12th. The pain seems relieved this afternoon, but the patient is still suffering from loss of rest. To take belladonna, a quarter of a grain; extract of hyoscyamus, four grains: mix, and make into a pill. 13th. Slept well; feels better. The medicine has acted too freely upon the bowels. 14th. Is quite free from pain, but still a numbness exists in the old place. Continue the mixture. 15th. The pain has entirely left; feels more cheerful, and free from pain than she has done for many months; appetite improving. From this time the patient continued free from pain, and gradually recovered a great amount of health and strength under the continued use of the above medicine, combined latterly with some tincture of iron. Case 2., 1851. C. P. In this case the disease had been existing more or less constantly; the pain scarcely leaving her entirely for some months. Is now suffering from bilious diarrhoea. After prescribing a dose of calomel and opium, followed by a rhubarb purge to cleanse away irritating matter, I prescribed iodide of potassium, two grains; liquor of strychnia, five minims; water, one ounce; three times a day. After taking the medicine for some days, the pain entirely ceased. The treatment was continued for six weeks, and she has had no return of the symptoms for now nearly twelve months. In Ague cases.-Jan. 5th, 1852. J. W. was taken ill yesterday, just before leaving work, with violent pain in the left side, and with uncontrollable shivering, followed by fever, with some amount of delirium, and then by profuse perspiration. Has not felt quite well for some time. Is suffering from the cold stage of intermittent at the present time; looks blue and pinched. Ordered calomel, three grains; Dover's powder, ten grains; to be made into a powder, and to be taken immediately. A compound jalap powder in the morning. Slept pretty well; medicine acted freely. Shivering returned in the morning. Altogether the patient does not think himself improved. Liquor of strychnia, forty minims; water, six ounces, to be made into a mixture, one-fourth to be taken every four hours. 7th. The time of accession of the paroxysm was later, and the attack less violent. 8th. Continues improving. From this time the patient gradually improved, the dose of strychnia being gradually diminished, and on calling to see him on the 14th, he had returned to work, feeling himself quite well. Dyspepsia.-J. S., aged thirty-five. Has been unwell for a length of time; has tried many things that have been prescribed for him, but without any benefit, and he believes very often with the reverse effect, and almost despairs of getting well. Has been under homœopathic treatment, but without advantage, and all the means he has used have been unsuccessful. Has dimness of sight; headache; un pleasant taste in the mouth in the morning; always sleepy; appetite capricious; sometimes feels hungry, but never enjoys his food; bowels at all times constipated; sleep at night disturbed. Prescribed a plain, simple diet, and to take the following medicine:-Liquor of strychnia, twenty minims; sulphate of magnesia, half an ounce; peppermintwater, six ounces: to be made into a mixture. One-fourth to be taken three times a day. Also, the following pill:-Mercury and chalk, three grains; powdered ipecacuanha, half a grain; extract of hyoscy-' amus, sufficient quantity to make into a pill. The medicine having been taken for some days, and produced the desired effect upon the secretions, I prescribed liquor of strychnia, thirty minims; peppermint-water, half a pint: one-fourth to be taken three times a day: aloes, two grains; to be taken occasionally before dinner. On seeing him three days after, he described himself as better in health and spirits than he had ever been before in his life; for the last two days he had been a different being; a load seemed removed. A week after, he continued remarkably well, ate, drank, and slept well, and enjoyed his food and exercise. He did not wish to relinquish his medicine, as each dose seemed to relieve him. From this time he went on well; but although now he has discontinued taking his medicine very nearly eighteen months, he still retains some by him, which he takes occasionally. These are a few out of many cases giving an average sample of the beneficial effects of this medicine: I have a number of cases which have been thus treated, but cannot say that my legitimate confidence has been ever overthrown.-Lancet, Dec. 24, 1853, p. 601. 23.-ON SLEEPLESSNESS, OR DISTURBED SLEEP, WITH [One of the chief causes of this state of the system is over-work, both of body and mind, but especially the latter. Everything must be done to warn the patient and enforce a more suitable arrangement of his labours; nevertheless, we should studiously avoid seriously alarming him, as this itself may increase the complaint. It must be a part of the duty of such patients to take a due proportion of daily exercise in the open air, and] When all that is possible has been done for avoiding the causes of mental worry, and when all needful advice and encouragement have been given, we have next to direct our attention to the consequences, some of which will often continue long after their exciting cause has ceased to operate; while others are perpetuated by some persistent and unavoidable source of anxiety. Now, the first and the most frequent consequence of over-work or anxiety-the one, too, which, more than any other, is productive of further mischief-is restlessness, or some form of disturbed and unrefreshing sleep. And the chief cure for this, after the cause has been as much as possible avoided, is an opiate at bed-time. So far as I can see, it is of little importance what preparation of opium or of morphia is used. For hospital patients I generally order the compound soap pill; one advantage of which is, that its name does not indicate its opiate nature. The dose must vary according to circumstances. In ordinary cases, five grains of the pill, i.e., one grain of opium, may be taken every night at bed-time. In a case of much excitement, with extreme restlessness or a threatening of delirium, the dose must be double or treble that which I have mentioned. In such cases, however, the opium would be best given in a liquid state, in the form of tincture, or the solution of the muriate or acetate of morphia. The time for the continued exhibition of the opiate must vary according to circumstances, and will be much influenced by the success of the treatment. The object is to break the habit of dreaming restlessness, and to procure sound and refreshing sleep. In many cases this object may be attained by the nightly repetition of the dose for one week. It is seldom necessary or desirable to continue the medicine for more than a month, though in some cases it may be expedient and beneficial to extend the period considerably. In many cases have found that the beneficial effects of the medicine have been immediate; the patient has slept soundly, the distressing dreams have ceased, the appetite has returned, and all the symptoms which depended on loss of sleep and loss of appetite have quickly disappeared. After a few nights of sound sleep have been procured by the opiate, the dose should be discontinued, and in most cases the patient will continue to sleep as well without the medicine as with it. There is, probably, no one medicine which has the power of quickly removing such a multitude and a variety of distressing symptoms as opium, when its action is really favourable, in the cases to which I refer. It is not, however, to any specific efficacy residing in the opium, but to the marvellous influence of sleep in refreshing both body and mind, that the benefit is really due. The value of the opiate consists in the fact, that, on the whole, it is the safest and most certain means of procuring sound sleep. The use of opium as a medicine is sometimes attended with unpleasant consequences, and it does not always effect what is desired. I proceed now to indicate some of the unfavourable results of the opiate treatment, and the precautions which ought to be observed in the use of the medicine. One of the most frequent discomforts attending the use of opium is a feeling of nausea and faintness either with or without headache in the morning after awaking. The best cure for this is a cup of coffee or tea, with some solid food, followed by a walk in the open air. In many cases the opium, although at first it may disagree, yet produces no unpleasant effect after the second or third dose. The nervous patients who require the method of treatment which I am advocating, almost invariably suffer from constipation,—a torpid condition of the bowels being, in fact, one of the natural consequences of the general debility which characterises the patients in question. Although the immediate effect of the opium is to increase the constipation, yet its ultimate tendency is to restore the regular action of the bowels by means of the invigorating influence derivable from sound refreshing sleep, and an increased appetite for food. The temporary constipation may readily be obviated by an occasional mild aperienta seidlitz powder, or a compound rhubarb or colocynth pill. The inconvenience arising from the astringent effect of opium upon the bowels is so easily met and removed, that it would never deter me from giving the medicine in any case which appeared to require it. One of the most serious objections to the use of opium, is its tendency, in some cases, to produce an effect the direct opposite to that which we require,-to produce wakefulness and excitement, instead of sleep and composure. It is only in a small proportion of cases that this difficulty arises. It may sometimes be overcome by changing the form of the medicine, or by increasing the dose of the opium or morphia, and, in other cases, by combining the opiate with a moderate dose of antimony-James's powder, or tartar-emetic-a combination which has been strongly recommended by Dr. Graves, to procure sleep and check delirium in many cases of fever. It must, however, be admitted, that some patients cannot tolerate opium in any form or in any dose; and nothing can better show the value of this drug than the difficulty of finding a substitute for it. We may try henbane and hop, and these will sometimes effect our object; but their action is very uncertain in comparison with that of opium. (Since this lecture was delivered, I have found reason to believe, that one of the best substitutes for opium in the cases referred to, is, chloroform, in doses of from Mx. to mxx., made into a draught with mucilage.) It is well to remember that an opiate enema will sometimes procure refreshing sleep when opium, in any form, administered by the mouth is either quite inoperative or productive only of distressing excitement or sickness. But may not the frequent repetition of an opiate dose become a necessity for the patient? May we not be instrumental in making him an opium-eater? I admit that the danger of such an evil, if real, would be a very fearful one. There are few results of medical practice which I should regret more than the reflection, that I had in any way contributed to render a recourse to narcotics or stimulants habitual or necessary to a single patient. I believe, however, that a cautious use of opium is attended with little danger of leading to so terrible an abuse of the drug. In giving opium to hospital-patients, I never tell them what they are taking; and one reason for preferring the compound soap pill, in such cases, is, as I have before intimated, that the nature of the medicine is not apparent from the prescription, if the patient should read it. The opium should be discontinued as soon as it can be dispensed with, as soon, that is, as restlessness and frightful dreams have ceased to harass and exhaust the patient. The rapid convalescence, and the renewed health, and strength, and spirits, which are wonderfully promoted by securing sound and refreshing sleep, will generally enable the patient at once, and without difficulty, to dispense with the use of opiates. I should withhold opium from a patient who neglects any directions which I have given him as to exercise, diet, and the general management of himself, and whose restlessness and nervousness appear to result from such negligence. In other words, I would not encourage a patient to trust habitually to opium for the removal of discomforts which might be avoided by the exercise of self-control, and by obedience to natural laws. The cases in which the opiate treatment is most rapidly and completely successful are those in which the nervous symptoms are the result of some past grief, or anxiety, or fatigue, the impression of which remains, and is perpetuated by the patient's inability to obtain refreshing sleep. In such instances, a few nights of sound sleep, procured by means of the opium, rarely fails to effect a rapid cure, and this, too, after the nervous symptoms have continued for many months, or even for years. The first, third, and fifth cases, the particulars of which I gave in a former lecture, are good examples of the beneficial effects of the plan of treatment to which I refer. Another class of cases in which equal benefit is often derived from a similar method of treatment, are those in which nervous restlessness has been induced by continued over-work, whether mental or bodily. In such instances, it is obviously desirable, as I have before intimated, that the patient should rest, or diminish his labours, if possible; but the patient may assure us that he has no alternative but to go on with his work, or to lose his employment, and with it his means of living. In such a case we may often prevent over-worked men and women from breaking down, and enable them to go on in comparative comfort by giving an opiate nightly for a week or two. Refreshing sleep will be induced, the appetite will return, and, as a consequence, the strength and appetite will revive. And the strength and spirits thus obtained are not false and artificial in the same pernicious way as the stimulus obtained from alcohol, by which too many are tempted in the circumstances to which I have referred. The temporary help which a languid body or mind derives from alcohol is generally followed by a corresponding amount of depression, and with this there comes a craving for a repetition of the stimulant. Another bad result of the 1 |