varolii when this contraction occurs; a dry tongue contra indicates it use, and also a hot dry skin sometimes 267 It is contra indicated in res- piratory diseases with mutch secretion as it paralyzes the bronchial tubes and they do not take cognizance of the mucus, and the patient thus drowns in his own secre- tion; especially be careful of the use of Opium in bronchitis, do not use it in capillary bronchitis in children; then in all diseases of children be careful of the use of Opium, let it be the smallest possible dose to achieve your object. If you give a child a dose of Opium in the morning; just drop in and see the child before bed time. Now how 268 will we meet the contra indica- tions? If you have cerebral congestion and pain you cannot quiet that pain except by the use of Opium; now combine your Opium with the Bromides; the effect of the Bromide of Potassium is to diminish the vascularity of the brain; the better way would be to give your Bro- mide 15 or 20 minutes before the Opium, Bromide is slower in its action than Opium, therefore if you combine the two you will get the effect of the Opium before you do that of the Bromide; just remember that and anti date the 269 unpleasant effect of the Opium by the use of your Bromide. If you have a dry hot skin you can give a Dovers Powder, this excites the skin, the Ipecac being a little relaxing. If you have loss of appetite you can use your Opium with a Bitter, and thus overcome the contra indications. If constipation exist give your Opium with a little Calomel or give it with any laxative. In fevers; now here is where I want you to understand the use of Opium. In fever the patient is restless and sleepless, he must be quieted; if the pupils are not contracted 270 you can probably use it alone we can use Opium and Chloral together, Chloral for its effect upon the circulation and Opium for its effect upon the cerebral cells; Chloral has its effect upon the cerebral cells by its effect upon the heart and circulation Chlo- ral is an antipyretic it will reduce the fever 1 . 2 or 3 degrees. Now if you want to use Opium where there is failure of the heart, combine it with a little Belladona. If you have restlessness with depression combine your Opium with Belladona or Atropia. Where you have vascular excitement 271 use your Opium with Chloral or Antimony, hold to your Opium if the pupil is not contracted. Now as to the Therapy. In stomach disor- ders, if you have a cancer of the stomach teach that patient to become an Opium eater as soon as you can. In all inflammatory diseases of the stomach if the patient will hold the Opium, all well; but if not give it hypodermically the organ must have rest; give Opium to meet that general therapeutic law “rest to the inflamed organ.” whether it is gastralgia, gas- tritis, ulcer or cancer, just 272 remember that Opium is the remedy; if you want to use a counter irritant then use a blister. Now in nausea and vomiting. Now vomiting may be due to a number of causes; it may be due to cerebral con- gestion, treat that with Bromide; it may be due to in- flammation of the brain, well we sometimes have to use Opium here but when we do, we give it to gets it seda- tive effect and give it in large doses to get the stage of stimulation as short as possible in cerebral meningitis this rule applies although its 273 use is somewhat dangerous. We have vomiting from reflex irritation of the uterus and ovaries; wherever you have sexual excitement then Bro- mide is the remedy. You may have vomiting from an over loaded stomach, or you may have bilious matter in the stomach, but do not use Opium there; then we have vomiting from Haem- orrhoides This is due to refle action. Now always find out the cause of vomiting and then treat it accordingly In diarrheas first get rid of the offensive material then use Opium to quiet 274 the peristaltic action and diminish morbid secretion In acute dysentery get rid of your offending material before you give your Opium and always insist that the patient have the movement of the bowels while upon his back; for just as soon as they get up they will strain, and that is not rest for the inflamed organ. He cannot strain while lying upon his back; I do not care what your treatment is but keep your patient absolutely upon his back, I insist upon this; keep him there no matter what he may say; 275 quiet him if necessary with Opium or Belladonna Sup- positories. In dysentery of malarial origin use Quinine and Opium, now you must combine your Opium and Quinine in these cases or you will do nothing. In Cholera Morbus Opium is the remedy used hypodermically: in Cholera Infantum you may give the Compound Opium Powder, it contains about one gr of Opium to 40 grs of aromatic chalk powder; dose according to age. In passive hemorrhage Opium acts nicely in stimu- lating doses. In almost all serous inflammations Opium 276 is the best remedy, in acute peritonitis it is the sheet anchor we have nothing that will take its place; Opium must be used in peritonitis the amount should be enough to keep the patient quiet and allay the pain, keep the bowels locked for 3 . 5 or 10 days if necessary, then move the bowels by an Ox gall injection. In severe inflammations every where let the pain be your guide except in Bronchitis where the secretions are excessive be careful of the use of Opium in the third stage of Pneumo- nia where resolution appears. 277 Let your patient sleep 8 hours out of the 24, if it is an Opium sleep it is better than dozing about every now and then. In delirium tremens if you have a strong healthy man, just put him to sleep with Bromide and Chloral; if you have an old drunkard and there is a little tendency to feebleness, give a little Opium with Bel- ladona. In shock or injury Opium and Alcohol sustains and supports. Be careful of Opium in neural- gia as the patient may want to continue its use. In asthma use Opium and 278 Iodide of Potassium. If you have a little hacking irritating cough combine your Opium with a little Wine of Antimony; dose 1/20 of gr of Opium to about 15 drops of the Wine of Antimony. In the cough of Consumption minute doses of Opium are often beneficial but do not give enough to take away the appetite; the Opium however does not take away the appetite so much as this constant coughing. Often in Consumption the gastric irritability is due to the reflex action of the irritability of the lungs; you will note 279 this in relation to the Pneu- mogastric nerve. Now you give a patient who has a bad cough, one eight of a gr of Opium every three hours until you have quieted the irritability of the stomach, and bye and bye he can take a little food and di- gest it. In the morning give them a good rum punch before rising, this will help them to tide over the fatigue of dressing. If you use Opium carefully in Phthisis it is a good remedy. We now come to the Bromide of Potash; the dose is from 10 grs to 3 – or 4 drachms. 280 It is antagonized by all the Sulphates and all the stimulants; it is aided by all medicines that tend to depress. Its physiological action upon the nervous system is to quiet. In the brain it diminishes the cir- culation and leads to cere- bral quietitude. Upon the Spinal Cord it diminishes its action; it lessens the force of the heart and respiratory movements; it quiets the sympathetic system. The effect upon the heart is sedative; upon the genital organs it is sedative hence it is used in all diseases associated 281 with sexual excitement. Re- member that in sexual excitement of the generative organs Bromide of Potassium is the remedy. Bromism leads to acne, it leads to motor disturbance, weakness, and pallor of the skin. It interferes with the proper oxidation of the blood, and is eliminated by the skin and kidneys. These are the disadvantages of its use. Now in order to overcome the difficulty of the skin use Fowler’s Solution; to overcome the anaemia use the Bromide with Iron. Now the Therapy of Bromide of Potassium. 282 In cerebral congestion non inflammatory it is the best remedy we can have; it diminishes the receptive power of the cerebral cells, and it is best remedy we have in sleeplessness from over work, in sleeplessness without pain. In Epilepsy it is the --- remedy; epilepsy that occurs in the day time is more amenable to treatment than that which occurs at night; the dose in Epilepsy is as much as your patient can carry in his stomach. In epilepsy with anaemia give your Bromide with Iron. In convulsive attacks of 283 children Bromide is an ex- cellent remedy, especially in spasmodic croup. It simply diminishes the re- flex irritability of the spinal cord. In nocturnal emis- sions if the patient is pletho- ric give Bromide; if he is anaemic give it with Iron and let him take the Sulphur baths. Now as to the treatment of Bromism; wherever Bromide has a depressing influence upon the heart combine it with Iron or Digi- talis, or you can combine it with a little stimulant sometimes if necessary. You must use Bromide so 284 as to obviate its unpleasant tendencies. Remember Bro- mide of Potassium increases the action of Opium; all Anodynes intensify the action of Opium but obviate its unpleasant action. We will now take up Chloral or Chloral Hydrate. This drug should be pre- pared with a good deal of care by the Chemist, many of the unpleasant effects of this drug have been attributed to an impure article; when buying this be sure it is the pure drug. When you first prescribe Chloral let the dose be small. 285 Death has resulted from half a drachm of Chloral; if you want to increase its action combine it with an alkaline, combine it with Bromide of Potash. Chloral is of no use in rheumatism; if you give it there you must give it with an Alkali because the blood is less Alkaline than it should be; of course if you want to allay pain in rheumatism you can give Opium. Now what is the physiological action of Chloral. When applied lo- cally it has a slight power of obtunding sensibility; if you combine Camphor and 286 Chloral you get a liquid which is an excellent application for a neuralgia of the super- ficial nerves, be careful however not to blister the face; you can use this in intercostal neuralgia. Chloral is sedative to the general nervous system by diminishing the force of the heart, it leads to arterial anaemia; the sleep induced by Chloral is a natural sleep, it is the most natural sleep we can induce by drugs; upon the spinal cord it has a sedative action, upon the sympathetic system it has the same effect. 287 It diminishes reflex irritability Use Chloral in cerebral con- gestion with a strong heart and high arterial tension. Bromide of Potassium acts more directly upon the nervous system, and secondarily upon the circulation. Chloral acts more directly upon the circulation, upon the respiratory organs a slight effect. In the Chloral habit remember there is no stimu- lating effect, it is entirely depressing. Chloral poisoning results in death by the heart in diastole, the patient simply dies of inanition. We use Chloral wherever we have 288 wakefulness with high arterial tension with a strong heart; then Chloral is the hypnotic. Wherever you have wakeful- ness from anaemia with pain do not use it. We use Bromide of Potassium in over study in persons who are not very strong; but you take the strong man full of blood and you want to lessen the force of the heart, you can do that with Chloral. If there be pain present give your Chloral with Opium. So natural is the sleep of Chloral that you can waken the patient, and let him eat and drink and he will drop 289 off to sleep again; the effect of Chloral will last 24 hours and longer; remember there is no stage of excitement with Chloral, it is depressing right from the start. If you have pain present it is of no use giving Chloral as it will not allay pain. Chloral relaxes spasm by its action through the arterial system, thus relaxing the muscles. We also use it to reduce temperature. We use Chloral in fevers to lessen the hearts action and lower the arterial tension, and when you do that you lessen the burning of the tissues. 290 Under the influence of Chlo- ral in fevers with a hard, full, and strong pulse, the patient will sleep and his pulse go down from one to three degrees; you can use it in patients with wild delirium and with high arterial tension Do not use it in a low muttering delirium with a feeble pulse or you will kill your patient; if a patient is suffering from arterial anaemia your dose of Chloral may be fatal; if the pulse be 80 or 90 and it is full, hard, and strong, then your Chloral every time. Now as to Delirium Tremens 291 use your Chloral here in the first attack with a strong healthy man, he can stand a little depression; but with an old drunkard who has had Delirium Tremens several times, with a pulse slow and feeble, if you give Chloral there you will have a Coroner’s inquest, give such a man a little Opium and a little Belladona. In the former case you can give Bromide and Chloral with excellent effect. In old drunkards give your stimu- lants. In old drunkards drachm doses of Tinc Digitalis can be given, it is wonderful 292 how they can take it; but you give this Digitalis to a man full of blood and it will simply lift the top of his head off, therefore use your Choral with caution. Note use of Morphia when pain is present with high arterial tension. Now as to this whole subject of insomnia what remedies shall we use? Hypnotics under certain conditions. Now we use Alcohol when there is ab- sence of inflammatory con- ditions of the brain, when there is arterial anaemia, when we have a tired condition of the cerebral cells, when 293 we have that sense of fatigue in the cerebral cells; we then give a good dose of Alcohol and the cerebral cells receive a good supply of blood, alcohol will not relieve pain unless given in intoxicating doses; it is an excellent hypnotic in old people, convalescence, or failure of the heart. We use Opium as a hypnotic when pain is present, we have no antidote for pain like Opium, this acts specially upon the cerebral cells and secon- darily upon the circulation. Chloral remember acts more upon the circulation and less upon the cerebral cells. 294 In these four drugs, Alcohol, Opium, Bromide of Potassium, and Chloral, we have reme- dies which will produce sleep in almost any case; you must combine them as the case may indicate. We will now take up Bella- donna, the leaves and roots are the parts used medicinally. We have the Tincture, Solid Extract and so on; dose of the Tincture from 5 to 10 drops; Fluid Extract from 1 to 5 drops; Solid Extract from ¼ to 1 gr. Now as to its physiological action. The first effect of small doses of Belladonna upon the brain ^ 295 is to excite it, upon the heart to stimulate it; upon the spinal cord stimulation; upon the third nerve it paraly- ses it; upon the radiating fibres and upon the sympathetic nerve it gets full control, and thus we have excitement there. Effect upon the intestinal tract, it stimulates it through the Sympathetic nerve. A large dose increases the action of the heart still more, a very large dose over stimu- lates and depresses it. Small doses upon the respiratory organs increase their action, in very large doses it tends to depress. Remember the Symapathetic 296 nervous system is the ma- chinery which runs us while we are asleep and this will not stand this general stimu- lation and depression, hence we must be careful when we use a stimulant upon the sympathetic system. If you use Belladonna you must use it within a certain point. Upon the secretions; it dries up the secretion of the mouth and skin; first it dries up the secretions of the intestinal tract and then increases it; it is eliminated by the kidneys, we use it for its local action upon the bladder, incontinence of urine; or 297 painful affections of the bladder. Now Belladonna upon the brain, just stimulates it, in large doses the delirium becomes muttering, and lastly there becomes a profound stupor and the patient dies in coma. Now as to the treatment of Belladonna poisoning. You can antagonize it with Opium up to a certain point but not very far; now Opium dilates the veins and arterioles while Belladonna closes them to a certain extent. Opium produces sleep and coma with low blood pressure, Belladonna induces wakefulness with delirium with high blood 298 pressure; you will notice how they antagonize each other up to a certain point; but carry the action of Belladonna beyond that point and it acts with Opium and we get coma; both of these drugs dry up the secretion of the mouth and the throat, and both destroy life in exactly the same way. Opium stimulates the heart and then depresses it; Bel- ladonna stimulates the heart and then when the sympathetic system is worn out, we get just the same effects as in Opium. You can antagonize the Opium as long as you can 299 secure the stimulating ef- fect upon the heart by the Belladonna. Now as to the Therapy of Belladonna. When you have a feeble circu- lation and a low anaemic condition of the brain, small doses of Belladonna will increase the action of the heart and send more blood to the brain, and thus relieve that anaemia. The chief use of Belladonna is to relax spasm now let that be your chief use for this drug. We use it in renal colic, hepatic colic or intestinal colic; it is useful in dysmenorrhea, an excellent combination is Opium, Belladonna, 300 and Hyosciamus; or Opium, Stramonium, and Hyosciamus. In that difficulty known as rigid Oss we use an ointment of Belladonna, it will sometimes diminish the rigidity of the Oss by con- tracting the blood vessels and diminishing the blood supply; in Lead colic Opium with Belladonna is a most excellent thing; Belladonna increases the secretions, and one effect of the Lead is to dry up the secretions; some claim that Lead colic is paralysis of the tract; others say that is paralysis of the intestinal tract induced by 301 spasm, and that it is worn out by the spasm. Now in Asthma; this is nothing more or less than spasm of the Bronchial tubes, here we have an excellent remedy in Belladonna but still it will not take the place of Iodide of Potassium; but there are forms of Asthma in which Belladonna will relieve with wonderful rapid- ity. Now in stricture of the bowels use your Belladonna it increases the secretions and tends to relax the spasm of the bowels, but remember it will not allay pain. A small suppository of Morphia 302 and Belladonna for stricture of the neck of the bladder, is an excellent thing to re- lax the sphincter muscle take special notice of this, always pass the catheter yourself after using Bel- ladonna. In constipation we have more or less spasm of the bowel, now do you not see how Belladonna comes in by starting the secretions and relaxing the tension of the bowels. In Hooping cough you might try Belladonna; a nervous cough is better controled by Belladonna than any thing else. Calculus in the bladder; 303 by the irritation of this the bladder will contract; now give Belladonna here entirely it is eliminated by the kidneys and thus acts lo- cally upon the membranes of the bladder. Now in incontinence of the urine in strong plethoric children, we have the best remedy in Belladonna that we have; examine the urine and find out the cause of the difficulty, children bear Belladonna exceedingly well; if you want to cure a child of incontinence just use your Belladonna until you get its physiological action, you will have to give 304 as much to a child as you will to an adult. Now the second use of Belladonna; whenever pain be present no matter what the contra indications may be, use Opium and meet the con- tra indications with other remedies. The third use of Belladonna is upon the heart and blood vessels, give it in small doses frequently repeated; if you give a large dose the stage of stimulation will be short remember that; the Sympathetic system will bear slight stimulation for a long time, let the doses over- lap one another. Now we 305 often have profuse sweating; in a rheumatic sweating do not stop that, let them sweat; in some forms of fever we want sweating, then do not give your Belladonna; but re- member in the night sweats of Phthisis we have Belladonna; remember it dries up the secretion of the mouth and skin Now as to the local effects of Belladonna: It closes up the blood vessels and keeps the blood away from the congested parts; a Belladonna plaster will often relieve neuralgia; its effect upon the eyes is well known where there is danger of 306 adhesion the oculist keeps the pupil dilated, then if adhesion takes place it is better to have the pupil dilated than otherwise. Its effect upon the eye should be understood because if your dose is too large it dilates the pupil, so that the patient cannot see; if you are going to use Belladonna with adults always explain its symptom. I will now call your atten- tion to two other drugs. Hyosciamus and Stramonium Dose of fluid Extract from one to five drops; solid Ex from ¼ gr to 1 gr. The dose of Stra- monium is a little less. The physiological action is almost 307 identical with that of Belladonna, only Hyosciamus will allay pain better than Belladonna, it is also an hypnotic. Now I often use Hyosciamus in cough mixtures where there is a nervous element, especially when the cough is in excess of the amount raised, you can use Hyosciamus with a little Opium. Then the use of Hyos- ciamus is to allay pain, produce sleep oftentimes by relieving the cough or nervous excitement, to relax spasm, and quiet nervous perturbation; it is better than Belladonna to quiet nervous exc- itement. I want to invite your attention 308 now to another class of remedies, heretofore we have been treating of cerebral stimulants, now I call your attention to a remedy that effects the spinal cord. Nux Vomica, dose of the Tincture is from 1 to 10 drops, about 5 drops is the usual dose given in ordinary cases. Incompatibles are those medicines which will diminish the circulation in the spinal cord, that is incompatible therapeutically. Its action is intensified by all spinal stimulants. Now as to its physiological action, upon the secretions it tends to excite; it is the most bitter medicine 309 in the Materia Medica, it is however a clean Bitter, and as a Bitter we use it as a tonic combined with Quinine, Iron, or any of the Bitters it is a most excellent Tonic; upon the brain its action is almost negative; upon the spinal cord it excites to a marked degree the reflex irritability, and it simply produces death by spasm. Now as to Strychnia poisoning what is its effect upon the heart? It is a stimulant to the respiratory organs; upon the heart it is a stimulant; all the organs under the influence of the spinal cord are more or less influenced 310 by the action of Nux Vomica; the effect of small doses is to merely stimulate the spinal cord, the effect of large doses is to increase reflex irrita- bility. The motor system is more or less influenced, the muscles being contracted under its influence. The effects of a poisonous dose of Strychnia may appear in a few minutes, or it may be delayed for an hour or more according to the rate of absorp- tion; if there is food in the stomach containing Tannic Acid, the poisonous effect will be long delayed; but when once you get its full 311 effect, the patient will com- plain as through an electric shock had gone through the system; the body is drawn back, it extends to the respi- ratory muscles and the mus- cles of the face; for the time being the patient cannot breathe and becomes black in the face, and the patient dies from spasm of the respiratory muscles. The abdominal muscles are also contracted until they feel like a board; there is more or less spasm of the heart, we have discharges from every channel from spasm; this condition lasts but a few 312 moments. As soon as the spasm is over everything be comes relaxed, and the patient becomes quiet; the only sign left is extreme fatigue, they want to be let alone. Under the influence of Strychnia the body is extremely sensitive, so much so that even a breath of air will cause a spasm. Remember now that the brain is perfectly clear, and the patient is aware of all his suf- ferings. Now as regards the diagnosis of Strychnia poisoning it is not unfrequently used by suicides; now how will you diagnose it from Tetanus. With traumatic tetanus you 313 will have a wound, in Strych- nia poisoning you have nothing of that kind; in traumatic tetanus the muscles of the jaw are the first to become affected; in Strychnia poison- ing the muscles are all equally affected, the stronger muscles however taking the ascendancy. In Strychnia poisoning the jaws become relased as the spasm passes off, the spasms of Strychnia come right after the other, in tetanus they occur at longer intervals; traumatic tetanus may last days and even weeks, but Strychnia tetanus will be fatal in a couple of hours 314 unless relieved; Bromide, Ergot, Chloral, will relieve here. As to a Post Mortem in a case of Strychnia poisoning you have little or no appearance at all, except a little congestion; its operation is short that congestion occurs to no great extent. Now as to its Therapy. Just a bitter tonic to the stomach. In diarrhea if it is atonic treat it with Nux Vomica; now if constipation is due to want of tone you treat with Nux Vomica also, lack of tone may occur in either of these cases. Now bear in mind that certain drugs have a certain 315 action up certain portions of the body. Nux Vomica acts upon the spinal cord as high as the Pons; it acts upon the muscular structures everywhere let them be vol- untary or involuntary. In any atonic condition Nux Vomica is the best remedy we possess, where the failure has been brought about by failure of the nervous system; in Amenorrhea you can over- come this difficulty oftentimes with Nux Vomica and Iron. Now in poisoning from Nux Vomica, firm erections and ejaculations of semen are characteristic. In failure 316 of heart, Nux Vomica and Digitalis; the Nux Vomica acts upon the nerve forces, while the Digitalis affects more di- rectly the heart muscle itself. In paralysis; here is where Nux Vomica has been used and abused greatly; in the paralysis of diphtheria we have nothing that will take the place of Strychnia, give it to child or the adult; to the child in very small doses 1/200 of a grain will be sufficient, give it in an elixir. A favorite prescription is this; dilute Phosphoric Acid with Acetate of Strychnia, give this in 317 an elixir of Calisaya for children. If it be for an adult, give 1/64 of Nux Vomica, 10 drops of Phosphoric Acid in a tea spoonful of the elixir. In general paral- ysis when shall we use Strych- nia? Do not use it early in the disease, wait until the clot has been absorbed or organized, wait for about from 4 to 6 months before you give the Strychnia; now on the other hand do not wait too long until the reflex irri- tability is lost or you will do no good; feel your way cau- tiously along, let your judgement guide you in that. Nux 318 Vomica or Strychnia is an ex- cellent remedy in Lead colic, it tones up the muscular lining of the bowel and secures an evacuation. Now in Epi- lepsy if you have a strong plethoric patient, Bromide is the remedy; but if you have a weak, feeble, anaemic patient; extremely nervous from loss of power then Strychnia is the remedy. When the attacks come in the night and Bromide fails to control them, try your Strych- nia. In Asthma: this is a nervous affection and the spasm of the bronchial tubes is sometimes due to failure 319 of the nerve forces; in this case Nux Vomica is better than Bromide of Potash. If you have over excitement remember; above all things avoid the use of spinal stimulants. It has been observed of late by excellent medical observers that the long continued use of Nux Vomica, or the short continued use of the same in large doses will produce a condition of diabetes. I know of cases where upon the administration of Nux Vomica, the patient will become diabetic. Now how does this induce it? It is a spinal stimulant, it acts 320 as far up as the Pons; we have what is called the diabetic area up as far the fourth ventricle: therefore if you stimulate the base of the brain with Nux Vomica, you will get sugar in the urine every time. When you use Nux Vomica for a long time, examine the urine of your patient and look for sugar. This is a remedy that can be used as well as abused to a great extent and advantage. Now be careful in prescribing stimulants of all kinds, I have warned you before of other stimulants and now I warn you of Nux Vomica. 321 The next remedy we will now take up is Digitalis, the leaves are the medicinal parts of the plant, the leaves of second years growth; its common name is Fox Glove --. Note. While giving Nux Vomica warn your patient not to use tobacco, they are antagonistic. Now the dose of Digitalis, of Fluid Extract from 1 to 2 drops; of the Tincture 1 to 20 drops; of the powder 1 to 2 grs. The antagonists are all depressing agents. Upon the brain Digitalis has little or no effect; upon the spinal cord none only so far as a 322 better circulation affects the cord, upon the heart and cir- culation is the best effect; it has a special action upon the muscular structures of the heart, Nux Vomica acts indirectly upon the heart, thus we combine the two together. Digitalis stimulates the cardiac branch of the Pneumogastric nerve; it energizes the heart and slows it. What is the power of the vagus nerve over the heart? It is inhibitory; stimulate the Pneumogastric nerve at the base of the brain, and you get a full hard strong pulse as in apoplexy; stimulate the heart through the Pneumogastric 323 nerve, and you intensify its action and slow its power; it increases the length of the diastolic action of the heart, it increases arterial tension it diminishes the lumen of all the vessels, so that there is a pressure in the front as well as in the heart. Under what circumstances would you use it? You would use it when the heart is weak, in cardiac failure you would use it; in cardiac power you would use Aconite. Upon the temperature Digi- talis has but little or no effect; upon the stomach it has little or no effect or no special effect; 324 in large doses it will produce sickness and vomiting; upon the kidneys it is diuretic. Now as to its Therapy. In heart disease it has its chief use, in pure failure of the heart without any valvular lesion whatever, Digitalis is the best remedy we possess; you need not look for any thing else in the Materia Medica it acts upon the moto muscular powers of the heart and thus increases circulation; in simple dilatation of the heart we have no remedy that will take the place of Digitalis. In simple hypertrophy of the heart Digitalis should never be used; where 325 the heart is strong and powerful Digitalis should never be used. Now what is the effect when we have valvular lesions of the heart? In valvular lesions we ether have obstruction or leakage; in either case if it be at the Mitral valve we have more or less congestion of the lungs. Now in all your study of heart disease, hold your study to the left side of the heart, in 49 cases out of 50 the disease occurs on this side; if a child is born with heart disease it will almost invariably be on the right side. Now let us take Mitral stenosis and discuss the action of 326 Digitalis, now suppose there is an obstruction to the flow of blood into the left ventricle, the patient will complain of a shortness of breath, the blood dams back into the lungs: after a fit of coughing there is a dark bluish appearance of the face, the blood dams back upon the ascending Vena Cava, then to the liver, and then to the intestinal tract and we get hemorrhoids. Mitral obstruction means all this and we get a certain kind of dyspepsia associated with heart disease. Now if you give Digitalis it energizes the systolic and lengthens the 327 diastole, it thus gives the auricle more time to empty itself into the left ventricle. When the left ventricle contracts it throws the blood forward with greater energy and thus unloads the lungs; now con- tinue that at each beat and we get more blood out of the pulmonary circulation, and sends it into the systemic cir- culation, that is the best method of treating that form of Bronchitis; now that is Mitral stenosis. Now what is the effect of Mitral regurgitation? The effect is the same, but now the ventricle fills perfectly 328 when the systolic contraction occurs more blood will go through the widely open aortic orifice, far more than will go through the narrow choked opening of the Mitral orifice, and hence you gain in that way, you throw more blood through the aortic orifice and but a little goes back into the auricle; this is the explanation we have. We often find in Mitral stenosis that by the use of Digitalis the whole aspect of the patient is changed. Now in an aortic stenosis Digitalis must be used carefully; now as long as the hypertrophy is able to overcome the obstruction 329 at the aortic valve, let it alone; you will need to use Digitalis when the heart power is failing, no other. Digitalis is not to be used in Aortic diseases until there is failure of the heart. Now what is the danger in Aortic regurgitation? It is simply this failure of nu- trition of the heart; the heart is nourished through the Coronary arteries, these are filled by the recoil of the arterial system, but if the force of that recoil is expended in sending blood back into the ventricle, the heart does not get its supply; the heart fails from both ways, the walls become stretched and 330 the hear must become hyper- trophied to lift that amount of blood in the aorta; in doing this it is simply over distended and this leads to atheromatous degeneration. A patient suffering from obstruction may live for a long time; but a patient suffering from an aortic regurgitation must go down. Now I want to call your attention to another fact; how is it that in using Digitalis in certain diseases of the heart, that the cure is rendered more or less permanent? The dilation is more apt to occur when you have relaxation of the 331 heart walls, then again the stimulus of action of a muscle is always a stimulus to nu- trition; a heart that is toned up well is always nourished well; improved systemic cir- culation means improved heart nutrition. Now in con- traction of the heart the venous blood is squeezed out of it, if the contraction be feeble you will not get the venous blood all out and you will get im- perfect nutrition of the heart; now if the heart throws but a small quantity of blood into the systematic circulation, the recoil will be weak; now here you will give your Digitalis 332 you will energize its contrac- tion, by this means you throw out all the venous blood and increase the nutrition, as the recoil is strengthened the nutrition of the heart is increased by a good supply of blood. Under the influence of Digitalis you will have in- creased recoil, and increased filling of the Coronary arteries hence an improved condition of the heart. That is where the disease of the heart is not too severe, that the cure is often permanent. Now remember that Digitalis like every other special stimu- lant wears out by over excitement 333 it will be followed sooner or later by a corresponding de- pression; do not continue the use of Digitalis too long. I was reading wher one of our best authorities say, give it indefinitely; but I do not believe that; if you do you will get your stage of depression it may be a year hence or before or later. Give your Digitalis until you find your systemic circulation is well carried on, until the work can be carried on without it. There may be a time in the history of the disease, when you give it only just to support your patient and keep them 334 comfortable. Now remember the first leak of the aortic valve begins to dilate the heart, and if the nutrition is kept up the hypertrophy will do so too, but there is a time when the hypertrophy will cease and you may loose your patient. Now many of the books say do not use Digitalis in hyper- trophy,but there is a time when hypertrophy stands in relation to the heart, as in a weak heart. Now sometimes we have the power increased to three times and the work to four times; in that case you will have to give a 335 stimulant, and there is where you can use your Digi- talis, there your hypertrophy stands in relation as to a weak heart. Then again we rave the power at four times and the work at three times; there you require a cardiac sedative there you can use Aconite, you must depress the heart when the power is greater than the work required. Now in Cardiac and Renal dropsy, remember that if it is from failure of the heart give Digitalis; in acute diseases attended with failure of the heart, just recall the fact that Digitalis is the 336 best cardiac stimulant that we possess, back that with Nux Vomica this stimulates the heart through the nervous system; in failure of heart from low forms of fever this is excellent. Now a word in relation to the cumulative effects of Digitalis. It some- times produces a peculiar eruption of the skin, the patient complains of an itching and burning of the skin; if it does this it usually fails in its diuretic effect. Now if the patient dies of Digitalis poisoning the heart is found contracted, the heart is in systole at the 337 at the time death occurs. The next remedy we will take up is exactly the oppo- site in its effects, that is Aconite; the leaves and roots are officinal; dose of Fluid Extract half a drop to two drops; dose of Tincture half a drop to five drops. We have an Alkaloid of that but I do not care to discuss it, as it is very powerful th dose of the English preparation is 1/64 of a gr: try and become accustomed to a single prepa- ration and use that; I value this remedy and always carry it with me. Now as to the indications of Aconite. 338 Remember that you have a direct antagonist in Digitalis; Aconite poisons the system and leaves the heart in diastole, in this case wrap your patient up in hot blankets, put a warm application over the heart, a good large mustard plaster made with warm water; it kills by allowing the heart to become paralyzed, the symptoms are those of failure of the heart; a small weak pulse it may be slow but if it is a poisonous dose it will become rapid and feeble; the surface of the skin will be cold and clammy, the breath will be cold, hands and 339 feet cold, respiration slow, oxidation imperfect and finally the patient dies. Now here always use an hypodermic injection of Digitalis, give it until the heart overcomes its tendency to paralysis; one point further always keep your patient in the recumbent posture, keep the feet a little higher than the head, the patient may die of syncope. If you follow this treatment you will almost always save your patients life. Now the physiological action of Aconite; on the nervous system it has a peculiar effect, on 340 the ends of the nerves; it obtunds its sensibility, we therefore use it as a local anodyne especially of the superficial nerves, then it acts upon the trunk and finally upon the spinal cord; first it acts upon the sensory nerves and then the motor nerves, a patient cannot walk from Aconite poisoning. Now upon the circulation this is its chief use, it slows circulation and reduces the heart action; upon respiration it has but little effect, upon the temperature it lessens it because it diminishes the force of the hearts action, allowing 341 much of the blood to flow out to the surface and thus it is cooled off in that way; we have a certain amount of heat given off in evaporation, but remember in some cases we have profuse perspiration with no diminution of temperature; sometimes even under Aconite it is not lowered. Aconite is quickly taken up and quickly eliminated, give half a drop every 10 or 15 minutes until you get the effect de- sired, give it in small repeated doses. Keep the patient under the influence of every remedy, you use if want its con- tinued effects. Aconite is 342 eliminated by the kidneys and somewhat by the skin, it is a non irritant. Now as to the causations for its use: in old people be careful of the use of Aconite especially where there is any tendency to failure of the heart. In all diminution of heart action be careful of its use. Now the indications. You can always use it in the strong and plethoric, where the disease is associated with a full strong pulse; it is an admirable reme- dy in the fevers of children we have no remedy that will equal it. In facial neuralgia we use it associated with 343 Chloroform; Chloroform with a little Soap Liniment makes an excellent combination. In Sthenic fevers associated with high arterial excitement use Aconite every time, it brings the pulse down to normal or a little below. In Tonsilitis in the early stages; you can sometimes cut it short in the early stages by giving half a drop every half hour. Aconite diminishes con- gestion; sometimes we have an obscure inflammation associated with high temperature; and here you may save your patient by Aconite. In Pharyngitis, Laryngitis; and in 344 the early stages of Pneumonia you can use your aconite, but do not use it after exu- dation takes place; then trust to your patients strength and use stimulants. In Pleurisy just weaken the heart with Aconite and obtund the pain with Opium. In Peritonitis use Opium and Aconite in the early stages; in puerperal fevers if it is of the sthenic type use Aconite; if it asthenic stimulate the parts. In the eruptive diseases: there are two stages in Scarlet fever; the eruptive stage and the stage of desquamation, now Aconite will sometimes bring out 345 the rash better than any thing else; then when the scales are failing off just moisten that skin by giving Aconite, for the heart is good and strong. In measles if you give Aconite you will lessen the chances of Bronchial distur- bances; if it is a strong healthy child you can associate it with a little Citrate of Potash, you will find the patient will have less danger of patchy pneumonia: In Erysipelas if it is a strong healthy person give Aconite; but if it is a low grade of inflammation and shows venous congestion, you would not give Aconite; you 346 would want Iron and Digitalis you want sustaining measures. Now after vaccination we often have a little erycipelatous inflammation, and yet it is not erycipelas; now just give small doses of Aconite bear this in mind. We will now take up Veratrum Viride; the Fluid Extract is commonly used; dose of same from 1 to 5 drops; dose of the Tnicture 2 to 10 minims. The antagonists are just the same as in Aconite. Physio- logical action, locally it is an irritant to the skin; it has not the anodyne properties that Aconite has, it burns 347 the skin, and to the nasal mucus membrane it is an irritant. Upon the circulation it has a most marked effect in large or small doses; it diminishes the hearts action; upon the respiration it has but little or no effect except as a secon- dary effect through the cir- culation. Now in true Sthenic arterial excitement use Veratrum Viride; in Sthenic pneumonia you will use Veratrum Viride; it acts simply by diminishing the hearts action; where the heart is beating at the rate of 140 per minute it is going to tire 348 itself out, if you diminish that to 80 you give it time to recover, and thereby give margin of time for the disease to run its course. In acute parenchymous in- flammations of the lungs, liver, and many of these internal congestions, you can control them by Veratrum Viride. It is however a power- ful irritant emetic; do not use it in peritonitis use Aconite there; it is such an emetic that you cannot proba- by poison a strong man with it, he will simply throw it off. In acute pain with cerebral hyperaemia we have 349 an excellent remedy in Veratrum Viride, now if you want to hold the stomach quiet give a little Opium with it. Aconite and Veratrum viride induce sleep by bringing the brain down to the sleep point, but you do not want to use them if the patient be anaemic, never think of using them with a feeble pulse or weak heart. We will now take up the subject of Emetics. To define emetics, they are medicines which induce evacuations of the stomach upwards, as a class of remedies they have unfortunately fallen into 350 disuse; the general impression upon the laity is that emetics simply produce evacuations of the stomach. Now there is not an organ in the body that is not affected by an emetic; the stomach, liver, portal circulation, bronchial tubes, nervous system and intestinal tract; to under- stand the action of an emetic you must understand the organ involved. The muscu- lar coat of the stomach is chiefly concerned in the act of vomiting; old persons have more difficulty in vomiting than children; in children the stomach is 351 more perpendicular than in the adult, in children an emetic will act without much depression. Now we have the nerve supply from the Pneumogastric nerve for the stomach; if you irritate the peripheral end of the nerve, you have a reflex action in other organs which this nerve supplies, the result is the respiration, heart and circulatory system is much affected. The Sympathetic System is now being studied more and more in order to discover its intimate connection with the abdominal viscera. Often you will find vomiting 352 from irritation of the bladder, ovaries, or uterus; this is reflex irritation; a little Iodine or blister over the ovarian region will stop the vomiting from this cause, hemorrhoids may cause persistent vomiting. Now we have different kinds of Emetics; we have Specific Emetics and Irritant Emetics. A specific emetic will act wherever applied, such as Tartar Emetic; an irritant emetic will only act by contact as Sulphate of Copper for in- stance. Tartar Emetic and Apomorphia are peculiar spe- cific emetics. An irritant emetic causes a large amount 353 of secretion of the stomach and nausea, this nausea causes profuse salivation which is swallowed with air, this is churned up with albuminous matter and vomited. Now the effect upon the brain it diminishes the force of the arterial pressure and the brain becomes less active. Upon the bowel it increases the secretion; upon the glandular system there is stimulation throughout; upon the respiratory centres it is depressing; upon the muscular system it is relaxing. Age modifies the effects of the emetics, be careful of 354 their use in old people with degenerate arteries; at the time of vomiting there is venous con- gestion, during the act of vomiting the blood is damned back upon the lungs. Do not use emetics in old persons unless it is necessary in a case of poisoning. Now as to sex, females do not bear an emetic as well as men; the mode of living has a modifying effect; persons living on coarse food will bear them better than those living on rich food; fleshy persons bear emetics better than thin ones; the condition of the system also modifies the 355 effects of emetics. In narcotic poisoning it is almost impossi- ble to get a patient to vomit, the time at which you give an emetic must be taken into consideration. In narcotic poisoning remember if your patient does not vomit he may die from the effects of the emetic. In all cerebral congestions avoid emetics, avoid them when the muscular contraction will endanger the patient; be careful in hernia, or an irritable stomach. Avoid emetics in debility unless there is some good indication. Emetics are indicated in the absence of cerebral congestion, 356 when the vessels are not too full and will bear depression. Now when to give them. If you want to get the sys- temic effect give them fasting; if you want to get the peculiar sedative effect of Ipecac give it at night fasting; always have a definite object in giving your emetic. Now the first discharge from the stomach will consist of undigested food or mucus if the vomiting persist you will be very apt to get bile. In excessive emesis warm water is good, a mustard plaster over the stomach or a little opiate will often relieve; if the vomiting become very excessive 357 you will have to treat it as a Gastritis. We give an emetic when there is a foreign body in the bronchi or trachea, an emetic is not confined in its action to the stomach. Now you will often be called upon to treat nausea; just push your emetics and secure vomiting. Hives can often be relieved by emetics; we give emetics for their effect upon the whole abdominal viscera. Now as to its revulsive action; sometimes by the use of an emetic you can get a good revulsive action of the nervous system, give them a dose of Ipecac or Sulphate of Zinc 358 if you find a stout hearty girl lying on the floor in hysterics give her an emetic. In chil- dren Ipecac is the best remedy we have give a child from 2 to 5 grs, an adult from 10 to 20 grs; it acts in from 15 to 30 minutes. Apomorphia has come into use of late years and is an excellent remedy where the patient cannot or will not swallow we can use this hypodermically; Apomorphia is derived from Morphia by Hydrochloric Acid and heat; dose by the stomach 1/8 gr, hypodermically 1/12 or 1/16 gr but do not carry it in solution make your solution when you 359 you are going to use it, this drug has a very depressing effect upon the heart, the dose here given is however perfectly safe. You may use this in narcotic poisoning. Never use Lobelia as an emetic. Do not use Tartar Emetic in children as it is a very depressing emetic, the Yellow Sulphate of Mercury is used largely in croup the dose is from 2 to 15 grs; if you want to leave it in the house leave it in 3 gr powders, this is a terrible poison when not eliminated; it produces emesis with great convulsive action so much so in croup that it said to throw off 360 the membrane. Sulphate of Zinc, dose 5 to 20 grs give it in water, it produces but little depression and produ- ces its effect in 15 to 30 minutes. Sulphate of Copper, dose from ½ to 2 grs is an irritant emetic. Mustard, dose tea spoonful in half a tumbler of warm water. Alum dose a small tea spoonful in half tumbler of water. We will now take up Elimi- natives; cathartics are classed under this head. Eliminatives are medicines which pass out of the blood by way of the glands; cathar- tic medicines taken into 361 the blood find their way out of the blood by way of the intestines; diuretics by way of the kidneys; diaphoretics by way of the skin; expecto- rants by way of the bronchial glands. Eliminatives stimu- late the glands which excrete them, they simulate the natural process. If we have a dry hard cough we give re- laxing expectorants; every gland in the body has its special work to perform; the ni- trogenous elements passing out by way of the kidneys; fatty matter by way of the bowel, certain matters pass off by way of the skin. 362 Now the indications for their use. We use them where the function of a gland must be restored or stimu- lated. If a diuretic be di- rected from its natural channel, it will pass out by the skin or bowel and stimulate these glands, these are termed complimentary organs they help one another. Astringents tend to lock up the glands which excretes them this is an exception to the rule. We use eliminatives to eliminate poison as in Syphilis or Typhoid fever; then we use them for depletion. We will now take up the 368 3 first of the class, - Diaphoretics, they increase the function of the skin; when the skin is freely acting the urine is frequently highly colored and slightly acid. If you have a hot dry skin with a full hard pulse, just give nauseating or relaxing diaphoretics; if you have a cold surface of the skin give a stimulating diaphoretic, as Alcohol; in a hot dry skin we have nothing better than Antimony in small doses. In rheumatism a patient will sweat profusely at 103, this due to formation of lactic acid in the blood 364 and is an exception to the general rule. If the skin sweat freely other glands will act less freely, you cannot get a patient to sweat with a diarrhea. We use diapho- retics in acute nephritis to give the organs rest and allow the inflammation to subside; we take away his nitrogenous food and give him but little exercise. Now profuse sweating is very debilitating, you should look up the therapy of night sweats; you may control them with Sage tea and intensify its action by a little Atropia or Aromatic Sulphuric Acid. 365 These sweats debilitate both nervous and muscular sys- tem, the salts of the blood are drained away by them and salt is essential to the normal nutrition. Certain conditions modify the effects of diaphoretics, young children and old persons do not as a rule perspire; climate has much to do with the action of the skin, they act badly in cold climates; give diaphoretics at night and facilitate their action by warm drinks; there is one exception that is, when the pulse is full hard and strong, where the patient is feverish; then 366 you want to cool him down to the sweating stage, if the patient is cold bring him up to the sweating point. Now in order to arrest the sweating just rub him off once with coarse towels, lay off one cover after the other, cool him off gently or you will give him cold You will notice that all fevers break up with a sweat from some part of the body; we use diaphoretics in inflamed mucus membranes to direct the blood to the skin; they are indicated in the early stages of bronchitis &c; in a convalescence diaphoretics will do harm. Glover’s powder is 367 an excellent diaphoretic with hot drinks if the fever be not too high; Aconite is an excellent diaphoretic when the pulse is full hard and strong; then again Liquor Ammonia Acetalis in tea spoonful or table spoonful doses every hour or ^ two, give it with a little Citrate of Potash and you get the good action of each. Now take Jaborandi and the amount of sweating it will produce is simply marvelous. We will now take up Cathartics; these are medicines that evacuate the bowels down- wards, increasing the number and quantity of the stools. 368 They operate in about two hours first by increasing secre- tion and secondly by increasing peristaltic action; purgation is an increase of the normal function of the bowel, in a severe case of constipation caused by an over distension of the bowel, you may resort to the use of Nux Vomica and Belladonna. We have in cathartics medicines acting upon different parts of the intestinal tract; we can produce liquid stools; normal stools in larger amounts; or any kind of stools by knowing the remedies we deal with. We have specific cathartics 369 which operate wherever applied. The first discharge from a cathartic is almost always faecal; this however depend upon the medicine and the contents of the bowel; give Aloes and the first is faecal: give Salines and the first is faecal, the second is watery; give Elaterium and the discharge is watery and faecal; give Calomel and the discharge is of a bilious char- acter; give a drastic purge and the discharge is mucus and watery. In fevers do not be above looking at the discharge, but always notice it. Then certain medicines 370 change the color of the discharges Iron changes them to black; Hematoxin gives them a red color. When you are giving a child Bismuth he will pass a dark looking faecal matter and the odor will be very bad. The time in which cathartics act varies; a rapidly acting cathartic should of course be given in the morn- ing; a slowly acting one give at night. Now some of the remote effects of cathartics; it dries up the mucus membrane of the mouth; lessens the action of the brain the blood cannot be in the bowels and the 271 brain at the same time; it diminishes the action of the pulse, the skin becomes cold and dry. If you give a cathartic to an old man who has not had an evacua- tion for some days, give him an injection of ox gall to aid the cathartic. In children the bowel is more or less sensitive so be careful of the use of cathartics; in children that may be suffering from a large amount of mucus in the bowel, the medicine is simply rolled up in this mucus and passed off in this manner, this having no effect; in old persons 372 enemas with a little Nux Vomica and Belladonna is often useful. In preg- nancy always be careful of the bowels, in this condition the best cathartic is the Compound Licorice Powder of the German Pharmacopeia. In warm climates the functions of the bowel are much increased, hence we look for diseases of the bowel as this predisposes it to disease, in warm climates cathartics act better than in cold; frequent repetition of cathartics wear out the excitability of the bowels, the condition of the system 373 at the time of administering the medicines has a modifying effect; diseases of the brain generally lead to constipation. Now bear in mind Aloes acts upon the colon; Castor Oil, Senna and Salines upon the small intestine; Gamboge upon the stomach and duo- denum; Colocynth upon the whole intestinal tract; never use Gamboge alone. Castor Oil produces a general tendency to sleep; Rhubarb and Aloes are tonic; Salines are refrigerant. If you want a moderate action of a cathar- tic give it in small doses frequently repeated, you 374 might give it three times a day when a cathartic is likely to gripe combine it with a car- minative, if it be irritant shield it by mucilaginous drinks. Now the classifications. We have laxatives; purgatives; dras- tics; and hydragogue cathartics. Laxatives are mild in their operation; purgatives act more promptly but never inflame the bowel; drastics act powerfully irritating the mucus mem- brane causing nausea and griping; hydragogues produce copious watery stools. The effect of cathartics is to eli- minate morbid matters from 375 the blood, their use is indicated in almost every disease, there are very few diseases where you may not use a cathartic at the outset, except of course in inflammation of the bowels. Constipation may arise from a variety of causes we often have it from deficiency of se- cretion, under these circum- stances a blue pill is the best remedy: oftentimes you can cure constipation with Iron if anaemia be present you may have constipation due to obstruction that perhaps can be removed by ox gall in enema; uterine irritation will sometimes block up the 376 bowels for weeks; women who suffer from uterine difficulty will almost always suffer from constipation; constipation may depend upon diseases of the nervous system, especially diseases of the brain; in habitual constipation use some mild laxative and pay strict attention to diet and drink then find out the cause and treat accor- dingly; do not use drastics in this case. Diarrhea is often treated with purgatives, diarrhea is only wrong when it becomes excessive, so that in most cases you can en- courage it as in most cases 377 you can encourage it. Rhubarb and Magnesia is an excellent combination in the diarrhea of children in summer time; diarrhea in renal diseases must be en- couraged to stop this in this case is to destroy the patient’s life. If mild purgatives fail to cure a diarrhea you had better resort to astringents but first see that the intestinal tract is free from any offen- ding matter; you can use the compound Chalk and Opium powder, this contains one gr of opium to 40 grs of chalk; combine that with Bismuth and you will have 378 one of the best combinations I know of. Now in fevers we have increased retrograde metamorphosis, that matter must be eliminated and the way to eliminate it is by ^ the intestinal tract, so in fevers never allow the bowels to remain locked, or you will get delirium, coma vigil, and perhaps death. We use cathartics in dropsy as hydragogues; in brain diseases we give cathartics as a revulsive; we use cathartics in diseases of the skin such as Urticaria we give a good saline cathartic; we use Croton Oil in Apoplexy as we 379 want a speedy revulsive effect, if the man cannot swallow just rub your Croton Oil up with the white of an egg, put this on the back of his tongue and it will go down itself. Do not use potash in intestinal diseases use soda or magnesia. We often use Sulphur and molasses, dose from half drachm to two drachms; then again we have the Compound Licorice powder, the German powder is best and is used in piles; in the treatment of piles a tea spoonful of Glycerine in a little water the first thing in the 380 morning is excellent, avoid the use of Aloes in piles un- less in a relaxed condition. Carbonate of Magnesia is a laxative and is used in constipation conjoined with acidity; dose 5 grs to 1 drachm; rub this up in Rhubarb and you have an excellent remedy in the summer diarr- hea of children; in acute diseases due to the acid con- dition of the blood, we often have an excellent remedy in magnesia. Dose of Castor Oil from a tea to a table spoonful. Oftentimes in giving medicine you will have to bear this in mind 381 that the worse it tastes the better they will like it, this depends upon the people you have to deal with; remember this in people who have been under homeopathic treatment and make their medicines palatable. Do not dose a child very heavily, Castor Oil as a rule is mild and certain acting in from 4 to 6 hours it is of benefit in the puerperal state and pregnant women, we often give Castor Oil to encourage the milk it will then often purge the child. Rhubarb, -the root is often used, dose of Fld Extract is 382 is from half a drachm to a drachm; dose of the powder from 3 to 20 grs, we often put it in digestive prepara- tions it increase the flow of bile, the astringent prin- ciple of Rhubarb does not pass out in the milk, but only the purgative principle. Duodenal Catarrh is often well treated with Rhubarb and Phosphate of Soda; the worst agent we can use for habitual constipation is Rhu- barb. Note following pres n _ Rx Powdered Rhubarb ʒ ·/l Bicarbonate of Soda ℈ ··/ll Ipecac Powd gr ··/ll Syrup Simp ʒ ·/vl 383 Wintergreen Water add. This makes 12 doses and is excellent for the summer diarrhea of children, dose one tea spoonful. When you speak of diseases before people use common terms. Aloes is used largely for its action upon the lower bowel, dose from 2 to 20 grs, dose of the Tincture half an ounce; 1 gr of Aloes, 1 gr of Iron and 1 gr of Quinine is an excellent combination. The blood supply of the pelvis is increased by the action of Aloes, hence we sometimes use it in menorrhagia, it will increase the menstrual flow; the 384 time of its action is 12 hours it is eliminated by the glands of the lower bowel; we use it in melancholia, we use it in hemorrhoids after delivery when the blood is in a sluggish condition; it is contra indicated in in- flammation of the intes- tinal tract. Jalap. – Dose of Fl Extract from 5 to 20 grs; dose of the Resin of Jalap from 2 to 5 grs, this is an excellent remedy for children; dose of the Tincture ½ drachm to 2 drachms Compound Jalap powder one part Jalap and two parts Bicarbonate of Potash, dose 385 from 5 to 30 grs, it acts upon the upper portion of the in- testinal tract and is apt to produce vomiting, as it pro- ceeds downwards it produces irritation and tenesmus; time of action, from 2 to 4 hours; its action is local it is not absorbed; the resin of Jalap is tasteless. In fevers where you want to deplete and get a revulsive action use Jalap; in Anasarca it is excellent; in Croup it is often used; it is contra indi- cated in inflammatory con- ditions of the bowels. Another substance is the Confection of Senna, dose from 386 one to two drachms; dose of Fld Extract half an ounce; dose of infusion a tea cupful. We have a combination of the Fld Ex Sennae and Spigeliae, dose one tea spoonful and if you will add to that a grain or two of Santonine you have an excellent combination for the treatment of lumbricoid worms; this causes flatulence and griping so be careful in giving it to nursing mo- thers,it acts in from 4 to 6 hours. The Confection of Senna is used in constipation, hemorrhoids, and fissure of the anus. Saline Purgatives. They are 387 the salts of the Alkalies and Alkaline Earths. They move the bowels without any unpleasant symptoms, they are cathartic refrigerants, if they do not act upon the intestinal tract they act upon the skin or kidneys; a Saline never acts by its lo- cal effect; we use them in acute inflammations be- cause they act without un- pleasant feelings; we use them in sthenic fevers, we use them in renal dropsy they are cooling and non ir- ritating, they produce no unpleasant effect upon the heart. We use them in 388 oedema of the brain, we often use them in faecal impaction we can moisten the impaction by a good dose of Rochelle Salts. In Lead Colic or Dysentery they are excellent. Dose of Sulphate of Magnesia from ½ ounce to 1 ounce: Ro- chelle Salts the same; then there is the Seidlitz Powder. Always give your Salines on an empty stomach and well diluted, they may take from half an hour to two hours to act. Drastics. Scammony, Gam- boge, Croton Oil, Elaterium, Colocynth &c. Elaterium is a very excellent 389 remedy for one or two uses. Dose of the Resin of Scammony from 5 to 10 grs, it is almost always used in combination; dose of Colocynth the same. Compound Cathartic pill, from 1 to 3 grs this acts upon all portions of the intestinal tract, Gamboge forms 1/10 part of this pill and that is the only use it has in the Materia Medica. The active principle of Colocynth is Colocynthine. We have what is known as Podophylin or May Apple, dose of the Resin from ¼ gr to 1 gr it has a little action upon the liver and moves the bowel 390 gently; this is an irritant and should be well cut with the Sugar of Milk; whenever you give Podophylin prepare your own pills; it is a chologogue increasing the flow of bile and the intesti nal secretions; when you use it with Belladonna you obviate all possible tendency to griping. Now Elaterium; this is the juice of the Squirting Cucumber, dose from 1 to 20 grs it increases the secretion of the liver and all along the intestinal tract; it is a mild and gentle cathartic but always follow it by some 391 Saline; or another combination is this. Rx Calomel gr Xll Rhubarb Powd gr XX Aromatic Powd gr V Mist et div Chart IV One powder every 2 hours until the bowels more freely, usually 2 and sometimes 4 powders are required, in young children give 1 gr of it rubbed up with Sugar of Milk until the bowels more. I now want to call your attention to Expectorants; these are medicines which promote or modify the secretions from the mucus 392 membrane of the respiratory tract, I want you to study their action. In perfect health a man should cough or expectorate but very little if any; if you could look at the bronchial membrane at the outset of a cough, we should find the membrane dried up; after this stage of dryness we have an inflamed condition and the secretion is poured out, there is then too much secretion, as this however becomes purulent and free the patient feels better and begins to improve as it is thrown off. The first change is in the 393 quantity and quality of the secretion, next the secretion is increased, and thirdly the secretion becomes viscid; now you cannot treat these stages all alike. Whenever you have a cough it is generally caused by some foreign body in the bronchial tubes; if you use Opium and check the secretion you do harm; when there is irritation along the bronchial tubes nature gets up a profuse secretion, which prevents the air from getting at the surface and causing irritation. Now some of the causes of a cough: diseases of the fauces 394 or larynx, a slight difficulty in the larynx will produce a fit of coughing which will last for some time; we may have a cough due to tubercular matter in the lung substance itself, an ever present source of irritation; we have a cough due to pleurisy caused by reflex irritation; we have heart coughs as in Mitral regurgitation, when the blood is damned back upon the lungs, in this case the expectoration is a mucus secretion, in such cases give a heart tonic in pleurisy you can give Opium and relieve the pain, if you have an irritation in 395 the bronchial tubes you would not give Opium, or you would drown the patient in his own secretion. We may have nervous coughs, stomach coughs, uterine coughs caused by reflex action. Learn first the causes of the cough, then treat the cause and you will remove the cough. Now a good many will sleep all night and then have a fit of coughing in the morning, you will find that such people generally sleep with their mouth open; in such a case you would give something that would promote secretion, if there is a large 396 amount to be raised you give an expectorant; now the danger in bronchitis is that the patient may be worn out from the loss of sleep caused by coughing and then they maybe drowned in the secretion of the bronchial tubes. Sometimes in bronchitis we have a great deal of coughing with but little expectoration, this shows there is but little secretion in the bronchial tubes; you can then give 1/24 gr of Morphia and 5 or 10 drops of Wine of Antimony you give just enough Morphia to allay the irritation, and the Antimony to help the 397 secretions; or you can use a little Dover’s powder instead of Morphia. Now the contra indications for the use of Opium. Whenever you have a copious secretion in the bronchial tubes never give Opium, in such a case you want stimulants to aid in getting rid of this material; give such as Carbonate of Ammonia to help raise the matter. Now the difference of treating Bronchitis. If you have an inflamed bronchial tube you cannot let it rest for one moment, it is in constant action and hence a difficulty 398 arises in treating pulmonary diseases. Now in Laryngitis if you perform tracheotomy it will get well in a day or two; in unilateral diseases we can often strap the side and thus give it rest, but in Bronchitis we cannot do that. Now as to the temperature, this influences very much the character of the secretions; if the skin acts freely the secretion will not be so profuse. Now as to the subject of mouth breathing; on a cold day we ought never to breathe through our mouth, children should not be allowed to sleep with their mouth 399 open, instruct the mothers as to this. Now how will you treat this Bronchitis? When you take cold try to flood the blood out to the cutaneous surfaces; if there is elevation of temperature try to depress it. If you see a cold at the outset give them diaphoretics and put them to bed, give them a Dover’s powder with hot drinks and in nine cases out of ten that will cure their bronchitis. If when you are called you find the skin dry, the first thing you do is to relax that skin; if the bowels are loaded 400 give a purgative, give Calomel; if there is a cough with little expectoration, give Morphia with Antimony; you must relax that skin or you will have your Bronchitis last for days and weeks; use relaxing stimulants in the first stage, and stimulating expectorants in the second stage; when you have a dry hard cough do not think of a stimulating expectorant. Note list given for medicine case for country practice. Tinct of Aconite “ “ Nux Vomica “ “ Digitalis Fld Ex. Belladonna 401 Fld. Ex of Ergot Monsels Solution Fluid Dover Powder m ·/l for gr ·/l Soluble Ammonia Carb Pill Morphia Sulph aa gr 1/8 Pill Cathartic Comp Vegetable Gallic Acid Chlorodyne Powders Apomorphia aa gr 1/8 Ipecac aa gr xx Calomel aa gr x Sugar of Milk ““ gr ···/lll Croup Powders Turpeth Mineral Zinc Sulphate gr aa gr v ~ Now as to the affections of the air tubes; in the acute 402 affections poultices are excellent the best is Linseed Meal; if it be in an adult with sluggish skin, face it with mustard; if it be in a child use two tea spoonfuls of mustard to 15 of Linseed meal. Poultices stimulate the right ventricle. The danger in Bronchitis at the extremes of life, is from exhaustion and from stimulants especially Opium; not from Alcohol. If the cough is a tight nervous cough you may use your opium. Now as to expectorants; they achieve two objects they loosen the secretion and aid in expectoration; in the first stage 403 the indication is to relax the vascular system in bronchitis, such agents then as Gartar Emetic, Epicac, Potassium Hydrate &c; and these agents by a mild counter irritant, use a little Croton Oil paint, Now here is a general rule; never give stimulating stimulants until the skin is moist and the phlegm loose; give relaxing expectorants as long as the skin is dry and the phlegm tough; when we have free secretions you can use your Squills, Senega, Carbonate f Ammonia &c, but never use these in the first stage. In the second stage you 404 use your stimulants, milk punch, Egg nog, beef tea &c. In old people you must sustain them through every attack; bronchitis in an old man of 75 is worse than pneumonia in a young man of 35 years, bear that in mind. Medicinal Agents. Squills, Senaga with a little Chloroform and one of the mineral acids. If there is a danger of failure of heart give Carbonate of Ammonia with Digitalis. In convalescence use the best stimulants you can get. If in an adult somewhat feeble give Carbonate 405 of Ammonia, give the Iodide of Ammonia; I do not know of any remedy so well adapted as the Iodide of Ammonium with a bitter tincture; in the latter stages of pneumonia or Bronchitis you can if you desire add to this Carbonate of Ammonia. If there is anaemia present give Citrate of Ammonia of Iron. Now as to chronic bronchitis; this often depends upon rheumatism, treat it then with Salicylate of Soda; if it depend upon anaemia treat it with iron; do not treat your bronchitis but treat the 406 cause with Tonics, good food, Cod Liver Oil, Iron, out door exercise &c; you may sometimes find it will yield to Digitalis. Bronchitis with Emphysema; Digitalis will almost always relieve there; in Bronchitis with spasm of the muscles use Bromide with Belladonna, sometimes you can relieve that spasm by Gobelia if you use it cautiously. Expectorants liquify the matter to be brought up, in some cases they act by increasing the secretion when deficient, in other cases they act by diminishing the 407 secretion; during the use of expectorants keep a due amount of warmth to the skin; if you chill the surface you get a coriza; during the use of expectorants avoid the determination of the secretions to the urinary organs; the effect of almost every expectorant is transient. Classification of Expectorants is divided under the head of Nauseating and Stimulating. Under the first head, Tartar Emetic, Ipecac, Lobelia, Iodide of Potash, warmth and steam. Ipecac is the only one you ought to use with children; Lobelia only use when the 408 malady is associated with spasm; Tartar Emetic should only be used in strong healthy persons. Ammonium Chloride, this is a stimulating expectorant and is given after the first stage has passed, always give it in ice cold water; do not try to cover up the taste with Syrups. Senega, this is the most stimulating of its class, it should be used in the second stage. Balsam of Tolu; Squills. The only trouble with these is that they are apt to produce diuresis. The Syrup of Squills and Carbonate 409 of Ammonia are incompatible, if you combine them you get an acid. Now as to the combination of expectorants, you can give them with licorice, syrups or glycerine. Ipecac may be given alone but it may be combined with demulcents; Senega you can combine with Antimony. With pneumonia remember you have a self limited disease. Alteratives. These are medicines which remove disease without revealing their mode of action. In their effects and modes of action they differ; their 410 mode of influence is unknown all that we know of alteratives are empyrical facts; they affect the solids and the fluids; it is absurd to deny the value of this class of remedies. We will take up Mercury, we have the ointments; we have Hydrargrum Conertia dose ½ gr to 10 grs; pills of Mercury, Blue Mass dose 5 to 15 grs follow this with a Saline; Yellow Sulphate of Mercury dose 2 to 5 grs; Corrosive Sublimate dose 1/30 to 1/10 of gr; Mild Chloride of Mercury dose 1/20 gr to 20 grs; Green Iodide 1/6 gr to 1 gr; Red Iodide 1/30 to 1/10 of gr; then 411 we have the Liquid Nitrate of Mercury, it is never used internally it is excellent for the removal of Syphilitic growths; then we have the mild Citrine Ointment write for the mild ointment, then we have the Oleate of Mercury this is excellent for external application. Now for Corrosive Sublimate poisoning, use the white of eggs, milk &c; the Acid Nitrate is powerful poison; Metallic Mercury has no action only by its weight as in catharsis. The vapor of Mercury is absorbed by the skin and leads to Mercurial poisoning 412 Small doses of Mercury become tonic to the blood, but I do not think it ought to be used as a tonic; it has a peculiarly selective action upon the lymphatic glands, especially the salivary glands but it leads quickly to a pathological product; it is eliminated by every gland in the body and Iodide of Potassium hastens its elimination. Now as to the therapy of Mercury. In Syphilis with a hard chancre and an affecting sore, always begin at once with Mercury push your Mercury until you just get its constitutional 413 effects; it is not indicated in soft chancre. Do not salivate your patient but watch him carefully and keep him within that point, use your mercury carefully and you will not get any unpleasant results. Now in a child born with Syphilis there is nothing that will take the place of Mercury; use the mercurial Ointment or give small doses of the grey powder. In eyeritis use Mercury. In true croup, Yellow Sulphate of Mercury; in the treatment of diarrhea, the Bichloride of Mercury 1/10 gr every hour. 414 Ringer gives some of the best points in the management of the diarrhea of children of anyone that I know of. You can introduce the Mercury into the system by the stomach and inunction; we use it by fumigation preparations of Calomel are the best here; the quantity of Calomel burned should be from 8 to 15 grs, the patient to remain in the box for 15 minutes. Now let me give you briefly the best treatment for Syphilis. Use Mercury in the primary affecting sores use it for the affections of the skin; 415 wherever you have maculate and papillar erruption. Use the Iodide of Potassium in the tertiary stage, you can combine Mercury and the Iodide of Potassium. We will now pass to the Iodine and Iodide of Potassium. Compound Tincture of Iodine is used much in Malaria the chronic form; dose 10 to 15 drops give it after dinner. We have Ammonium Iodide, an excellent preparation we have what is known as the colorless Tincture of Iodine, this leaves no color on the skin you can use this with females, the color 416 is destroyed by the Sulphite of Soda. Physiological action: it is an anti speptic and a disinfectant; the Tincture of Iodine is an excellent counter irritant; the vapor is irritant to the bronchial tubes and must therefore be given largely diluted; it is used in malarial diseases where there is glandular enlargement. Now the Therapy of Iodine. It is a counter irritant where we have swollen glands, chronic abcess, swollen joints, in chronic pleurisy, emphysema &c. 417 Iodide of Potossium. This belongs to the same class of Alteratives it is very diffusible ten minutes after it has been taken you can detect it in the urine; on the brain it has no special action it has no effect upon the respiration or temperature, it effects in the main the secretions; upon the salivary glands there is marked increase of secretion, on the urine no marked action; we use this to remove metals from the system, we can remove almost any metal from the system by Iodide of Potassium. 418 On the mucus membranes it is an irritant locally; it produces a free secretion of the catarrhal secretions generally. We use it about the mouth and throat, in brain diseases of Syphilitic origin, there is nothing like it for brain tumors. We use it in hepatic diseases; aortic aneurism, be careful in treating aneurism of the aorta you do not produce disease of the kidneys; we use it in catarrh; spasmodic asthma; and in chronic bronchitis Iodide of Ammonia; in Scrofula Iodide of Ammonia with Cod Liver Oil. 419 Always be a little careful of the use of Iodide of Potassium in the treatment of nervous diseases, be careful of the kidneys. In chronic rheumatism with a tendency to periostitis use Iodide of Potassium. Finis ~ Med. Hist. MS. B 110 Book taken apart. Leaves deacidified with mythyl magnesium carbonate. Folds & leaves mended as necessary. Resewed with new end paper signatures & unbleached linen hinges. Rebound in cloth. Sky Meadow Bindery April 1986