EP IBM A BRIEF TREATISE THERAPEUTICS J/MILNER FOTHERGILL, M.D., M.R.C.P. Edited for the U. S. Pharmacopeia WM. H. ROUSE, M. D., PH. C. With the addition of Chapters on DIET FOR THE SICK, By Mrs. Emma Draxt, Matron of the Michigan Medicine Hospital, Detroit. ^ Ai. '77^-Y SEP DETROIT: The Illustrated Medical, Journal Co. Copyrighted 1884. ?i The Illustrated Medical Journal Company's OTHEK PUBLICATIONS.* LEONARDS PHYSICIAN'S POCKET DAY-BOOK- Accommodates charges for 50 patients daily for 13 months, besides other entries. Bound in maroon Russia, flap and pocket. Price, $1.00. LEONARD'S AUSCULTATION, PERCUSSION and URINALYSIS; an Epitome of the Physical Signs in Health and Disease, of the Heart, Lungs, Liver, Kidneys and Spleen. Cloth: 160 pages, hi Illustra- tions. Price, $1.00. LEONARD'S DOSE BOOK— Contains doses of more remedies than any otber Dose Book issued. Some 40,000 sold. Price, Cloth, 75c. Dose Book and Anatomist combined— Cloth, over 300 pages— $1.00. 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Price, two books, $2.50. CODES OF MEDICAL ETHICS.— Gives the Codes of I the three schools of practice. Price, Paper, 25c. GLAZIERS TRICHINAE AND TRICHINOSIS.— A brief though full history of the growth and symp- toms of the disease from this dread parasite. 17 Illustrations. Price, Paper, 25c. DISEASES OF THE NASAL CAVITY AND PHAR- YNX.— Translated from the German of Michel, by Prof. Yemans. This book has been highly com- mended by the press. Price, Octavo, Paper, rl.00. *** Full Descriptive Circulars free on application, or any of the above sent post-paid on receipt of price by the publishers. THE ILLUSTRATED MEDICAL JOURNAL CO., Detroit, Mich. ^F°Sold by all Medical Booksellers. A BRIEF TREATISE THERAPEUTICS BY J. MILNEB, FOTHERGILL, M. D., M. R. C. P. INTRODUCTION. HOW TO CONSTRUCT A PRESCRIPTION. The student, when brought in contact with disease single-handed and alone, is often sorely puzzled to tell what to prescribe, and how to go about it. He may have heard lec- tures on the practice of physic, and been told that constipation may be treated by vegetable and mineral purgatives; but how to combine them, and in what doses to give them, he is unable to decide. Or he may have heard Materia Medica lectures, and been told that iron is indicated in anaemia; but he is far from seeing his way to prescribe it satisfac- torily. Suppose the case is that of a pallid man, with constipated bowels : the first thing to be done is to select a suitable laxative, say sulphate of magnesia. Now comes the dose. As it is to be taken several times a day, the dose must be much less than when given in one dose, as a purgative. For the latter, the average dose is %i; but as a laxative it will be found that £j. is usually quite sufficient three times a day. Then there is the anaemia INTRODUCTION. to be considered. For this the old tincture of the muriate of iron is well adapted, in a dose of ten drops at a time. We have now got the main elements of the prescription together, viz. : Magnesium Sulphate, gj., and Tine. Fer. Mur. tti,x. But in all probability this mixture will gripe the patient more or less unless it be given with some warm agent or carminative. Consequently, then, the vehicle in which the essential factors are to be taken is a not unimportant matter. If the appetite be good, then mint water may be selected. The complete prescription would then stand: Magnesium Sulphate, 3 j. Tincture of Iron, tijjx. Mint water, \ i. Three times a day. But if, as is very likely, the appetite is defective., it is well to select a vegetable bit- ter as the vehicle. As many of these vege- table bitters contain tannin, they do not go well with iron, giving an inky color to the mix- ture, and so rendering it repulsive to the eye. And medicine is not usually very attractive at the best; so it need not be made more ob- jectionable than is absolutely unavoidable. So the bitter selected may be infusion of quassia. But quassia is not carminative, so it is well to add either tincture of ginger or of capsicum. The prescription would then stand : Magnesium Sulphate, 3 j. Tincture of Iron, hex. Tincture of Ginger, 3 j. Or Tincture of Capsicum, njliv. Infusion of Quassia, $ i. Three times a day. Or the patient has a cold, with some bron- chial inflammation present. Then the line HOW TO CONSTRUCT A PRESCRIPTION. 5 would go in this direction : First we require an agent which will make the action of coughing more efficient, while it also acts upon the bronchial lining membrane, making the secretion more free, and thus causing the phlegm to be more easily dislodged. Such an agent we find in ipecacuan. Say, then, ipecacuan wine fifteen minims. Then, in all febrile conditions, it is well to excite the action of the skin. For this end the acetate of ammonia is indicated. As I do not intend to confine myself to prescriptions in English, but shall use Latin ones at times, for the bet- ter education of the reader, so as to familiar- ize him with both, this will stand: Liq. A mm. Acetat., §i. Vini Ipecacuan, TTgxv. 6ta quaque hora. Or the patient is recovering from some acute disease, as typhoid fever, or pneumo- nia, and the tongue is not quite clean, and the appetite not active. Here a mineral acid is indicated, as phosphoric, for instance; in a vegetable infusion which need not be free from tannin, as iron is not to be in this mixture. Consequently the prescription will stand thus : Dilute Phosphoric Acid, TTfixv. Infusion of Cinchona, $ i- Thrice daily. Under this combination probably the tongue will clean and the appetite improve. Then it is well for the student not to forget that acids and alkalies do not go together, but combine, a fact not always remembered by young practitioners. Thus, for instance, in dyspepsia with much acidity, it would not do to write the following prescription : Sodse Bicarb., 3ss. Liq. Strychnice, nuiv. Inf. Gentian, ?i. 6 INTRODUCTION. The strychnine being dissolved in an acid medium, hydrochloric acid, would be thrown down in an alkaline mixture, with this result, the strychnine would be at the bottom of the mixture, and consequently the patient would get none of it ; till he came to the last dose, and then he might get more at once than was quite agreeable. In such cases the Galenical preparation must be chosen, the Tincture of Nux Vomica, The prescription then ought to stand : Sodae Bicarb., 3ss. Tinct. Nucis Vom., npx. Inf. Gentian, |i. Ter in die. To give iron with a vegetable bitter con- taining tannin is a very common error, pro- ducing a repulsive looking fluid. But this avoidance of incompatibles went to an unde- sirable length, when it decided that digitalis could not be combined with tincture of iron. In cases of heart weakness the following is an excellent combination : Tinct. Digitalis, llflx. Tinct. Ferri. Mur., njjx. Sp. Chloroform, nf>xx. Inf. Quassiae, f i. Ter in die. Spirit of Chloroform is pleasant to the taste, and can often be added to mixtures with ad- vantage ; it is also a stimulant. Or a patient may have constipation, with a foul tongue and a bad taste in the mouth. Here the fur, which consists of dead epithe- lium cells which are not properly shed, is usually stained by the bitter bile acids or their salts, so it is well to give a laxative which will also contain an ingredient which will act upon the liver, as mercury, for in- stance. The combination would then stand thus: INDICATIONS FOR TREATMENT. Pil. Hydrarg., gr. i. Pil. Col. Co., gr. iii. To be taken at bed-time. If the bowels are not freely opened, then a seidlitz powder, or an ounce of "black draught " in some warm water next morning. Morning laxatives should always be taken warm By so doing their action is more rapid, and the bowels are less apt to tease the patient during the course of the day, which is often very inconvenient. These minor matters are usually worth attention. INDICATIONS FOR TREATMENT. After making a diagnosis as to what is the matter with a patient, the next thing to be done is, to determine what is the lead- ing indication for treatment. The patient may be suffering acute pain, as in colic. Here the pain is at times excruciating and must be relieved. For this end opium stands facile princeps. "Mash Allah" (the Gift of God) is stamped on the cakes of opium by the Orientals. Then, as the colic is due to violent spasm of the muscular fibre of the intestine, it is well to give the opium with a carminative, as mint water, for instance, which will make a convenient vehicle. Then the pain is very depressing, as all pain is in which the abdominal portion of the sympathetic nerve is involved, and therefore a diffusible stimulant, acting rap- idly, is desirable. Such an agent we possess in carbonate of ammonia, of which sal vola- tile is a preparation. It would be well, then, to let the prescription stand: Tinct. Opii, 3 ss. Sal Volatile, 3 i. Aq. Menth. Pip., |i. Statim. INTRODUCTION. In these cases of severe depressing pain, a full dose of opium at once is in every way better than repeated small doses. (A word of caution as to dose. Children are very sus- ceptible to opium, and small doses often act very potently upon them. All agents which "depress " nerve action as part of their effect, are to be given with caution to children.) In many cases of colic the only thing at hand may be some laudanum and some spirits. It would then be well to give the laudanum, with two ounces of any spirit. In any case of colic, it is well to put cloths wrung out of hot water, and freely sprinkled with turpen- tine, upon the abdomen until relief is attained. Or the patient may be in a fit. Here really little can be done except to see that the patient does not do himself or herself any injury, if convulsed. In epilepsy, to loosen the collar and free the neck is indicated; and if the tongue is being bitten, put a piece of soft wood or a cork, betwixt the teeth to prevent the tongue being nipped. If a young woman, and especially screaming, it is probably hysteria, and then a jugful of cold water dashed over the head and face is effective, or a hand may be placed over the nose and mouth till the performance is arrested, and converted into a struggle to breathe. If it is pure syncope, it is well to allow the patient to remain in the recumbent posture until spontaneous efforts are made by the patient. In syncope there is temporary failure of the heart's action, and it is not desirable to re- move the patient from the horizontal posture, until there is evidence of the circulation being restored. If the patient be not in the horizontal posture when the faint comes on, she should at once be laid flat. INDICATIONS FOR TREATMENT. Or the patient may be bleeding profusely. Here it is desirable to put pressure on the vessels from which the blood flows. If from an artery, the pressure must be be- tween the heart and the bleeding orifice; if a vein, at the distal end of the limb ; if hae- moptysis, or haematemesis, keep the patient absolutely still under all circumstances. And now let me tell the youthful reader what he must not do. He must not give a stimulant if the patient faint. Here syncope is nature's mode of arresting the haemorr- hage; and though it may appear to indicate a supine and indifferent attitude, it is not wise to interfere with the syncope. To give a stimulant is to excite the heart's action, rouse the circulation, and restore the haemorr- hage. But so carry yourself that the alarmed bystanders shall recognize the fact that your inactivity is not the consequence of ignorance and indifference, but of greater knowledge than they possess. In their good intentions, persons guided by impulse, combined with ignorance, may become murderers. Or a patient may be suffering from great excitement, from brain disturbance, or from being mentally upset. Here a calm, self- possessed manner and bearing are of the greatest service, but medicine may be useful. Here a sedative is indicated, as chloral hy- drate, or bromide of potassium — alone or combined, and they may be given in what is termed a calmative, as camphor mixture, for instance. The prescription would stand : Chloral Hydrate, 3 ss. Potass. Bromid., 3 ss. Mist. Camphorse, I i. If required, this must be repeated in three or four hours. All depressant drugs are to be 10 INTRODUCTION. given with care and prudence, and the action of opium, chloral, and bromide of potassium will be contrasted in a subsequent chapter. Or the patient may be suffering from dysp- noea — the respiratory efforts being very laborious. Here it is well to give rapidly diffusible stimulants, which act promptly on the centres of the circulation and the respira- tion. Such agents we possess in ammonia, belladonna, and strychnia, while digitalis acts powerfully upon the heart. It will be well to prescribe in severe dj^spncea either : Amm. Carb., gr. v. Sp. Chloroform, Tlpxx. Liq. Atropise Sulph., Tip. Aq., Ji to be repeated in two or three hours; or if the right ventricle be failing, the prescription would be : Am. Carb., gr. v. Tinct. Nuc. Vom., ltpx. Tinct. Digitalis, ttex. Aq. Menth. Pip., § j. also to be repeated if necessary. Or if the reader be very inexperienced, and not famil- iar with modern therapeutical research, he might take a lower but safer (i. e. as regards public opinion, but not as regards the pa- tient's life) standing ground, and prescribe: Sal Volatile, 3 i. Sp. Chloroform, 3 ss. Aq., Si 4ta quaque hora. Where there is acute indigestion, it is well to empty the stomach by administering an emetic, as sulphate of zinc (jss), or ipecacuan wine (an ounce); or if these be not at hand, some mustard and hot water, or tickle the fauces with a finger until vomiting is induced. The same holds good of acute alcoholism. In all emergencies keep as cool as possible, and do not act hurriedly or excitedly, or you may do the wrong thing and defeat your aim. Then there is the question of the local measures to be employed. Heat is almost always soothing, except in headache, where cold applications give more relief. Cold water and vinegar, and eau de cologne, where practicable, are good measures for headaches. In dyspnoea, where the. right side of the heart is embarrassed, it is well to put hot poul- tices to the front of the chest; the heat stim- ulates the heart. In local abscesses a hot poultice is soothing. The case may be one of a broken rib, where a jagged end is rub- bing the lung-pleura at every respiratory act; here the most efficient local measure is to put the parts at rest, or as near as is attainable, by strapping or banding. In that form of pleurisy where a small nodule of tubercle, protruding from the lung, rubs on the costal pleura, and excites local inflammation and pain, then putting the part at rest by strap- ping gives the patient relief. Or there is a severe bruise causing much pain. Here soothing applications, as a piece of folded flannel, wrung out of hot water, and freely sprinkled with laudanum, or a poultice of poppy heads, are good measures to adopt. If a sprained joint is very painful, it may be swathed in bandages soaked with cold water, or cold water allowed to drop on the ban- WHAT TO AIM AT. When called in to see a patient, the stu- dent must expect to find the person acutely ill, or thought to be so by those around — relations, friends, or neighbors. The first thing to determine is, which is the case. It is not always easy to do this. How 12 INTRODUCTION. to determine which of the two is the case calls out the extent of the practitioner's knowledge, and tests the attention he — whether a young or an advanced student — has paid to the instruction of his clinical teacher. If the pulse, respirations, and temperature all be over the normal, then organic mischief of an acute character is usually afoot. On the other hand, there may be collapse or rup- ture of an internal blood-vessel without any of these. When so called in, do not rush at the patient with a stethoscope, but find out something about the individual, and then proceed to the disease and its amount. It is quite as important to know something of the patient generally, as it is to determine the extent of a pneumonia, for instance. You are going to treat the patient rather than the disease. You are going to influence the mor- bid process in the individual. Above all things, keep your head clear and cool, and so give your knowledge, be the same more or less, a fair chance to exhibit itself. First give relief to the patient; then relieve the minds of the friends. Make as good an im- pression as you possibly can, in order to acquire the confidence of the patient and the patient's friends, so that they will follow your instructions implicitly. The success of your plan of treatment will usually turn on the thoroughness with which it is carried out, and if you do not secure the confidence of the patient's friends, j-ou may be pretty certain that they will not follow your instruc- tions. Never be oblivious of the fact, nor be too acutely conscious of it, that the friends are examining you while you are examining the patient. Bear yourself accordingly, and it is better to err, if err you must, on the side of ASSIMILATION AND EXCRETION. 13 excessive care in your examination. Youth is apt to be self-confident, and it is very easy to make a mistake, even when years have rolled over the practitioner's head and taught him caution by a painful experience. Be not flip- pant then, and carried away with the impres- sion that you have arrived at your diagno- sis by some inspiration. Be painstaking in your examination, and thoughtful in your plan of treatment. CHAPTER II. ASSIMILATION AND EXCRETION. It is very important for success in treat- ment that the student have some good broad views as to assimilation and excretion, for, after all, sound physiological knowledge is the basis of the practice of physic. Let us consider digestion first. Digestion is essential- ly a process of solution. Our food is stored up in io soluble forms, else a steady rain might imperil much of animal life. Starch, then, is converted into sugar by a process of hydra- tion (that is, the adding of a molecule of water) under the influence of the ferments of the saliva. This sugar, being soluble, is absorbed from the alimentary canal into the blood, and then reconverted back in the liver into glycogen, or animal starch, by the re- moval of a molecule of water. This glyco- gen is given off as required into the blood as sugar, and is burnt by oxidation, and is largely the fuel-food of the body. Then the tissue-food, which is albuminous, whether as albumen, fibrin, casein, or legu- min, is digested by the gastric juice with its ferment, pepsin, and is also dissolved by a 14 ASSIMILATION AND EXCRETION. process of hydration, in which the highly- insoluble "proteid" is converted into the highly soluble "peptone," which readily passes through the wall of the alimentary canal into the blood. Here it is again passed back into a "proteid" by the removal of a molecule of water; without such change the peptone would as easily escape out of the blood as it passed into it. From these albu- minoids the tissues are made in growth, and repaired in adult life. Fat is saponified to some extent by the bile, emulsionised by the secretion of the pancreas, so that it is taken up by the lacteals of the intestinal villi, and thus is brought into the system. Fat is not only fuel-food, but is essential to the formation of healthy tissues. But for solution "disintegration" is essen- tial. Before either starch or albuminoids can be dissolved by hydration, they must be finely divided or disintegrated. For this end our teeth are provided. The food taken into the mouth is masticated, rolled about by the tongue, and mixed with the saliva, so that the starch is converted into sugar. This action of the saliva ferment, or diastase, is arrested as soon as the contents of the stomach become acid. Can we do anything to aid this part of the digestive act when imperfect? Sialogogues, or agents which increase the flow of saliva, are not a very important class of therapeutic agents. All tasty or sapid substances excite a flow of saliva, but the medicinal sialogogues are not many. Pellitory, jaborandi, and mercury are all sialogogues, but are not used as such to excite the flow of saliva for the conversion of starch into sugar. For this end we use artificial diastase, or maltine, produced in ASSIMILATION AND EXCRETION. 15 malting barley. This ferment, diastase, con- verts the starch into sugar. And is now large- ly used in the feeding of delicate children. It should be added to the milk and gruel be- fore it is taken into the mouth, not given after a meal, to be at once killed by the acid contents of the stomach. Then as to the digestion of albuminoids. Such forms of albuminoid matter as fall readily to pieces in the stomach, are more digestible than those which are disintegrated with difficulty. Thus, loosely-fibred fish, as whiting, is much more digestible than close- fibred beefsteak. Where there is much pain produced by the digestive act, the food, when solid, should be such that it is readily disintegrated. Pastry and closely-fibred meat should be eschewed. False teeth, if neces- sary, patience in the act of mastication, and properly selected food, are the means by which we seek to furnish relief when the mechanical obstruction to the digestive act is the source of trouble. Then as to the solution of albuminoids. We do not always attempt to directly stimu- late the secretion of gastric juice, though many agents will affect that secretion, but now commonly use pepsin procured artificially from the calf or pig. But we may combine these measures. The agents which increase the flow of gastric juice are called stomachics. They increase the vascularity of the stomach and stimulate the flow of gastric juice. Such agents we possess in alcohol and arsenic, each of which produces inflammation of the stomach in toxic doses. Ipecacuan produces this vascularity in small doses, but excites vomiting in large doses. An old dinner pill ran: 16 ASSIMILATION AND EXCRETION. Pulv. Ipecacuan., gr. i. Ext. Cinchonae, gr. i. Pil. Al. et Myrrh, gr. ii. Ringer tells you that an alkali will stimu- late an acid secreting surface, consequently alkalies may be given before meals, thus : Pot. Bicarb., gr. vi. Fowler's Sol., njji. Inf. Gentian, |i. Here is combined the alkali with arsenic in a bitter vehicle. BITTERS. We do not know the action of bitters, but we know well empirically that bitters increase the appetite and improve the digestion. Those containing tannin, as gentian, chiretta, or cinchona, etc., should not be given along with iron, as they form a tannate of iron (ink). Quassia is the bitter to give with iron. Quinine is to be used with iron, and not cin- chona. Then as to the use of artificial pepsin, which can now be procured in various forms. Given immediately after food, pepsin preparations add considerably to the solution of albumi- noids when the gastric juice is defective in quantity or in solvent qualities. Such, then, are the means by which we effect the diges- tion of albuminoids. Then as to fat. Fat, in the forms of fat, oil, and butter, is not acted upon by the saliva, nor yet by the gastric juice. When the contents of the stomach are thrust through the pyloric ring into the gut, they come in contact with the bile, and the bile acids saponify the fat. Oil will not run through filter paper, but when that filter paper has been moistened with bile, the oil passes through the paper readily. A process of sub- BITTERS. 17 division equal to disintegration goes on with fat before the pancreatic secretion emulsion- ises it, so that it can be taken up by the lac- teals. Can we do anything to aid this diges- tion of fats when defective? We can, by seeing that the fat is in a state of fine sub- division before it is eaten. Thus, butter well rubbed into stale bread, cut thin, is much more readily digestible than when spread in a thick layer, a fact never to be forgotten when delicate children are to be dealt with. Then fats vary in digestibility. Cod-liver oil is the most digestible of all fats, and can often be assimilated when the digestive pow- ers are unable to digest other fats. Then come cream or butter, or pig fat; solid mut- ton or beef suet requiring the strongest diges- tive powers. Agents which increase the flow of bile, as ipecacuan, or sulphate of soda, aid materially in the assimilation of fat; the first may be given in pill (see p. 16), the other added to the patient's bitter mixture in gss. doses. Sod. Sulphat., 3 ss. Ac. N. Mur. Dil., TiPvi. Inf. Gent., l\. will often be found a useful combination in simple loss of appetite with impaired diges- tive power. We can also stimulate the pan- creas by the administration of sulphuric ether. The pancreatic secretion not only emulsionises fats, but, in an alkaline medium digests albuminoids, and converts starch into sugar. Consequently we give artificial pan- creatic preparations at the end of the diges- tive act, to aid the defective action of the pancreas, when indicated. 18 ASSIMILATION AND EXCRETION. ARTIFICIAL DIGESTION. The digestion of food out of the body is now readily attained by the use of prepara tions of the pancreas of the pig. Milk and water, or milk-gruel, can be digested by pan- creatic solutions in the proportion of one pint to a teaspoonful of liquor pancreaticus (Wil- liam Koberts), and ten grains of bicarbonate of soda (in solution). Raised to a tempera- ture not exceeding 150° Fahrenheit, the near- er this the better, and put under a " cosey " for an hour, digestion is then nearly com- plete. Such artificially digested food is indi- cated in typhoid fever, gastric catarrh, gas- tric ulcer and cancer, and in all conditions of acute debility, especially when curd from plain milk, is found in the stools. Then assimilation can never be properly carried on if the bowels are loaded. Conse- quently always attend to the bowels. Keep them open by laxative pills as Pil. Col. Co. at bed-time, and, if necessary, a seidlitz powder, purgative waters, Carlsbad salts, or, bet- ter still, sulphate of soda and Rochelle salts (Sod. Pot. Tart.) combined in a warm bitter solution. In delicate persons, in all elderly persons, and in women at the change of life, care must be taken to see that the laxative does not gripe, and this may be done by adding a carminative, as Pulv. Piperis Nig. gr. ii., to the Pil. Col. Co. gr. ii. ; or tincture of ginger to the morning mixture. A glass of cold water first thing in the morning will often suffice to regulate the bowels. Hyos- cyamus is often added to the night pill to relieve griping (gr. i). HAEMATICS. 19 HAEMATICS. Then beyond the assimilation of the differ- ent forms of food, i. e., starch, albuminoids, and fat, comes that of the different salts of lime, soda, potash, and iron. Lime is requi- site for the formation of the bones : the blood salts for health, as anti-scorbutics, and for healthful assimilation, as seen in the effects of the profuse night sweats of phthisis, where the blood salts are drained away, and in the return of the appetite and assimilating power as soon as they are arrested. Lime is given to children chiefly in the form of phos- phate. In malnutrition, lime is largely given in the form of phosphites or hypophosphites. But of all haematics iron stands first. Iron is a tonic when given in full doses, as the old tincture of steel TTtx. to iUxx. As a haematic, it may be indicated in smaller doses. Tinct. Fer. Mur. ; ttex. Inf. Quassise, | i. Ter in die. is a capital tonic. Iron should always, if possible, be taken after food, say half an hour after; it can then be combined with arsenic, strychnine, or quinine. A good tonic pill is this : Strychnias, gr. i. Fer. Sulph. Exsic, 3 ss. Pulv. Pip. Nig., i i. Pil. Al. et Myrrh, 3 ii. In pil. 36 div. i. bis in die. A gentle action on the bowels is always good with a course of chalybeates, especially at the start. When iron causes headache, or a sensation of heat, it is well to give with it a mineral purgative, as Mag. Sulph., 3i. Cit. Fer. Quiniae, gr. v. Inf. Quassise, ? i. Ter in die. 20 ASSIMILATION AND EXCRETION. Then a stimulant form is sometimes indicated, as in certain anaemic cases with amenorrhoea, when the ammonia-citrate is very useful. Or it may be required as an astringent in certain cases, as in atonic diarrhoea, and the per- chloride and pernitrate are both powerful as- tringents. Tinct. Fer. Pernitr.. Itpxv. Inf. Calumbae, § i. 6ta quaque hora, is a good diarrhoea mixture in not very severe cases. The form of iron, as a medicine, which approaches nearest to the form it exists in the blood, is " dialyzcd iron" now sold everywhere. Under a course of iron the blood becomes richer, the face gains color, the patient improves in strength, and is lustier. When the anaemia depends on a specific poison in the blood, iron must be given along with the proper specific, as in gout (potash), in malaria (quinine), in syphilis (mercury), in lead poisoning (iodide of potas- sium;. Certain proportions of soda and potash are required for the blood, and nota- bly common salt (chloride of sodium), as this furnishes the hydrochloric acid for the gastric juice, and the soda for the bile salts. The buffalo will travel hundreds of miles to get salt, and so will certain African tribes. There are, however, conditions where iron is contra-indicated. It should not be given while acute inflammatory conditions are present. When the tongue is bare and denu- ded of epithelium, it is useless, indeed inju- rious, to give iron. When the tongue is laden with a thick fur, a layer of dead epi- thelium cells, indicative of the condition of the intestinal canal, then iron is not absorbed ; and it is useless to prescribe it till the tongue TONICS. is clean. In all conditions of biliary disturb- ance, and where lithates are present in the water, it is well to withhold iron. Water is a haematic in certain circumstan- ces. A draught of water on getting out of bed in the morning bathes the tissues, removes waste material from the body, and is an excellent hygienic measure. When containing a certain proportion of salts it serves this purpose even still more efficiently ; and the many palatable drinking waters now in vogue testify to the widespread conviction of this. Let this be ever borne in mind by the youthful reader that dilution with water in sufficient quantity is a most important matter in courses of alkalies and chalybeat.es. The advantage of mineral springs lies in the great dilution of the essential factor of the spring. The late Dr. Fuller insisted on this matter of dilution, and my experience cor- roborates his in every respect. Say the pa- tient is taking the following mixture : Pot. Bicarb., 3ss. Ferri Amm. Cit.. gr. v. Tinct. Nuc. Vom., TTPx. Inf. Quassiae, 1 i. Ter in die, it will be found that taken half an hour before meals with a tumblerful of water, the results are much more satisfactory than when no rules as to "when" or "how" are laid down or followed. Such a mixture is indi- cated when the acute symptoms of rheumatic fever have abated, and in many forms of atonic rheumatism or gout. TONICS. We are very little wiser as to the modus operandi of tonics than Galen was. A tonic is an agent which gives tone to the system. 22 ASSIMILATION AXD EXCRETION. Quinine, strychnine, and at a long interval, gentian, calumba, and chiretta, are bitter tonics. Cascarilla, cusparia, and chamomile are aromatic tonics agreeable to the stomach. Then the mineral tonics are iron, arsenic and copper, chiefly the two first. In convales- cence, in conditions of debility, and loss of appetite, tonics, and especially the bitter tonics, are indicated. So long as the tongue is furred, it is well to withhold iron, and to give something like this : Quin. Sulph., gr. i. Ac. Phosph. Dil., njixv. Inf. Gentian, ^i. Ter in die. Or, Liq. Strychniae, Tijjiv. Ac. Hydrochloric. Dil., Hflx. Inf. Cascarillae, |i. Ter in die, and to act upon the bowels with the measures described, p. 18. Under the influence of a tonic the appetite improves, the digestion gains vigor, and the patient experiences a sensation of energy dependent upon a feeling of well-being. How far tonics act specially on the centres of the respiration and the cir- culation is not yet definitely known. Proba- bly tonics act on all nerve-centres, some act- ing more on some, others on other centres. EXCRETION. To comprehend excretion correctly, the student must grasp the subject from the point of view of evolution. In the little jelly speck, the amoeba, the tiny particle of food is seen to disappear by a digestive act which entails no special organs. As life advances upward, we find an alimentary canal form- ing, and upon this a liver, etc., become devel- oped. But all organs with ducts are but por- EXCRETION. 23 tions of the general excretory surface ; more specialised areas still possessing the charac- ters of the primitive exterior. Consequently we find that in conditions of jaundice, the bile is not excreted by the bowels, as it is normally, but by the kidneys, for the urine will leave a deep bile stain on the linen; or by the mammary glands, the milk also stain- ing any object with which it comes in contact. In conditions of arrested action of the kidneys we may have, and commonly do have, urae- mic diarrhoea, and even ureous vomiting, while the breath has a urinous odor. "When the action of the kidneys is arrested or defec- tive, other excretory organs take up the work, eliminating the nitrogenised waste. The kidneys are involutions of the skin, and in scarlet fever, when the cuticle is shed, there is very frequently "desquamative ne- phritis." Recent observations have demon- strated that in the presence of urea, uric acid, the phosphates, chlorides, and sulphates of the alkalies, the constituents of sweat, are those of urine. Even carbonic acid, which is usually supposed to be given off by the lungs only, is exhaled from the skin. In the lower animals, cutaneous respiration is in- deed an important matter. The practical utility of remembering the common origin of the excretory organs lies in the fact, that other organs can help out special organs when functionally disabled. Thus in acute nephri- tis, we put the bowels into energetic action with cathartics, and excite the skin by hot baths, till the patient sweats freely, and so relieve the kidneys. Not uncommonly diar- rhoea is a compensating action, not a disease per se. The first patient seriously ill when I took my father's practice, I killed. She was 24 ASSIMILATION AND EXCRETION. the subject of chronic Bright's disease, of which I was not aware, and had severe diar- rhoea, which, after much difficulty, I succeeded in arresting by the usual combinations of astringents and opiates. Bnt instead of im- proving, when the diarrhoea was checked, in a few hours the patient grew worse, and soon went into ursemic coma, which proved quickly fatal, the breath producing grand crystals of hydrochlorate of ammonia on a microscopic slide moistened with dilute hy- drochloric acid. I fully realized what I had done, and was very sorry for the poor far- mer whose wife was thus removed, but my regret did not and could not restore to him his wife, however much I might take the matter to heart. But the lesson it taught me will never be forgotten, and the avowal of it here may put many a student on his guard in similar cases. Since then I have made it a rule, in all cases of diarrhoea where there is any suspicion of kidney mischief, not to attempt to check the diarrhoea, except by food, until the other excretory actions are set agoing. Chronic skin affections of a gouty character are very common in chronic renal disease, and are curable only by measures which strike at the casual disturbance, name- ly, accumulation of nitrogenised waste in the blood. This nitrogenised waste may take the form of either bile acids or uric solids, and either circulating in the blood gives rise to much disturbance. Very many of the maladies met in practice are not associated with lesions readily recognizable in the dead-house, and of these the troubles associated with excess of waste form a large proportion. For the EXCRETION. 25 treatment of these maladies we use a class of agents called alteratives. ALTERATIVES. "These may, perhaps, neither stimulate nor depress, so far as can be perceived, any function of the body; their action may be silent and imperceptible, their mode of influ- ence may be unknown, but their therapeutic effects are among the most assured of clinical facts." (H. C. Wood). So far experimenta- tion has thrown little light upon these agents, but clinical experience is rich as to their utility. Mercury is a powerful alterative, especially useful when the retrogade changes in albuminoids are not going on satisfactorily. It seems t© facilitate the oxidising processes requisite for their -removal. Arsenic acts upon all the excretory organs, and is a power- ful alterative of a tonic character, often most useful in cases of malnutrition with consoli- dation of one or other lung apex. The use of arsenic by the Styrians to give them good "wind" and a ruddy countenance is well known. Then iodide of potassium is a favor- ite alterative. "Donovan's solution," a com bination of iodine, mercury, and arsenic, is a powerful alterative, not as much used as it might be. Then in many cases the alkalies are very useful in the removal of excremen- titious nitrogenised material. The value of mercury as an alterative is vividly shown in the following case, very common in practice. A person has a foul-coated tongue, a bitter taste in the mouth, and general malaise, with more or less headache. Vegetable purgatives are taken until free purgation is induced. Yet the condition is little relieved, if at all. A mercurial pill is prescribed at bed-time. 26 ASSIMILATION AND EXCRETION. and an alkaline saline purgative in the morn- ing; and, presto, the tongue cleans and all the unpleasant sensations pass away with the bile laden stools so induced. This is a subject which attracts very little attention in hospi- tals, and especially teaching hospitals; but it is one of considerable importance in daily practice. An alterative is an agent which is given off by the different excretory sur- faces, and probably stimulates their activity, and so alters the condition of the system. " To deny the existence or value of medicines of this class because we cannot tell why mer- cury relieves syphilis, or why iodide of potas- sium cures rheumatism, is as absurd as to deny the existence of the syphilitic or rheu- matic dyscrasia, because we do not know their ultimate nature." (H. C. Wood). As to how to use these alteratives, a few illus- trations may be given. Thus in rheumatic pains it may be well to prescribe Pot. Iod., grs. v. Pot. Bicarb., 3ss. Inf.'Buchu, 5i. Ter in die. If there be any deposits in the urine, it may be well to give Pil. Cal. Col. Co. gr. iv. every second night. Or in a case of chronic syphilis Liq. Hyd. Bichlor., 3 i. Tinct. Fer. Mur., Tlftx. Inf. Quassise, § i. would be a good prescription. Iron given along with mercury prevents the cachexia which large doses of mercury taken contin- uously are apt to produce. And it is a most important matter to remember in the treat- ment of constitutional syphilis, that iron ad- ministered with mercury obviates the ill effects which the mercury alone is apt to produce. EXCRETION. 27 Or a person is suffering from a chronic con- dition of imperfect health, as, for instance, a girl at puberty, who is pale and listless, and "good for nothing," and in whom the cata- menia are not being properly established. Here there is probably constipation, and aloes is both a purgative and a stimulant to the hemorrhoidal vessels which supply the uterus. Consequently Arsenic, gr. ij. Fer. Sulph. Exsic, 3 i- Pulv. Pip. Nig.. 3 iss. Pil. Al. et Myrrh, 3 ij., m. ft. In pil. 60 div., one to be taken twice a day after meals, would be a good measure to adopt. Here the chalybeate is given with an alterative and a laxative, and in a few weeks probably the patient will be much relieved. Such a pill is also excellent where there is general mal- nutrition, with consolidation of one or both lung apices, especially when the night-sweats have been arrested. At the commencement of a severe cold, it is well to give as an alter- ative combined with a sudorific Cal., gr. iv. Pulv. Antimonial., gr. v., at bed time, and a black draught, or seidlitz powder in the morning; and after that Pot. Iod., gr. iv. Liq. Amm. Acet., 5i. 6ta quaque hora. By giving the powder the night before the morning purgative, the reparative processes will be aided and expedited. I did not be- lieve this in my early days, but a little expe- rience soon convinced me on the matter. In strumous children the addition of iodine to iron is excellent, as seen in the Syr. Ferri. Iod. 28 BODY TEMPERATURES. It is, however, not till he gets "into prac- tice " for himself and feels the pressure of the competition for an existence, when pa- tients are something more than mere social units (as they are in a student's eyes in a hospital out-patient room), that the young medico is likely to take any interest in alter- atives, or to appreciate their utility. CHAPTER III. BODY TEMPERATURES. The temperature of the body in health is at or about 98-5° Fahr., and this is maintained alike in Arctic regions, and in hot countries where the surrounding temperature varies greatly. The student should have a clear idea of the production and dispersion of heat in the body, in order to wield his clinical ther- mometer skillfully, and to interpret correctly the information it furnishes. The body heat is produced by the union of carbon and hydrogen with oxygen, in the vis- cera and the muscles ; and, to a small extent, by the oxidation of albuminoids, chiefly in the liver. Heat is radiated from the body by the cutaneous, or heat-losing area; chiefly by the cooling effects of the evaporation of water, i. e., by insensible perspiration. The more the blood is in the internal, or "heat-produc- ing " area, the more body -heat is evolved ; while increased vascularity in the skin in- creases the heat loss. In a cold temperature, the skin is cool and marbly, and devoid of sensible perspiration ; in hot climates the per- spiration is very profuse. Violent muscular exertion induces sensible perspiration, and thus increased heat production is accom- BODY TEMPERATURES. panied by increased heat loss. Again, if a draught of iced fluid is swallowed, while the person is very warm, sensible perspiration is experienced almost immediately. The cold fluid contracts the blood-vessels of the inter- nal area, the warm blood is driven to the surface, and then ensues perspiration, which of course increases heat loss ; and so we feel more comfortable. If the student will bear in mind these physiological facts, he will more clearly comprehend — and this is, in practice, a very important matter — the difference be- twixt a pyretic condition with a " dry " skin and one with a "wet" skin. Let me try to make this quite plain to the youthful reader. When the skin is " wet," it is obvious that the heat loss must be great, and considerably above the normal. It is quite clear then that the heat production must be very great for pyrexia to be maintained with a wet skin. On the other hand, in ordi- nary pyrexia, as at the beginning of a com- mon cold, or in the early stages of the exan- themata, and in typhoid fever, the skin is dry and imperspirable, and thus there is little heat loss by evaporation. Of course there is a certain heat loss from the hot vascular skin ; but as the cooling effects of evaporation are the chief factors in heat dispersion, which is unequal to the heat production, the body heat accumulates and a state of "fever" is insti- tuted. Now it is quite clear to the student, that his line of treatment in the first case, is not to attempt to increase "heat-dispersion," but to limit "heat-production." In the sec- ond case, increased ' ' heat-dispersion ' ' is es- sentially the matter to be aimed at. How then are these ends to be attained ? I will try to tell. 30 BODY TEMPERATURES. Depressants, or remedial agents which lower activity in the body processes, are of two classes, (1) nerve depressants, and (2) vas- cular depressants. The agents which will de- press nerve-activity will be considered further on (Action and Inaction). VASCULAR DEPRESSANTS. A vascular depressant is an agent which lowers the heart's activity, and this affects the production of body-heat, first by slowing the blood-current, lowering the blood-pressure in the arteries, and so limiting the oxidising processes in the lungs and elsewhere. Thus it strikes directly at heat-production. This would, however, not be very efficient if at the same time these agents did not act on the peripheral vessels. These agents also dilate the cutaneous vessels, and so increase heat loss; not only that, but they act upon the sudoriparous glands and induce perspiration, which had previously been arrested, and thus directly increase heat dispersion. These agents are antimony and aconite, par excel- lence. Chloral hydrate and opium (potent nerve-depressants) also lower heat production and increase heat dispersion. Now let us see how these agents can be made useful in the treatment of pyrexia. Say the student is called to a case of severe cold, with tumes- cence of the lining membrane of the respira- tory tract. The skin is hot and dry; the patient is feverish and thirsty. He is drinking cold fluids, which, in being raised to the body temperature, neutralize so much heat. Here it is evident that heat dispersion is what is required. To restore the action of the su- doriparous glands will at once give relief. So it is well to give BODY TEMPERATURES. 31 Pulv. Opii.,gr. i. Pulv. Antimonial., gr. v. for an adult, at bed-time. This will probably provide a fair night's rest; then something of this kind may be prescribed : Vin. Antimonial., TTJlxx. Liq. Am. Acetat, I i. 6ta quaque hora, the first dose to be taken early in the morn- ing. Some half-hour after it is taken, give the patient a draught of hot fluid, as milk, beef tea, weak tea or coffee, or cocoa. Per- spiration is most easily and readily excited about 6 or 7 a. m. , as a phthisical patient can tell you. Repeat this the next morning. The effect of this line of treatment is to make the skin moist, and so aid heat dispersion; to make the pulse soft, and so to lessen the vas- cular turgescence of the congested mucous lining of the air passages ; and with this low- ering of the turgescence, secretion" is restored, and the mucous membrane is soothed thereby. There is less irritative cough, and the expec- toration is easier. The cough set up by the irritation caused by the congestion and dry- ness was useless and exhausting. Now it is less, but it is accompanied by expectoration. This action may be facilitated by the inhala- tion of steam, or, still better, the fumes from a large sponge, wrung out of hot water, on which a tablespoonful of turpentine has been dashed. Or a large bucketful of water may be placed on the floor of the room, if the patient be a child — for children cannot readily be taught to inhale. So much for the treat- ment of a common cold. [Hot bricks placed in water is a very con- venient method of generating steam for the sick-room.] 32 BODY TEMPERATURES. * If the patient is a child of twelve with measles coming on. Here again is a fast pulse, a dry skin, and rising fever. The tongue is furred, and it may be necessary to prescribe Cal., gr. iii. Pulv. Jalap, gi . V'. at bed- time. But the main treatment would be to prescribe Vin. Antimon., Vin. Ipecacua !., a" ttjjx. Aq. Anethi, 3 ij. 4ta quaque hora, which would keep down the pyrexia pretty well. Or aconite may be used after the plan advocated by Sidney Ringer. Tinct. Aconiti., Tini. every hour. But perhaps it would be more convenient to prescribe Tinct. Aconit, Ifl) iv. Vin. Ipecac, M x. Aq. Anethi. 3 ii. 4ta quaque hora. But the student must never forget that children bear depressants badly,£ e. , ordinary doses will at times produce alarming prostration ; so he must be on his guard in this matter.. On the other hand, children are tenacious of life. Or a patient has typhoid fever. Thirty years ago he would have been dosed with anti- mony ; fifty years ago he would have been bled; now most likely he is put in a cold wet sheet, or placed in a bath of water at 95° Fahr. , and cooled down. The bleeding would affect the heat-producing processes, by the abstraction of a number of the red blood- corpuscles — a very direct means of striking at the pyretic state. One of the best and most skilful general practitioners I know, practises in a country district with a hardy rural popu- lation around him. He always carries his lancet-case with him, and in rising pyrexia from a local inflammation, usually commences his treatment by a moderate bleeding. His experience tells him that these persons bear bleeding well; and after this depletion, the medicines he prescribes act more efficiently than where no bleeding has been practised. The rational, intelligent use of the lancet must come in again. To return to the typhoid fever patient. He should be kept in bed in a well ventilated room; his stools should be carefully disinfected the moment they are passed, and at once removed from the sick chamber and buried; he should be fed on milk essentially ; but if ' this curd too much, the milk had better be diluted with water, and some form of farina added, to prevent a firm curd forming in the stomach. When the milk curds too firmly, the white curd is seen in the pea-soup coloured stools. Such is the management of the case so far. Now, what should be given to the patient as medicine ? If the case is a mild one, it is customary to let it alone and watch it, or perhaps give some mineral acid, as phosphoric or hydro- chloric, well diluted with water. Acid. Phosp. Dil., ttexv. Syr. Simplic, 3 i. Aquae, 3 ii. 6ta quaque hora. would be pleasant and refreshing to the pa- tient, to say the least of it. But my own private opinion is that the acid to be used here is essentially the hydrobromic. There is a tendency to cerebral excitement and de- lirium at nights, which is aggravated by opiates. Bromine is a nerve sedative of a potent character, as the extensive use of the 34 BODY TEMPERATUBES. bromides testifies. If I were directing the treatment of typhoid patients, the hydro- bromic acid would be freely used. It is as pleasant an acid as any other, and is sedative to boot. Ac. Hydrobromic, TTflxx. Syr. Simplic, 31. Aq- ?j. every four or six hours, would be the mixture employed If the case be pyrexia associated with local inflammation, the student must look to two separate matters: (1) the position and extent of the local inflammation ; and (2) the general disturbance of the patient. Patients of the phlegmatic order often show little general systemic disturbance, even with extensive in- flammation. Those with a mobile tempera- ment will manifest much general perturbation from a slight cause. It is well to appraise each factor carefully. In the nervous person it would be well to use chloral hydrate in small doses, often repeated. Chloral Hydrat., gr. x. Mist. Camphorae, | i. 6ta quaque hora, would probably produce satisfactory results, [f the pain is great, as when a serous surface is inflamed, the analgesics are indicated as well as depressants. Say it is a case of pleu- risy in a fairly strong man. Then Tinct. Opii, ll^xx. Via. Antimon., ffijxv. Mist. Camphor., §i. 6ta quaque hora, is my favorite mixture. But here crops up the question of the local treatment, a matter we had not to deal with before. Here is the dry inflamed pleurae rubbing on each other at every respiratory movement. This produces BODY TEMPERATURES. 35 the acute pain requiring the opiate. To re- lieve this some leeches may be used to deplete the costal pleura; or it might be well to at- tain the same end by a hot poultice. Here the dilation of the cutaneous twigs of the inter- costal arteries depletes the pleural twigs and so furnishes relief. But there is another mat- ter to be attended to, and that is — rest of the inflamed part. Putting a flannel binder round the chest, and so limiting the thoracic move- ment in the respiratory act, lessens the pleural friction which is the source of pain; the respiration being thus made almost entirely abdominal. A large poultice both depletes the costal pleura and limits movement; con- sequently it is always well in pleurisy to order one. • In peritoneal inflammation opium should be given freely and boldly. The more severe the pain, the larger and more frequent should be the dose of the opiate ; while the belly should be covered by flannels wrung out of hot water and freely sprinkled with turpen- tine and laudanum. During acute pain of inflammatory origin, push opium freely; withdrawing it as the pain subsides. "We now come to the subject of pyrexia with a "wet skin." This is very commonly seen within a week or two of parturition ; but is also seen under other circumstances. The body temperature is high, and the heat dis- persion from the moist skin is considerably more than the normal heat loss in health ; con- sequently there is a very great heat produc- tion. But it is useless to attempt to meet such pyrexia by any means of heat dispersion — unless it be that of external cold— so we must look to something else. Extensive ex- perimentation on the Continent has demon- 36 BODY TEMPERATURES. strated the utility of quinine, and of digitalis, in lowering the body temperature in condi- tions of pyrexia. Quinine is believed to in- terfere with the oxydising processes and so to arrest pyrexia. Digitalis acts by contracting the peripheral arterioles which are dilated in pyrexia. (It is a law that the blood pressure in the arteries and the body temperature stand in an inverse proportion to each other. Digitalis increases the ventricular contrac- tions, contracts the arterioles, and thus fills the arteries). We cannot regard the explan- ations so far attempted of the action of quin- ine or digitalis as quite satisfactory ; but their value clinically is established beyond ques- tion. The following combination has done me yeoman service on numerous occasions. Quinise Sulph., gr. v. Tinct. Digitalis, Ac. Phosph. Dil., aa njlx. Aq. li. 4ta quaque hora. It should be given at longer intervals as the pyrexia defervesces. Our knowledge of quin- ine and digitalis as anti-pyretics is in its in- fancy; while experience is too conflicting about salicylic acid for anyone to attempt to appraise its value as an anti-pyretic. Low Temperatures. — In the treatment of low temperatures we can use heat, either ap- plied externally, or, as hot fluids, taken in- ternally. A hot poultice over the heart will always stimulate its action. If a lo*w tem- perature is not the result of disease of the lungs or heart, it may be due to alcoholic in- toxication, or to the effects of opium, chloral, aconite, or other toxic agent, which kills by bringing the circulation and the respiration to a standstill. The temperature falls as these vital actions are arrested; while the fall of INFLAMMATION. 37 temperature further paralyses their enfeebled centres; and so life is extinguished. Medi- cinally the best agent to employ is belladonna, which increases body heat and excites both the circulation and the respiration. It should be given in the form of atropine, which is tasteless, the dose of which can be carefully measured. Belladonna has an unpleasant taste, and all galenical preparations of it are of uncertain strength. It may be given Am. Carb., gr. iv. Liq. Atropiae Sulph., tth i. Aq. Menthse," ?i. 4ta quaque hora. Such a combination I find most useful in cases of chronic bronchitis and emphysema, where there is a strong tendency to a low tempera- ture. If the case were urgent, as in alcoholic poisoning, my own plan would be to inject subcutaneously thirty minims of the Liq. Atropiae. On Feb. 14th, 1878, I had a grain of sulphate of atropia injected, at once, into the arm of a woman who was dying from opium poisoning, with the most satisfactory results. In the United States atropine is used for the treatment of collapse, with such results that this use of it is extending. Its use is indicated in the collapse due to burns. CHAPTER IV. INFLAMMATION. Inflammation may be acute or chronic. As the first it is commonly seen as pneumonia, as inflammation of a serous or mucous mem- brane, or of the bones or rather periosteum. It occurs in the latter often in a subacute or chronic form. As chronic inflammation it is well seen in the valves of the heart, which are commonly the seat of chronic changes. 38 INFLAMMATION. The student has been taught that inflamma- tion is not merely vascular congestion — it is vascular congestion, and something more, viz., a production of cell growth, to speak broadly. Inflammation of a serous membrane is commonly followed by a fluid accumulation in the serous sac, which has to be dealt with in its turn. The pathology of inflammation must not detain us, however. In inflammation of any area, large or small, the minute blood vessels of the affected area are dilated, while the nutrient arteries are full and dilated. (A patient of mine has ec- zema of the scalp ; when the eczema is active his temporal artery can be seen pulsating dis- tinctly.) This is accompanied in ordinary in- flammations by a state of general high arterial tension ; so that there is an abnormally large quantity of blood in the affected part. We can attack this condition of the vascular sys- tem by the measures mentioned in the pre- ceding chapter. We know of no agents which will directly affect the inflamed part, but we can often afford direct relief. For instance in a phlegmon we can put on leeches; or in a whitlow abort the suppuration by an incision into the inflamed parts, without wait- ing for suppuration. But in glandular in- flammations we try other measures than in- cision; for instance, in a bubo we put on a lead and opium lotion, and when all tender- ness is gone, paint it with iodine to promote absorption. In the preceding chapter the treatment of pleurisy was described. The agents which lower blood pressure in the ar- teries and also promote perspiration (and con- sequent heat dispersion) allay pyrexia. But by lowering the blood pressure in the arteries generally we lessen the vascularity of the in- INFLAMMATION. 89 flamed area, i.e., less blood is driven into it in ' ' sthenic " inflammation, the form now spoken of. If the patient has a full, rapid pulse and a high temperature, from a thera- peutic point of view, these two matters are more important than the seat of the inflam- matory aetion, or even its extent. To lower the blood pressure is to "starve " the vascular zone. Antimony, aconite, and other depres- sant agents have been used for this end ; and it is not "bad practice" in the country to commence by letting a little blood, six to ten ounces, or so. If the patient is in acute pain, analgesics must be administered. If the patient has a hot head, flushed eyes, sharp pulse, and rolls the head about in agony, you would diagnose meningitis and give Pot. Brom., Chloral Hydrat., aa 3i. Mist. Camph., \i. 4ta quaque hora. increasing or decreasing the dose according as the symptoms deepened or were relieved. Then you would put cold to the head, as pounded ice and salt, or cloths saturated with eau de Cologne, or vinegar and water. In- stead of bleeding, you would probably find it more convenient to use a brisk cathartic, as Elaterii, gr. 1-12. Pulv. Scam. Co., 3i. Copious watery stools take a quantity of water from the blood, and so deplete an in- flamed area. Opium is not good in inflam- mations within the cranium or thorax; but below the diaphragm, and in inflammations in the limbs, it is invaluable. [In many cases hot applications to the head and back are much better than cold in cere- bro-spinal meningitis.] 40 INFLAMMATION. If it is a case of pneumonia, it may be well to prescribe Vin. Antimonial., llflxx. Liq. Am. Acetat., $ i. 6ta quaque liora. To put on a large jacket poultice, and so to dilate the vessels of a large cutaneous area, is "to bleed the patient into his own vessels " pretty effectively; or aconite might be used. If, however, the patient be seen when the dis- ease is far advanced, and the danger immi- nent, death must be averted if possible. The patient is pale, the respiration is very rapid, the pulse weak and thread-like — the patient, indeed, is dying with pulmonary engorge- ment and a right heart distended nearly to paralysis ; and where the right heart is throb- bing and palpitating in its attempts to carry on its work, then try to keep the heart and respiratory muscles at work, and combine di- rect stimulants to the respiratory centre, as ammonia, and strychnine, with a distinct stimulant to the cardiac centres, as digitalis: Am. Carb., gr. v. Tinct. Nuc. Vom., Tinct. Digitalis, aa HEx. Aq. $i. 4ta quaque hora. It would not alter the therapeutic line of attack whether the case was one of pneu- monia, simple or tubercular, bronchitis, or capillary bronchitis ; you really treat the dis- ease through the patient. Your distinct busi- ness is to avert death. The above combina- tion has done me great service many a time, and will do so for you too, if given at the right, time and place. Never mind antiquated text- books; when you have passed from the ex- amination table to the bedside of your own patients, you will soon find that much INFLAMMATION. 41 required for the first is of precious little ser- vice at the bedside ; and further, the painful discovery will dawn upon you that what is required for everyday practice has almost en- tirely to be acquired after your educational course is ended. When you have ' ' sthenic " inflammation to deal with, the indications are (1) to relieve pain; (2) to lower the vascular activity, gen- erally and locally ; (3) to lower the tempera- ture — these two are attained by the use of de- pressants; and (4) to keep the stomach and alimentary canal in good order. If unfortu- nately the stomach gets upset, you must in- stantly "change your front," to use a mili- tary expression. Never treat the stomach with disdain. Compromise with it you must. Other measures, no matter what they are, must be suspended, and the stomach treated when irritated. Pot. Brom. 3j. Mist. Bism. Alk., 5i. 6ta quaque hora, may be tried if sickness supervene. If the stomach be acid, add to the milk taken a suffi- ciency of prepared chalk, or magnesia, to neu- tralize the acidity, and prevent the milk curd- ling too firmly. If the tongue is raw and de- nuded of epithelium, stick to this line with might and main — to the exclusion of all else, viz., to keep the stomach in good humor. If the tongue is foul, a calomel and colo- cynth pill at bed-time, and an ounce or so of black draught, will often do good. But whe- ther you flog on the vital centres of respira- tion and circulation, or you attend to the stomach, of course turns on the exigencies of each case. You must use your own judg- ment in every case, or get some wiser head to 42 INFLAMMATION. tell you. As long as life is not very seriously threatened, keep a steady eye on the condi- tion of the tongue. "Asthenic" , inflammation is common among our city population: ill-bred, ill-fed, the blended products of drink, poverty, lust, and syphilis; reared on tea with a dash of alcohol; a race deteriorated in physique by inheritance and wrong rearing, our city -bred patients of the lower class almost never need depressants. They bear them badly. The quinine and digitalis mixture above is in- finitely better for them. They need alcohol in liberal quantities; they are accustomed to it ordinarily, and need extra large doses in disease. They have very little "margin of health," and little or no physiological capital to fall back upon to enable them to resist the stroke of acute disease. You must feed them, and give tonics. The fluttering pulse and heightened respiration require Am. Carb., gr. iv. Inf. Cinchonae, | i. 4ta quaque hora, or they sink, or the combination with atro- pine is indicated at an early stage. If an in- flammation in them does, at an early stage, present " sthenic" symptoms, they soon pass away, as a rule, and give place to "asthenic " symptoms. Depressants they will quickly sink under — a moderate dose of chloral if sleepless — and all call for further medical interference is abruptly ended. In others, especially persons of broken health and shat- tered constitutions, drunkards, or debauchers; or with constitutions sapped by overwork, syphilis, or struma, the same tendency to rapid failure of the vital powers is experi- enced. I can not and do not profess to put INFLAMMATION. 43 an old head on young shoulders; but I can tell the student what he has to try to do. It will depend much on his own willingness to learn as well as his intelligence, how far he profits by what I write. Students are apt, at times, not to look straight at facts, but to quibble, to argue for argument's sake; to de- liberately close their minds against the ingress of information, and then of course they are no longer teachable, but harden themselves in ignorant skepticism — a very bad mental attitude to adopt! After the brunt of the inflammatory action has been withstood successfully, and the acute symptoms are over, then comes the " wreckage of the storm" to be dealt with. If the tongue cleanse satis- factorily, then something of this kind is indicated : Quin. Sulph., gr. i. Ac. Phosp. Dil. lip xv. Inf. Gentian. | i. Ter in die ; or five drops of the liquor strychnia may be substituted for the quinine. If there be a quantity of lung consolidation remaining, a thickened pleura, or peritoneum, a mercurial will often be of signal service. Inflam- matory products, syphilitic growths, like the spare albuminoids (the luxus consumption of the Germans) become so altered by the action of mercurials that they are readily got rid of. The fact we know; the explanation of it is shrouded in "the darkness that pre- cedes the dawn." If there be pleuritic or pericardial effusion, a blister will often lessen the bulk of fluid and "promote absorption." Here, too, an occasional mercurial is often useful ; but be careful to see that tonics and chalybeates are also administered to weak patients. 44 INFLAMMATION. The lines laid down here for the treatment of inflammation apply to strictly surgical cases. The medical aspect of surgical cases requires more attention than is at present accorded to it. In osteitis and periosteitis, to allay pain, to lower vascularity, and to pro- mote sleep, are often as important matters as the local surgical measures. Where a surgi- cal measure has given systemic relief, little or no medical treatment may be required. But before this, or when the relief afforded is partial, medical measures may be of the greatest value; and it is not wise to overlook them. Best may be of the most essential service. In inflammation of a joint we recognize this, and secure rest. We strap a thorax in pleurisy when a broken rib is rubbing the pleura into inflammation; or when a tubercle protrudes from the lung and produces the same result. But in the treatment of- endo- carditis this has been utterly forgotten. Yet when an inflammatory storm is passing over the valve-curtains of the heart, lighting up a growth of connective tissue corpuscles in the fibrous structures beneath, we forget the lessons of pathology. The greater the strain upon the valve-curtains, the greater will be the growth of these corpuscles, whose ulti- mate contraction will distort and mutilate the valves. Keep the patient flat on the back for days after the active symptoms have passed away; what is a week in bed to a crippled existence with a leaking or stenosed mitral valve? Calm the circulation, and the nervous irritability and desire to be getting up, with chloral if necessary. To use meas- ures to give tone to the circulation, to throw more strain on those valve-curtains by getting INFLAMMATION. 45 the patients up, is unreasoning, mischievous energy. It is enough to make one despair of the reasoning power of the species to think of the treatment of rheumatic fever with endocardial complications, after the acute symptoms are over. The lessons of pathology so carefully conned in the dead-house are forgotten at the bed-side ; and the light they should project to guide our steps in practice is curiously wanting or neglected. Parenchymatous Inflammation. — Still more necessary is it to remember the lessons taught by pathology in those chronic modifi- cations of nutrition now called parenchyma- tous inflammations. ' Habitual use or over- stimulation of a part, by producing deter- mination of the blood to it, may readily drive it into inflammation,' writes Erichsen. The knowledge of this fact teaches us to lessen that demand upon the part which is driving it to inflammatory changes, and so avert the danger. This is often more efficient than medical treatment. ' The whole origin and course of the parenchymatous inflammation must be subjected to a birdseye view, and then each part of the whole seen in its true relation to the rest. At the same time each part should have special attention given to it and its needs. If it be interstitial pneumonia in a mason working on fine stone, he must leave his occupation and flee for his life. As a police officer, a soldier, or an emigrant, he may live; but if he remain a 'fine-hewing' mason, he will surely die; and that before long too. If the striker or boatman on the first evidences of aortic valvulitis quit his occupation and take to some lighter form of labor, he may live to a fair length of days. But if he adhere to what has produced 46 INFLAMMATION. disease in healthy organs, the morbid pro- cesses will be aggravated and the end acceler- ated. If the gin-drinker reform, his injured liver may last for years. If the gouty man reduce his consumption of nitrogen to what his kidneys, aided by his skin, can fairly eliminate, length of days may not be ab- solutely out of question ; but such prolonga- tion of life is incompatible with self-indulg- ence. Aortic valvulitis is common in ham- mermen or strikers, boatmen, and others wlie make sustained severe efforts, and thus throw strain upon the aortte valves; indeed, it is not a very rare thing to find an aortic cusp actually ruptured by severe effort. It also occurs in gouty conditions with an.hyper- trophied left ventricle and a tense incom- pressible pulse; where the aortic valves are closed violently by the high blood pressure in the elastic arteries. The dust of fine-hewing irritates the lungs, as does flour in millers and bakers, fine dust in dry grinding, as needle grinding; and in other occupations where mechanical irritants are inhaled. Al- cohol worries the liver into cirrhosis. Too much nitrogenised material excites a growth of connective tissue in the kidneys — ' the gouty kidney.' In all these cases our know- ledge of ' the natural history of the disease ' should guide us as to prevention, and the avoidance of the provoking cause of mischief. In those chronic modifications of nutrition in the joints found in the strumous, rest is all important. The thick epiphyses of struma are easily provoked by slight external causes to take on changes of nutrition and growth. Instead of a moderate production of healthy cells, imperfect cells are produced in ab- normal quantities; there is an increase of ANAEMIA. 47 quantity with a decrease of quality: until this may reach the production of pus or suppuration. To rest the part is as important as to improve the nutrition; while 'diseased tissues need the baptism of healthy blood for regeneration,' they also equally need rest for repair. If a knee, it should be put at rest with a leather case well fitted on, so as to abolish movement. If the hip joint is the seat of disease, take off the weight of the body by an appropriate splint; or if the patient is in bed, keep the head of the femur and the cup of the pelvis apart if possible, as pressure will lead to ulceration. If the spine is weak, take off the weight of the head and shoulders from the spine, by an external skeleton resting on the iliac crests and sup- porting the head and shoulders. Relieved from the superincumbent weight, repair is favoured in the spinal column ; which, when handicapped by that burden, must have got worse. What the surgical measures, Sayre's jacket, or what should be, it is scarcely my province to. say; I merely point out here the principle which must guide your practice — show how your practice can be rational. Under favouring circumstances the natural efforts at repair are often very successful. CHAPTER V. ANEMIA. It is usually easy enough to see that a patient is anaemic; but it is not so easy always to determine on what that anaemia depends. It may be due to want of food, or to imperfect assimilation. It may arise from a drain, as diarrhoea or lucorrhoea ; or it may arise from gonorrhoea, when it is due to chagrin and 48 ANAEMIA. discomfort telling on the digestive organs, rather than the mere loss by the discharge. Or constipation may occasion it. In woman, especially, a drain is no uncommon cause of anaemia. In such case it is well to prescribe : Mag. Sulph., 3 ss. Tinct. Fer. Mur., 1JB x. Tinct. Capsici, tijj iv. Inf. Quassise, I i. Ter in die. In elderly persons, and in women at the change of life, warm carminatives in their mixtures are always indicated; and they are always comfortable to any one taking a purgative. I believe this has been said be- fore, but it will stand repetition. When due to, or associated with a drain, stop the drain by appropriate measures. In simple ancemia, as seen in girls at puber- ty, any form of iron is useful. If very anae- mic, send them to bed for a week or two. Especially is this necessary when the patient is an overworked servant-girl. I well remem- ber a girl at the West London Hospital who was under my care for fourteen months, and in spite of every combination of iron and tonics, she stood still. She was sent into the hospital and put to bed, and under an ordin- ary steel mixture, in a week, most distinct and perceptible improvement was made ; and in a week or two more she was all right. I have not forgotten that lesson; and I hope the reader will not. In childhood it is well to give lime as well as iron ; and Parrish's chemical food is a very pleasant form of this combination. Often in strumous children cod-liver oil works won- ders. Then there are special circumstances which affect the anaemia, and require special and appropriate measures. In the anaemia so ANEMIA. 49 often found with consolidation of the apices of the lungs, it is useless to give iron, as an haematic, if at the same time the night sweats are allowed to go on unchecked. In malarial poisoning and the subsequent anaemia often seen, it is useless to give iron, unless at the same time the specific — quinine — be given with it. If there be congestion of the liver, with tenderness over it and a foul tongue, it is utterly useless to give iron. Clear out the liver and get the tongue clean, and then chalybeates will do well: Quin. Sulph. gr. ij. Tinct. Fer. Mur., Ac. Phosph. Dil., aa TIDx. Aq.. ii Ter in die; but if this be not done, it is waste of time to give iron. If there is toxic anaemia, as in lead-poisou- ing, it is desirable to get the lead out of the system by the iodide of potassium, as well as to order steel. In mercurial, or copper pois- oning, it is necessary to prevent more of the poison entering the system; and to let what is in get out, as well as give chalybeates. In gouty patients suffering from anaemia, while there are active symptoms, iron is of no service, unless it be given along with potash : Pot. Bicarb., gr. x. Ferri. Aram; Cit., gr. v. Inf. Quassise, ?i. Ter in die; well diluted with water, is a capital combina- tion. Usually it is well to let the active symptoms subside before resorting to iron. It would indeed be well to commence with Sod. Sulphat , Sod. Pot. Tai*t., aa 3i. Tinct. Nuc. Vom., rrg x. Inf. Gentian, 3 i. Ter in die, 5€ ANEMIA. until the tongue is clean and all active symp- toms are removed; then follow with the potash and iron. After rheumatic fever this combination is indicated for a while. In aiKBinia of syphilitic origin, a very wide class, I am sorry to say, it is necessary to give mercury freely. I hold with H. C. "Wood in favor of mercury versus large doses of iodide of potassium. At present the iodide is given in very large doses, £ss. to gi. Sometimes in syphilitic ulceration the iodide is to be pre- ferred to the mercurial alone. But it is well to combine the two : Liq. Hyd. Bichlor., 3 ss. Potas. Iodidi, gr. v. Inf. Gen.. 3 i. Ter in die, is a useful form. But in the ordinary cases of anaemia, which is sometimes very acutely induced at an early period, it is well to pre- scribe the following combination : Liq. Hyd. Bichlor.. 3 ss. Tinct. Fer. Mur.. ttjjx. Inf. Quassiae, 3 i. Ter in die. By giving iron with the mercury, full doses of the latter may be given to broken-down subjects without fear. My own individual experience has been that while I use mercury very freely in syphilis, no case of salivation or other mercurial trouble has occurred since iron has been systematically given with the mercury. *In the anaemia of syphilis, whether it be acquired or inherited it matters not, al- ways stick to the last combination; whatever local measures may be indicated. When the treatment has to be continued some time, it is well to give the two in pill form, which is tasteless and does not spoil the teeth. 51 Hyd. Bichlor., gr. v. Fer. Sulph. Exsic, 31. Pulv. Pip. Nig., 3ij. " Pil. Al. et Myrrh., q. s. ft. Inpil. 60div. 1. bis in die. Then it may be well to rub in a piece of blue ointment, the size of a large pea. every night, either into the inside of the limbs, or over the rash ; if rash there be. Also feed up the patient. Continue the treatment so long as any evi- dence of syphilis remains; and a little longer. Hound the poison out of the system thorough- ly and effectively; and perhaps the patient will never know more of it. When after the lapse of years a patient manifests syphilis in its later form, ' go for ! the poison again ener- getically. Syphilis, like gout and malaria, often shows itself actively after lengthened periods of quiescence; and like them requires active treatment at those times. In inherited syphilis, it is well to give Hyd. c. Greta, in two or three grain doses every night, when there is a copper-hued bottom, or the distinctive spots or 'snuffles.' This clears out acid masses of mucus in the alimentary canal. If there are sores, they should be washed, and then dust- ed with calomel. The treatment should be continued a month after apparent complete restoration to health. Relapses occur in chil- dren as in adults, and must be actively treat- ed. As a chalybeate to meet the general con- dition of anaemia or malnutrition in the qui- escent intervals, the syrup of the iodide from Til xx to tti xl three times a day is indicated. Then there is a form ot anaemia and mal- nutrition in infants and children from exces- sive appetite, or 'bulimia.' It is commonly seen after whooping-cough and measles. Here there is chronic inflammation of the mucous 52 PLETHORA. membrane of the aliment arj' canal, and. sensa- tions of hunger are intensified. The. child eats incessantly; and the more it eats the more it wastes. It digests very little of the large amount it eats; it grows hungrier and hun- grier, of course; and if the mother cannot, or will not restrain it to light meals of easily digested food, with proper intervals of rest for the stomach, the child will die. It may be well to prescribe : Pot. Brom., gr. ij. Aq. Anethi, 3 i. Ter iu die, to soothe the mucous membrane and diminish the sensations of hunger. PLETHORA. Is the opposite condition to anaemia — where there is too much blood in the sys- tem. Here it is well for the student to deter- mine whether there is 'true plethora,' with a full artery as well as a full vein ; or venous congestion with a slack artery. If the latter, Tinct. Digitalis, Tip x. Inf. Cinchonas, ? i. Ter in die, may be given as well as the Pil. Cal. Col. Co. at bedtime twice a week, and the saline draught in the morning. In the true plethora, with a tight pulse and often a throbbing head, it may be well to give Elaterii, gr. 1-16. Pulv. Jalap Co., 3 ss. at once, and follow with the mixture of nux vomica, three times a day. In cases of amenorrhcea in florid women, with plethora, it is well to use this mixture freely, and to order hip-baths when the menstrual period ought to be present, and the patient feels as if it were coming on. A regulated dietary BLOOD POISONS. 53 poor in albuminoids is necessary where a ten- dency to plethora of fulness of blood exists, no matter at what period of life or in which sex. ■ » CHAPTER VI. BLOOD POISONS. The student will often be brought face to face with conditions of blood-poisoning. This may be acute, from some poison absorbed from without the body; or more chronic from pus absorption within the body; or other matter, as in pyaemia. The treatment of blood poisoning is not very satisfactory. If it takes the form of diphtheria, with the throat patches; the line to adopt is to support the system by beef-tea and milk, giving wine when matters are critical, and the following combination : Pot. Chlorat. gr. iij. Tinct. Fer. Mur., ttqjv. Syr. Aurant, 3 ss. Aq. ad.j 3 ii. 6ta quaque hora, for a child of seven or eight; for an adult twice this dose, at four hours' interval. If there are accumulations of pus in the inter- muscular planes let it out freely; and it is well to do this antiseptically. For the treat- ment of blood poisoning we resort to ANTISEPTICS. These are agents which unite with organic matter in a state of molecular change, and in uniting therewith make insoluble and there- fore inert compounds. Just as in lead- poisoning sulphuric acid well diluted is given, to form the inert sulphate of lead, so in blood poisoning the sulphites are given to unite with and render inert the acting poison. 54 BLOOD POISONS. Sod. Sulphit., 3i. Pot. Chlorat.. gr. ii. Aq. Menth. Pip. I i. 4ta quaque hora, is good. Carbolic acid in atomized spray is often useful "for the patient to inhale. Or salicylic acid may be tried, as a salicylate of soda, 3ss. to gi. quater in die. Some of these agent, as Condy's fluid and chlorate of potash, both rich in oxygen, are supposed to act by furthering the oxidising processes, and so rendering the poison inert. Condy's fluid should be sprinkled about the bedroom ; while a sheet kept moist with a solution of it, or chloride of lime, should be hung over the door of the room. As a prophylactic to be taken by the attendants, the following is good, and not unpalatable. Take an oz. of chlorate of potash, put it in a quart bottle of wine with the juice of two good-sized lemons ; shake the whole till dissolved; then take a wineglassful three times a day. This is very good when there is scarlatina in the house; or for those in attendance upon patients suf- fering from acute blood-poisoning. The treatment of the more persisting pysemiae cannot be discussed here; but the line is to give the sulphite mixture regularly, and to keep up the patient's strength by good, digestible food, wine, and other stimulants; and thus enable him. if possible, to weather the storm. Malarial-poisoning takes the form of fever and ague, or dysentery. Iuiever and ague recurring in a person who has beeu subject to it, it is well to give Quin. Sulph., gr. iv. Tinct. Digital., m s. Ac. Phosph. Dil., ttq xt. A 3r 2. 1 Ter 11 in die. MALARIA. 55 with a Pil. Cal. Col. Co., at night, and mer- curial tonic in the morning. The poison lying chiefly in the portal circulation, evacuants are indicated ; as well as the malarial specific, quinine. In malarial dysentery, not the putrescent dysentery of camps, it is well to give ipeca- cuan in full doses. Say you give tti xv of laudanum to a patient, and in two hours, when the stomach is under the influence of the narcotic, Pulv. Ipecacuan., 3 ss. The patient for a few hours will be deadly sick, then vomit, and next day there is a nor- mal stool containing bile, and the dysentery is relieved. If not thoroughly successful in the first attack, repeat the manoeuvre. In the general management of specific fevers there are points to be attended to in all cases ; special points in particular maladies. Firstly, remember that the infectious power is at the decline of the malady; in scarlatina so long as there is an effete epidermal scale to be shed ; in small-pox so -long as there is a scab to fall. In measles we do not exactly know the peculiar infecting agent — possibly a mucous epithelial scale; but this is pure hypothesis. In typhoid fever the stools should be passed into a utensil containing a disinfectant, as chloride of lime or carbolized powder : some more of the disinfectant should be thrown over the motion as quickly as pos- sible, which should then be buried some dis- tance from the house, or in towns otherwise disposed of. These measures should be adopted for the protection of others. Now for the patient. We will suppose the case to be scarlatina. 56 SCARLET FEVER. Having made his diagnosis, he will put the patient into a good airy bedroom, and allow plenty of fresh air. With the rising temper- ature and the burning skin there is little fear of catching cold. But when the fever has defervesced, the skin is cool, and the epider- mis is peeling, chills are readily caught with the thin sensitive skin; then be very careful about cold. If the case is one of ordinary severity, give Pot. Chlorat., gr. x. Syr. Aurant., 3 i. Aq. an. 3 ss. tita quaque hora. If the throat is ulcerating, add Tinct. Fer. ■ Mur., ttix., to each dose, and give wine and beef-tea. Otherwise milk, milk and lime- water, or seltzer-water, should be the staple food. Cold sponging with vinegar and water may be practiced so long as there is distinct fever. When the fever is over, rub the pa- tient over daily with carbolized oil, one part of carbolic acid to forty of linseed oil, or cocoa butter. The patient should be washed daily, and then rubbed over with this carbolized oil. By this means the falling scales are disin- fected and removed. Be very careful against cold for a month after the appearance of the rash : very careful indeed. If the urine be- come albuminous, put the patient in flannels; sweat him, or her, in a warm bath; then purge with Elaterii, gr. A. Pulv. Scam. Co., gr. iij., for a seven year old child; and don't be afraid that this will kill a strong child. Give milk and potash water, and Pot. Bicarb., Fer. Aram. Cit., aa gr. v. Aq., §ss. Ter in die. SMALLPOX. 57 Any chalybeate tonic may be adopted in the convalescence. In measles, remember the lung complica- tions, and be on your guard against cold; in this, the early treatment differs from that of scarlatina. Put the children in a large room, and take care of draughts. If the mother has given some saffron tea "To strike out the rash," don't snub her or condemn it ; to do so would only be to let yourself down in her opinion, instead of convincing her: it.is a time-hon- ored remedy. Then give each child Vini Ipecacuan., HP v. Syr. Zingiber., vel Syr. Tolutan., 3 ss. Liq. Amm. Acet., 3 i. 4ta quaque hora, dieting as in scarlatina. With care the chil- dren should get through all right. If the lung symptoms are threatening, an emetic of sul- phate of zinc Oss. in § ii. of warm water) is indicated; and a grain of carbonate of am- monia to each dose of the above mixture. When convalescing, it might be well to give Sal. Volatile, grs. x. Inf. Cinchon. Flavae, 3 ii. Ter in die. When called to a case of smallpox, get the patient away if possible. If this cannot be done, give something like this : Ac. Phosph. Dil., M xv. Syr. Zingib. 3 i. Aq ad, \ i. 4ta quaque bora. Darken the room to check the development of vesicles on the face, and feed the patient. Patients will become severely ill with small- pox, and yet often recover. If prostration is setting in, I should feel inclined to try Am. Carb., gr. iv. Pot. Chlorat., ass. Inf. Cinchon., $i. 4ta quaque hora. 58 WHOOPING COUGH. The patient must be encouraged not to scratch the face, or pick the irritating scabs from the nose, else severe pitting will follow. A mix- ture of olive oil and calamine, in pro- portions enough to make a thin paste, is re- commended to be painted over the face daily, to reduce the risk of pitting. In whooping-cough it is well to give atropine. Liq. Atrop. Sulph., tijj i. Aq. Anethi., 3 i. 6ta quaque hora. • If the respiration be excited, Pot. Brom., gr. v. Syr. Tolut., 3 ss. Aq. 3 iss. 4ta quaque hora. may give better results. But study the char- acter of the respirations ; if shallow and rapid, atropine is indicated. Children stand belladonna well. If the child vomits with its cough, then feed it milk, or milk-gruel, immediately after it vomits ; so that the food may be digested and get out of the stomach before the next paroxysm. After the true whooping-cough is gone, a troublesome cough of like character may remain, a resultant ' trick ' of .the respiratory centres. Here it is well to prescribe : Quin. Sulph., gr. i. Ac. Hydrobrom., tTTJ xv. Aq., 3 ii. Ter in die. which often is very successful. After that any chalybeate, as Vin. Fer. 01. Morrh., aa 3 i. Ter in die, or half a drachm of Parrish's food thrice daily. Influenza is a depressant form of catarrh; more depressant than is generally credited. For it, give ERYSIPELAS. 59 Am. Carb., gr. iv. Sp. Chloroform., 11)3 xx. Inf. Cinchon., li. Ter in in die. and, if necessary, a pill at bedtime. A good pill in catarrh, chronic bronchitis, etc., for nights of broken rest from cough, is Pulv. Ipecacuan., gr. ss. Pulv. Opii.,gr. i. Pil. Scillse. Co., gr. ii. o. n. Where there is much embarrassment of the respiration, then Liq. Morph. Mur.. nj xxx. Liq. Atropiae Sulph., Hfl iii. Aq. Menth. Pip., § ss, o.n., is to be preferred. Any dimness of vision, or dryness of the throat from the belladonna, is quite unimportant; any action on the pupil no reasoning person would heed; for of what significance is it? It is one of the medical 'bogeys,' that's all. If the patient is incom- moded by the dimness of vision, as a needle- woman or an engraver, then it must be with- drawn ; or if the throat be disagreeably dry, the belladonna may be discontinued. Erysipelas appears in two forms, as a spread- ing dermatitis resulting from an injury, and as a specific disease in the face and head. As a mere dermatitis Plumbi Acetat., bss. Tinct. Opii., ?ss. Aq., I xx. is good, applied on lint covered with oilskin ; and to regulate the bowels, if the tongue be furred, by the means often spoken of in Chapter V. , and to treat the patient accord- ing to the general condition, and the tempera- ture according to the rales laid down in Chapters III. and IV. In true infectious erysipelas, it is well to give 60 GROWTH AND DECAY. Quin. Sulph.. gr. i. Tinct. Fer. Mur., IIJJ v. Aq. II. 6ta quaque hora, to use the lead and opium lotion warm, or to dredge the face well with flour ; this last is very desirable when there is much exudation, as this fluid possesses a high infecting power. [A solution of hyposulphite of soda and tr. iodine and glycerin are useful local appli- cations for erysipelas.] In the treatment of the pyrexia associated with blood-poisoning proper, not specific poisons, it is well to adopt the measure advo- cated for ' ' wet-skinned " fevers, spoken of in Chapter III. CHAPTER VII. GROWTH AND DECAY. It is well for the student to remember that the anatomical basis of our divisions of mala- dies is a convenient 'arrangement for text- books, but is not so we'll adapted for the bed- side. Physiology must guide our practice ver} r much more than it has done, or was able to do in past times. A fair knowledge of anatomy has long been obtained, but such an acquaintance with physiology as is of any value in practice as a light and a guide, is as yet only possessed by comparatively few. Yet it must be the basis of treatment, just as anatomy is the basis of diagnosis. An infant is often disturbed in its digestion, has a swollen belly, with loose stools and much colic, evidenced by long cries. Here it may be well to see the mother, or nurse. If I she have leucorrhcea and cold feet, with con- TEETHING. 61 stipation, put her right, and then the child will improve. Give her Sod. Sulphat., 31*. Pot. Bicarb , grs. x. Tinct. Zingib., I1J} xx. Inf. Cascarillae, 5 i. Ter in die. and instruct her about using injections for her leucorrhcea. If the child be weaned, see to its having the milk of one cow, or the Swiss preserved milk — a great advantage to town children. If the child is still griped, or if it still throw up its milk firmly curdled, give it Potash. Bicarb., grs. ii. 01. Cajeput., TT|3 i. Syr. Zingib.. ttq xv. Aq. Anethi, 3 i. 6ta quaque hora. If hand-fed, a little prepared chalk or mag- nesia powder in its milk is indicated. [Cows to afford wholesome milk for infants should be healthy, and have good food and care. Overheating by driving, and un- wholesome food and drink — distillery feed — will induce unwholesome milk.] Teething often gives trouble, and then it is well to see to the gums, and lance them when a tooth is protruding, and the point is hot and tense. Gut the point, or points only; don't draw a lancet along the whole gum, and so leave a cicatrix to divert the teeth, that are yet to come, from the straight line. When there is much irritation produced by the teething, you may prescribe Pot. Brom., grs. v. Aq. Anethi, 3 i. Quater in die. If there be any heat of. head and constipa- tion, add Tinct. Sennse, ttj, xx., till the bowels are well opened. 62 HYDROCEPHALUS. When there is hydrocephalus suspected, or present, give this Pot. Brom. grs. iij. Pot. Iod . grs. j. Aq. Anethi, 3 i. 6ta quaque hora. The plan of blistering the head with croton oil liniment has still its advocates; but it is not now. fashionable. Then there is infantile remittent fever, with its diurnal variations of temperature, com- mon in children. Open the bowels with Pulv. Scam. Co., grs.. vi., for a seven-year-old child, first thing. Then give it. Quin. Sulph. , gr. h. Ac. Phosp. Dil., TTE v. Aq. Anethi, 3 ii. Ter in die. Remember that of all the acute maladies of children, indigestion stands fii'st in the rapid- ity with which the symptoms develop ; and the temperature rises. Give an emetic, Cal., grs. iv. Pulv. Ipecacuan, grs. x., and get the offending mass off the stomach at once. After this the temperature usually falls, especially when the calomel acts on the bowels. If a delicate child, it may be well to give the ipecacuanha without the calomel, and after the child has been sick, to give it a dose of castor-oil, say % ss. When there are frequent attacks of indigestion, give strict injunctions regarding its dietary — milk, sim- ple milk puddings, or a little soup or fish ; little meat or pastry ; but stewed fruit and cream ad libitum. Then give it " Sod. Bicarb., grs. iii. Bism. Trisnit.. grs. v. Mist. Acacise, x, Inf. Calumb., 3 ii. Ter in die, before its meals. CHOREA. 63 Very often you will get a distinctly strumous child to deal with. Diet it as above, and give after food Vin. Fer. 01. Morrh., aa 31. Ter in die, and you will usually be gratified by seeing that the child improves very decidedly. Send it to the sea-side, and when the stomach has been put right by the bismuth mixture, give it the oil and steel wine, and plenty of butter on its bread. Then be watchful as to the subject of growth. Children grow by fits and starts. When acutely growing they are not idle but languid ; and cannot ' do their lessons.' Put them to bed and give them Quin. Sulph., gr. ss. Ac. Phosph. Dil., Tty v. Aq. 3 ii- Ter in die, and let them have plenty of milk. In conse- quence of the growth of the epiphyses, pain in the joints is often experienced and attri- buted to rheumatism. If rheumatic, a mixture of potassium bicar- bonate and the ammonium citrate of iron is indicated. Chorea is common in children. When it is the result of fright it is apt to be very in- tractable. When the result of seat -worms give Pulv. Scam. Co., grs. iv., to be repeated till the worms are all expelled. Then give Pot. Brora., grs. v. , Fer. Pot. Tart., grs. iv. Aq. 3 ii. Ter in die. At other times, when the chorea is evidently due to a 'growing fit,' where the spinal cord 64 INCONTINENCE OF URINE. is tardy or lingering in its consequential growth, Liq. Arsenic. Hydrochlor., iii. Tinct. Fer. Mur., Tip v. Aq. Menth. Pip., 3 ii. Ter in die, will often do good service. If the child is very ill keep it in bed. When a child is badly nourislied, and you have put its bowels in order, given it steel wine and cod-liver oil, and yet it does not thrive, it may be well to rub it daily with olive oil or neat's foot oil — cod-liver oil smells too unpleasantly. Let the mother first wash it with so ip and water to clean away the epidermal cells and oil of the previous in- unction and 'cleanse the pores of the skin,' and then rub the infant's body well before the fire, with half an ounce of oil. This will often produce results at once surprising and satisfactory. Incontinence of urine in children is a com- mon malady. It arises usually from hyper- esthesia of the vesical centres in the lumbar portion of the cord, so that in sleep any irri- tation in the pelvis, as ascarides in the rectum, is apt to cause these centres to relax the vesi- cal sphincter — misinterpreting the irritation for the call of a full bladder. First remove any local irritation, seat-worms, a long pre- puce, etc., and then give' Liq. Atropiae Sulph., W. ii. Aq. Anethi, 3 i. Ter in die. [The Liq. Atropiae of the British Pharma- copoeia is of the strength of four grains of Atro- piae Sulph. to 3 j Rect. Sp. and 3 vij of water.] Children, like rabbits, stand belladonna well; do not be afraid of poisoning them with any reasonable dose of atropia. Also bear in OLD AGE. 65 mind that the irritability of the bladder so common in old men, where their rest is broken by having to get up several times to make water, is greatly relieved by belladonna. Liq. Atrop. Sulph., Tin i. Inf. Buchu, vel Mist. Camph., 3i, Ter in die, will often give decided relief, In the treatment of children avoid two ex- tremes in the use of calomel ; do not look upon it as a panacea always to be given, nor go to the other extreme of never giving it. In troubles in which the liver is involved, an occasional dose of calomel is excellent at any period of life, save for persons with cirrhosed or contracted kidneys — in other words, the subjects of Bright's disease, who are very susceptible to mercury, as they also are to opium. With these persons both these agents are simply 'poisons.' OLD AGE. When approaching old age is beginning to lay his grip upon the organism, and the changes known as ' senile ' are inaugurated, our prac- tice must be modified. As age progresses, the utility and tolerance of iron diminishes. In conditions of debility in young persons a chalybeate tonic is almost universally indi. cated, but with elderly persons something of this kind is to be preferred as a pleasant tonic: Amm. Carb., grs. iv. Sp. Chloroformi, njj xx. Tinct. Nuc. Vom., ttjj x. Inf. Cascarillae, 3 i. Ter in die, Sal Volatile, 33. Sp. Chloroformi, H\) xx. Inf. Cinchon. Flavae, 5i. Ter in die, All laxatives must be well charged with carminatives Such a pill as : Strychniae, gr. ^ Pulv. Pip. Nig., gr. ss. Pil. Col. Co., grs. iiss. every second or third night, is indicated in constipation. For the morning laxative the following are useful : Haust. Nig., §i., in an ounce of hot water, or Hunyadi Janos a sufficiency, with a teaspoonful of tincture ginger, and some hot water. Ordinary pur- gatives, as effervescing salines, are apt to lie too cold on the stomach for elderly persons. If their assimilative organs become impair- ed, the dietary of childhood is desirable. Mentally and bodily, we find the proverb ' once a man and twice a child ' holds good. Milk puddings, stewed fruit and milk, or cream, bread, butter, and jam, or honey; fish, poultry, game ; little kickshaws rather than solid meat, should form the bulk of the die- tary. Remember that whether bile acids or lithates, the troubles of advanced life are in- timately linked with the presence of nitroge- nized waste in the blood. Elderly persons soon lose heat, and should be well clad, especially whenever the weather is cold. This is very true of those who suffer from bronchitis or emphysema. In cold weather keep them warm. Give them ' treacle posset ' to go to bed with, if up. A warmed bed, a draught of hot fluid with alcohol, are required for ' the chill blood of age. Where they are teetotallers, 'treacle posset,' or a cupful of hot beef-tea, may be given instead of the alcoholized draught. When either extreme of life is attacked by bronchitis, keep up the system — feed. RHEUMATISM, GOUT, AND DIABETES. 67 As a cough mixture for old persons with chronic bronchitis the following is indicated : Am. Carb., grs. v. Sp. Chloroformi, III) xx. Tinct. Nuc. Vom.Hp vi. Inf. Senegae, ?i. 6ta quaque hora, to which may be added ten drops of tincture of digitalis if the pulse falters, indicating embarrassment of the right side of the heart. CHAPTER VIII. RHEUMATISM, GOUT, AND DIABETES. In acute rheumatism put the patients to bed in a flannel shirt, and in blankets ; nothing but woollen clothes near them. Enjoin abso- lute rest for the sake of the cardiac valves for several days after all active symptoms have disappeared. Use a hot bran bag or a poul- tice for pain within the pericardium, and hot solutions of bicarbonate of soda, ( § i to § ii, with laudanum half an ounce) on flan- nel wrapped round the swollen painful joints. Internally : Pot. Bicarb., 3 j. Tinct. Opii. , TTfl tv. Inf. Serpentariae, vel Inf. Buchu, I i. 6ta quaque hora, with a copious draught of water is good; the opium being increased or decreased accord- ing to the pain — mind this. Others prefer : Sodae Salicylat., 3i. Mist. Camph. ?i ; but the first always served me well. At night : Pulv. Opii., grs. ii. Pulv. Aloe Co., grs. iii. ; Pulv. Opii., grs. ii. Plummer's Pil., grs. ii. RHEUMATISM, GOUT, AND DIABETES. may be given with advantage. Do not dis- turb the patient too much by giving purga- tives ; but if necessary, give a purgative water, a dose of Carlsbad salts, or a Seidlitz powder. When the active symptoms subside : Pot. Bicarb., grs. x. Fer. Am. Cit., grs. v. Inf. Quassiae, § i. Ter in die, well diluted with water, slides the treatment from alkaline to chalybeate very agreeably. If a strumous young person, give cod-liver oil as soon as possible ; and get the patient to the seaside as soon as the weather and the condition will permit. [n chronic rheumatism it is well to pre- ' scribe : Pot. Iod., grs. iii. Pot. Bicarb., 3 ss. Inf. Serpentariee, ?el • Inf. Sarsse., %i. Ter in die, with Pil. Cal. Col. Co., grs. v., once or twice a week at bedtime. Then order a liniment, either Lin. Terebinth, or Lin. Camphoric, to be rubbed well over the painful part night and morning. When there is sciatica, give the above, and for a local application : Lin. Aconit. , 3 ii- Pulv. Opii. 3i. Sacch. Fcecis., 3 ii. spread on a V-shaped piece of lint, laid over the course of the nerve, with the point downwards ; covered with a similar piece of oil silk about half an inch larger, and secur- ed by a long stocking, with the foot cut off, drawn over all. Don't change the piece of . lint each day when the new dose of analgesic has to be applied. Gout is a troublesome malady to treat. First let us take an acute attack with very painful GOUT. joints. The Cal. and Col. Pil. with the Sod. Sulph. and Pot. Tart, mixture may be given every second night and morning ; then, Pot. Bicarb., 3i. Sod. Bicarb., 3 ss. Tinct. Hyoscyami, y ss. Inf. Buchu, 3 i. Ter In die, well diluted with water. Colchicum, you observe, is not in this mixture. I never give colchicum to a private patient ; my belief is, it arrests the gouty inflammation, and 'bottles up ' the gout-poison in the joint. I have seen patients sodden with gout-poison from the continuous use of colchicum, improved very greatly in their next attack from letting the ' gout ' run its course, and getting the sys- tem cleared of the poison. Attacks of gout clear the system, as thunderstorms cleiar the air in sultry weather. But as the gouty patient may be suffering keenly, and you and he may not be very thoroughly acquainted, it perhaps may be well to add. Vin. Colchici, M xv. to the mixture. To hospital patients, who must be well as soon as possible to work for wife and children, I never withhold colchi- cum ; but nevertheless, in reality it is ' bad practice!' The old and still favorite measure with many practitioners is : Mag. Sulph., 3 j. Mag. Bicarb., grs. v. Vin. Colchici., nji xv Aq. Menth. Pip., 1 i. Ter in die, and it is not a bad measure for giving relief in cases of acute articular gout; but, on the whole, the Pot. Bicarb, treatment is to be preferred. When the gout is firmly located in the patient, or in common parlance he is 'eaten up with gout,' 70 HEADACHE. Pot. Iod., grs. iii. Pot. Bicarb, 3 ss. Inf. Gentian., 3 i. Ter indie, swallowed with copious draughts of water, is a good measure. Then the food should con- sist of fruit, farinaceous foods, fish and fat — the four F's; albuminoid foods being taken but sparingly. Diabetes is a disease not to be confounded with mere glycosuria, as it has been too fre- quently. When the result of shock or emo- tion of whatever kind, it is far from intracta- ble to treatment. Opium in doses of from one to two grains night and morning, or codeia gr. \ ad gr. i, are often of much ser- vice. Then the patient may have a chaly- beate tonic, with advantage. A great matter is the avoidance of starch and sugar ; and a diet of meat and vegetables, known as greens, or of almonds or gluten biscuits is indicated. But for small quantities of sugar, especially in stout persons, and where there is no ill- health complained of, do not be too heroic in your dietary; just avoid sugar. Many a dia- betic has been made much worse by a too re- stricted dietary; but do not tell an examiner so, as your statement might be attributed to ignorance. CHAPTER IX. SLEEPLESSNESS — HEADACHE— COUGH— PALPI- TATION, ETC. Beyond the conditions requiring general management of the patient, there are some more special matters to be considered. They may well be taken from above downwards. Headache is a common complaint. If it is periosteal, iodide of potassium in five grain DELIRIUM. doses is good. Where it is inflammatory in character, Chloral Hydrat. Pot. Brom., aa. 3 ss. Mist. Camph., %i. 6taquaque hora, is a good combination. Clear out the bowels with a Cal. Col. pill at night, and the black draught, or its equivalent, in the morning. If there is a feeble pulse, with pam and weight at the vertex— the indication of cere- bral anaemia — Easton's syrup, or:- Cit. Fer. et Quin., gr. v. Liq. Strychnise, v\ v. Inf. Quass., ? i. Ter in die, is good. The same is good in cases of neural" gic face-ache, common in women ; here it is well to see if there are any drains on the system, as leucorrhcea, or menorrhagia. In epilepsy, however anaemic the patient, iron does not do well ; it may improve the general condition, but it aggravates the fits. It is better to give : Pot. Brom., 31. Mist. Camph., |i. Ter in die. Keep the bowels open, and see that the fits are not induced by a surfeit. Especially is the bromide useful in epilepsy associated with the catamenia. Delirium, when acute and not preceded by chronic evidences of brain disease, should not cause alarm, and does not in itself require treatment. If the head be hot, a bladder of cold water or of ice, is indicated. Sleeplessness is a matter often calling for treatment, and chloral hydrate is now largely resorted toby many persons, as- the numerous deaths recorded in the newspapers testify. When the patient complains of sleeplessness, 72 COUGH. find out, if possible, the cause. If due to pain, give opium; but if there also be a full pulse, give it with antimony or with chloral. Pulv, Opii, gr. i. Antim. Tart., gr. %. is good in sleeplessness due to pain, as in an abscess or whitlow, [n inflammatory con- ditions: Tinct. Opii, gtt xx. • Chloral Hydrat., bss. Mist. Camph., ?i. will often furnish relief. Children do not tolerate opium well, neither do persons with chronic renal mischief. Then for an adult: Chloral Hydrat., bss. Pot. Brom. 31. Mist. Camph., §i., will often give relief. A draught of alcohol at bedtime is often of great service, especially where worry is the cause of sleeplessness. And, mind, never forget to see to the feet. Cold feet have more to do with sleeplessness than any one thinks who has not studied the subject. Neglect of this fact often spoils an otherwise good line of treatment. Rub the feet well with a rough towel, put a bottle of hot water to them, and the patient sleeps. For sleep a condition of cerebral anaemia is essential, and cold feet keep the blood too much in the head. When there is heat in the head, give chloral in ^ss. doses, or: Tinct. Aconit., gtt iv. Pot. Brom., 31. Aq. Menthae., ?i., at bedtime. Persistent, severe headache is often syphilitic in origin, and requires specific treatment. Cough may be due to trouble in the bron- chial tubes. If in the first stage of bronchitis, give : Pot. Iod., gr. v. Vin. Ipecacuan., njj x. Liq. Am. Acetat., I i. 6ta quaque hora., 73 and allow the patient to inhale steam from a sponge or flannel wrung out of hot water, if more elaborate arrangements are not attain- able. It is often good practice, to add to the water some turpentine, so as to add its fumes to the steam. .This will produce relaxation of the congested mucous membrane, inducing free secretion, after which it becomes neces- sary to give stimulating expectorants — that is, agents which act directly on the respiratory, centres. These are ammonia, strychnina, and atropia. They may be combined thus: Am. Carb., gr. iv. Voi Tinct. Nuc. Vom., ttjj v. Inf. Serpentariae, |i. 6ta quaque hora. or: Elix. Doverinae, 3 i. Liq. Atrop Sulph., HJ)i. Aq. Menth., 5 i. 6ta quaque hora. A common mixture is: Am. Carb. gr. v. Spr Chloroformi, ttjj xx. Inf. Senegae, 1 i. 6ta quaque hora. Never shake a mixture containing senega, if you can help it. Why ? — just do it once, for the sake of the experiment. Again, cough may be due to the presence of a new growth in the lung structure, as a mass of tubercle. Here the offending matter can- not be removed, so the cough must be allayed by suitable doses of opium or morphia, which will add to the night sweats, if existing, or excite them probably when not present ; this may be prevented by combining with them belladonna, thus: Elix. Doverinae, 3 i. Liq. Atrop. Sulph.. njj i. Aq. Menth., |i. o.n., which is a most excellent night draught. Then cough may be a neurosis, as is often seen in children of both sexes, and in young HEART DISEASE. women, simulating the cough of phthisis, and often causing much needless alarm. Here a tonic, like Easton's syrup, or any of the iron tonics, will do good. Or it may be well to give Pot. Brom., 3 ss. Tinct. Fer. Mur., IIP x. Aq. Mentbse. 5 i. Ter in die. If this lock up the bowels, as it is very apt to do, give Elixir Frangulaxine before break- fast; or add it to each dose. To treat a cough properly, is often to get great credit ; but to do so you must, usually, be clear as to its cause, and treat it accordingly. It may be due to vascular congestion, as in mitral disease, when digitalis will do more good than any other cough mixture. Heart Disease. This brings us to the matter of the treat- ment of palpitation. Where palpitation is not brought on nor increased by effort, do not give digitalis, but bromide of potassium. But when the arteries are empty, the veins full, and effort brings on palpitation, give digitalis ; no matter what the condition of the heart, whether mitral disease be present or not. No doubt in mitral disease digitalis is of the greatest service. Tinct. Digital., Tinct. Fer. Mur., fty x. Inf. Quass., I i. Ter in die, is in general vogue in heart weakness. It should be given steadily for weeks. If the patient be very weak, let him rest in bed. Rest is a potent measure in heart-disease, as you will see often enough in hospitals, where no medicinal treatment but simply rest in bed, makes a wonderful difference in the patient. But some digitalis will make the improve- ment more rapid, and keep up the improve- HEART DISEASE. ment when the patient leaves the hospital. It is well to combine strychnine with the digitalis, thus: Fer. Am. Cit. grs. v. Tinct. Digitalis, nc x. Tinct. Nuc. Vom., 1TB iv. Inf. Quass., ?i. Ter in die. This will often give you the most satisfactory results. Where there is chronic dilatation of the heart, with or without mitral disease, it is well to give digitalis in pill form. Strychniae, grs. ii. Pulv. Digital. Fer. Sulph. Exsic, aa 3 ss. Pulv. Pip. Nig., 3 i. Pil. Al. et Myrrh, 3 ss, m. ft. In pil. 60 div. ; i. bis in die. The nauseous taste of digitalis is thus avoided, and the iron does not effect the teeth; finally, there are no medicine bottles required. Keep up the treatment for months, or years if necessary. But when you find the palpitation not produced by effort, and there is a tense artery, and evidences of a hyper- trophied left ventricle, with accentuation of the aortic second sound, give the patient alkalies, and put him on a non-nitrogenized diet. Here is 'the gouty Jieart,' whether actual disease of the aortic valves be present or not. Give Pot. Bicarb., 3i. Sod. Sulphat., 3 i. Inf. Cascarillae, ?i. Ter in die, with a calomel and colocynth pill once or twice a week. If there is a gouty state with a feeble heart, or the hypertrophied heart is failing, ten drops of tincture of nux vomica, of digitalis, or, maybe of both, prevents any depression the treatment might otherwise cause. In girls and young women, where there is violent action of the heart, with vio- lent paroxysms of palpitation at times, see to 76 DYSPNCEA. the bowels and iutra-pelvic irritation and treat accordingly. For the heart, if there be no mitral disease, digitalis is undesirable. Sod. Sulphat, 3 ss. Pot. Brom.. 31. Aq. Menthae, 1 i. Ter in die, is indicated. And put on a belladonna plaster. When thgre is a haemic murmur in the pulmonary artery, with palpitation in girls, that is, a condition of anaemia, give then a chalybeate and keep them in bed for a week or two. If a patient with known heart-disease has an attack of dysptum, is sitting in a chair, or propped up in bed; indeed, cannot breathe in the recumbent posture: what are you to do here? Put a hot poultice to the chest; heat stimulates the heart. Then give Am. Carb. grs. v. Tinct, Nuc. Vom. Tin t. Digital., aa !fl) x. Aq. Menthae, 1 i. 4ta quaque hora, until relie f is attained ; then reduce the fre- quency of the dose. Keep up the strength with beef-tea, milk, and alcohol. It might be well to take a few ounces of blood from the arm if the heart be felt beating violently, and the pulse weak and the face congested — showing that the right ventricle is overtaxed. At another time there is dropsy with heart- disease. First put the patient on the last mixture for a couple of days at least. Then he must be purged. Elaterii. gr MO. Pulv. Jalap. Co., 3 ss. in the morning early will usually bring away a number of watery stools. Do not think this too heroic treatment; the profuse cathar- sis gives great relief. Then give Sir James INDIGESTION. 77 Simpson's bath. That is, fill six or eight lemonade bottles with boiling hot water: cork them tightly. Then wring as many- worsted stockings out of hot water. Draw the wet stocking over each bottle, and pack them one by one round the patient in bed. In from thirty to forty minutes the patient is sweating freely. Let this go on till the end of the hour: then remove the bottles. The patient will continue to sweat for an hour or so longer. Then remove the wet blankets, without giving the patient cold. Do this twice a week, and purge twice a week, con- tinuing the mixture. Usually the dropsy will subside pleasantly. Do not prick the swollen legs, but if necessary put in Southey's drain- age tubes, and let the fluid drip off Ihe bed, not into it. If dropsical patients cannot, or will not stand purging, they usually die. CHAPTER X. ON INDIGESTION — DIARRHOEA — CONSTIPATION, ETC. In acute indigestion give Cal., gr. iv. Pulv. Ipecacuanha, 3i. to an adult. Get the offending mass up if possible; then in an hour give an ounce of castor oil to remove any portion left in the bowels. Always look out for acute indigest- ion in sharp high fever in children. Give them only half the ipecacuanha, or make them vomit by tickling the fauces with your finger: and mind when doing this they do not bite you. For diarrJum, first determine its form. If due to offending matter in the bowels, and the motions, though numerous, are small in 78 DIARRHCEA. bulk, and not accompanied by a sensation of relief, give one ounce of castor oil, or better still, Pulv. Rhei. ^i. Rhubarb first opens the bowels and then constricts them. For the diarrhoea from irri- tant matter in the bowels it is excellent. An ounce of the Tincture of Rhubarb may be substituted for the powder. If the diarrhoea is profuse in quantity and debilitating, it may be well to give adults Gretas Prep., 3i. •Tinct. Opii., W x. Tinct. Catechu, 3 ss. Aq. Menth., § i. 4ta quaque hora. or: Ac. Sulph. Dil., TIB xv. Tinct. Opii, HE x. , Inf. Haematoxyli, |i. 4ta quaque hora. To this may be added : Cupri'. Sulp., gr. ss. Pulv. Opii., gr. i. Ext. Haematoxyli, gr. ii, at bed-time. If there be much pain, an enema consisting of a pint of starch with a drachm of laudanum may be thrown up the bowel. Then there is the diarrhoea of liot weather, [The salutary 01 at least non-injurious ef- fects of diarrhoea in children during hot weather, should be received with considerable allowance; for it is often very injurious, even fatal.] which isa*s well let alone as regards medicine, and where a milk diet is sufficient for mild cases. Whenever the tongue is furred, especially yellow, encourage 'the diarrhoea. Do not attempt to stop it. Where there is the pale stools of children, without bile, known as 'the white scour,' in warm neigh- borhoods, give three grains of calomel. In UR-EMIA. < y diarrhoea in infants, see if there is undigested milk curd in the stools. If so, mix the milk with some lime-water, and add a dessert spoonful of baked flour, or some baby's food, to prevent a firm curd forming. Also do this when curd is found in the stools of a typhoid fever patient. When the diarrhoea is uremic in old kidney disease, with either complete or partial sup- pression of urine, do not attempt to stop the diarrhoea until the kidneys act well. To stop the diarrhoea without this is to imperil the patient's life still further. Put poultices over the loins, give a milk dietary with a little gin, and Pot. Nit. grs. v. ' m Liq. Fer. Pernit, TTJ3 xv. Inf. Calumbae, I i. Quater in die, if you must give some medicine. But eschew opiates and astringents till the kidneys act freely. Always remember that opium acts upon the viscera, through their nerve-ganglia, as well as upon the intestinal ganglia, or the cerebral hemispheres. Many an untoward result from opium would be avoided if this were more universally recognized. Conse- quently, never give opiates carelessly when a viscus is gravely embarrassed, and especially if the kidneys are the seat of trouble. Keep up the action of the skin ; avoid all nitrogen- ized food which will throw more waste into the blood and add to the gravity of the posi- tion. Keep your head clear and cool, and remember your physiology, and what has been said before in Chapter II., on 'Excre- tion,' and you will steer your patient through the storm successfully, at least in a majority of cases. But do the wrong thing, then dis- aster is pretty sure to follow. You may be- DIARKHXEA. come the object of suspicion with some of the friends of the patient, or busybodies, who will press upon you another and more energetic line of action. This is one of the greatest trials to which the young practitioner is subjected. But pursue your course un- swervingly. Then there is a form of diarrhcea which is distinctly nervous, and the result of our 'long run' expresses, not stopping for a couple of hours. Here it is well to give the patient Pulv. Rhei., gss the day before, and five grains of Pil. Saponis Co. at bedtime, and to put him on a milk and corn-flour diet. In colliquative diarrh