I think I have observed a great many times that with increasing arteriosclerosis both become less acceptable, and sometimes distasteful. There are exceptions, as there are even in regard to the greatest danger to old men, viz., sexual excesses. If a stimulant be demanded, a small quantity of an alcoholic beverage, with plenty of hot water, provided it is not the habitual, though moderate, drink ; or, better still, an ammonium, or a camphor-preparation, will be borne best. Drinks and clothing should be warm and a warmer climate selected ; that does not exclude, however, that the cutaneous nerves and the circulation should be strengthened by the cautious use of cold water and short sessions of massage. Water is not required in the same quantities that are demanded by the activity of all functions in early and middle life. Nitrogenous food requires more, to do away with its refuse. The liver and kidneys of the old, however, may become exposed to the same danger from the lack of water as those of the newly born. If much is required, or is wanted, it should be taken in small and frequent doses, to save the shaky heart and the arteries from sudden overexertion and overdistention. Should elderly and old people sleep long? That depends, provided they be of equal health and vigor, in part on their occupation, or labor. Physical labor requires much sleep, mental less.* Physicians who labor both physically and mentally require more sleep than most of them can, or think they can, afford. As a general rule, old people who sleep long and eat much, provoke senile degeneration. Long sleep and big meals should be in inverse relation to one another. By attention to the suggestions contained in these remarks, premature symptoms belonging to old age — otherwise the most incurable condition — may be pre- vented or postponed. Some of them are merely physi- cal and referable to the organs of circulation. Myocar- dial changes are mostly responsible for congested liver, for dyspnea and for alleged nervous palpitation ; and cardiac and arterial degenerations cause angina 'pec- toris, and fainting spells. But the brain does not only suffer in its physical sphere, and from mental incom- petency ; the emotional life is affected also. Calcifica- tion of arteries goes hand in hand with that of ideas and of sentiments. The crotchetiness, distrust, and 4 Tissues and organs do not suffer equally from exhaustion, or waste. Atrophy leading to death consumes 90^ of all the fat, but only 30/o of all the albuminates contained in the body. The liver loses 7 05^ of its fat, the brain none at all. The albumin disappears mostly from the muscles and from the skin, but less from the muscle of the heart than from those of the rest of the body. Evidently heart and brain can stand a great deal of wear and tear, and have to. 24 vehemence of old age is of arteriosclerotic origin. I knew an erudite, lovable and famous man, known all liis long life for his gentleness and restful ways. Quite suddenly his temperament changed, without visible alterations of his physical life, to such an extent as to cause general surprise and regret. My prediction that he would soon die was verified by his speedy death from apoplexy. Such occurrences may be prevented, or postponed ; but is it worth while ? If the foolish question has been raised: Is life worth living? the other question may be justified : Is a long life worth attain- ing ? A conduct according to sensible hygienic rules does not only prolong life with the outlook of merely procrastinating the undesirable symptoms, but age may be made to advance uniformly and without a disturb- • ance of equilibrium. Then the capability to work may be less, but wisdom will take the place of activity, and serenity that of pushing restlessness. Nor will work be impossible. Those to whom it was an enjoyment will always be able to perform it under the influence of its mental stimulus. That is why so many who never looked for enjoyment as such, and as the principal aim to be reached, remain young, though they have lived long, and may mingle with and learn from those young in years. Still, there are those who do not judge life by the number of sunsets they have seen, but by the amount of labor performed in their own interest or in that of mankind. There was your townsman, who died of old age while still young, but forced more beneficent work into a single year than many gifted men into a decade. He knew it was overwork, and also knew his personal danger. If he preferred to live in the memory of the present and coming generations to staying here in the body long and comfortably, that was his right, and, as he saw it, his duty. As medical advisers, however, we 25 do not deal with exceptional cases, but with the aver- age individuals of the race ; it is for them that our rules are made, and to whom our advice is given. Those with ways and aims and horizons of their own, select their own paths. The actual treatment is not unpromising. It is true, however, that arteriosclerosis is more or less universal and progressive. To control it, the avoidance of injur- ies is of more importance than medicines. The slow, gradual, indeed physiologic variety is not attended with much danger, unless it be complicated by bronchitis or kindred disorders, which are often fatal. When it is preeminently renal the prognosis is worse, though not so bad as in the advanced cardiac form. The cerebral variety may prove fatal at any time, but, on the other hand, it may pursue a slow course, and even bear apoplexies with ease for shorter or longer periods. The objects of preventive and curative treatment should be to make arteriosclerosis as slowly progressive and as uniformly physiologic as possible. Thus the har- mony of well- developed and strong manhood will gently evolve into that of equable enjoyment and gradual decline. The methods employed for the reduction of adiposity, which is a frequent prodrome or complication of senile changes, are attended with certain dangers. When emaciation takes place rather suddenly, cardiac weak- ness and neurasthenia are common occurrences, and even moderate exertion causes dilatation of the heart. Arteriosclerosis depending on syphilis requires great caution, for it is as little improved by mercury as many other manifestations of " metasyphilis." The main treatment of progressive senile changes should be directed against uncommon arterial pres- sure, which means, mostly, an impediment in the peripheral circulation ; perhaps also against sclerosis 26 as such. There are more means to combat the former than there are to benefit the latter. Moderate gym- nastics, manual and mechanical massage, horseback- exercise, walking, also skating and cycling without overexertion, and a very moderate amount of climbing, are useful muscular exercises, but they should never overstrain the heart. Massage in the warm bath acts beautifully ; still better the carbonic acid of mineral baths, such as those of Nauheim. Massage and missage are, however, different things. It requires anatomic knowledge to alternately compress and release the bloodvessels and lymph-ducts between the muscles, and few but medical men will ever be good masseurs. Amongst the drugs, the nitrites act favorably by their power to dilate peripheral arteries, and the iodids by lowering blood-pressure and regulating the per- ipheral circulation. Cardiac insufficiency, which is brought about either by peripheral resistance, or by myocardial changes, or by both, requires, besides massage and rest, an occasional purgative and frequent diuretics ; the use of milk in renal arteriosclerosis whose first uremic symptoms are dyspnea, headache, vertigo and tremor, and, I think, in gout also ; when there is much venous obstruction with mild cyanosis, an occa- sional venesection ; or when much cardiac dropsy, calomel. Diuretin, or better, theobromin — now and then morphin — acts much more safely than digitalis, amongst the preparations of which it is principally digitoxin that in the usual daily doses of from two to three milligrams is too likely to contract peripheral arteries, and thus to increase blood-pressure. The last evolution of life is death. Still, even death may be deferred and eased by the methods not only of hygiene and diet, but of pharmacotherapy. The latter has been blamed for its insufficient effects when applied to impossible tasks. As long as it was 27 not founded on clinical observation and on experi- mentation, it was unsafe and unreliable. AVhen, how- ever, absence of preconceived theories, instruments of precision, and experiments on animals gave it a standing amongst the exact sciences, its claims grew. Unfortunately, the action of an internal remedy cannot be followed by a lay eye, like the knife of the operator, and the prejudices of the public, founded on its igno- rance, have too often guided the very opinions of the medical man. When the Vienna school, following the French under Broussais and others, elaborated pathological anatomy and diagnosis — I refer mainly to Rokitansky and Skoda — they declared that diagnosis and autopsy were the only quintessences of medicine. Even Wun- derlich proclaimed in his early career that medicine should be science, not art. But the very accuracy of the diagnoses and of autopsies facilitated the appreciation of the effects or of the failures of medicines. The co- operator of those illustrious men — Hebra — proved every day of his life that diseases, hitherto incurable, were cured and healed by local treatment. The isola- tion of morphin by Magendie, and of numerous alka- loids afterward, rendered medication more accurate and controllable. Animal experiments added wonderfully to the certainty of drug-action ; ^ it was soon learned that much of that certainty was due to the chemistry of the drugs ; this was the first step in the direction of compounding new drugs by synthesis. By immun- izing animals against the toxins of certain bacteria, bacteriologic research has created serumtherapy, and clinical experience has added organotherapy, with its wonderful results as far as tested. It takes all the " Experiments on man himself have always been the results of brutality or of ignorance, and do not count. Experimentation and observation are not identical. 28 egotism and mental limitation of the most famous modem serumtherapist to deny the great value of organotherapy. Still, Behring goes further than that. He coolly asserts that there is no such thing as experi- mental pharmacotherapy ; as he never knew of it, it should not exist. He belongs to the class of men who are generally not bent upon underrating the signifi- cance of their own doings ; it was left to genuine medical men to be overmodest in the appreciation of their labors. There has been, for instance, an egregious amount of talk among us about the power of nature and the incompetency of man. " Natura sanat, medicus curat." Nature is the healer ; the medical man just takes care of the patient, and sees to it that nature can perform its work. For instance, you are told you do not heal a chlorosis by giving iron; you simply make the diagnosis and furnish the iron, and nature's stomach and intestines and pancreas and lymph-apparatus do the healing. It is nature that saves, not you. You imagine you heal a man poisoned by plasm odia by giving him quinin ; you are mistaken, it is nature that grows cinchona -trees, absorbs the quinin, circulates it and destroys the plasmodia. You think you save a man by cutting down on an appendicitis or a liver- abscess ; far from it ; you are only the scavenger, but nature forms exudation and adhesion and closes the wound. You keep skin and table and instruments aseptic and prevent suppuration, and think you did some praiseworthy thing in the way of prevention ; you are mistaken, for nature did it by furnishing water and a healthy cell-proliferation and permitting you to com- pound soap and corrosive sublimate. You find a man in the gutter suffering from sunstroke kindly furnished by maternal nature; you take him away, work over him for hours with ice or stimulants and friction — no thanks to you, it is nature that empties his cerebral 29 ljlood-ves8els, eliiiiinates toxinn, iind restores him. You jump into the river and resuscitate a drowned j^erson; I am mistaken — not you saved him ; for it is nature that sets the machinery of his heart and lungs agoing. If " nature" gave him no respiratory and circulatory centers what could you do ? Or yovi find a starving man, with a loss of one-third of his weight and in the delirium of hunger, your milk and whisky and beefsteak never save him. For if nature had not given that man digestive organs and gastric juice and absorbents, poor you, where would you be ! Or you are called upon to heal a fracture ; you cannot heal it at all ; all you can do is to adapt the ends of the bones and keep them in juxtaposition. You say all this is farcical ? So it is, but the absurdity of it is not mine. If there is anything insipid in man's so-called reasoning, it is this unmeaning wise-acredom of the relations of " nature '' and doctor to each other, and the playing with words. " Words are grown so false, I am loath to prove reason with them " (Shake- speare, " Twelfth Night," etc.). Nature does not kill and does not heal. If there were consciousness in nature, she would feel indifferent about what she is, viz. : mere evolution. Nature is sun- shine that grows harvests and sunstrokes; she makes moonshine for lovers and for burglars, and rain to feed men and to drown them, and the sun warms the unjust and the just. Nature is a Mauser bullet ; stand in its way, you are hit ; dodge, and you are saved — it makes no difference to nature. In nature a diphtheria-bacillus has its democratic rights and duties like George Wash- ington, and it killed him ; she has no predilections, no no reasoning ; she is cause and effect. She can be led and doctored. The engineer heals her deformities in the interest of commerce ; insurance companies correct her failures or calamities ; indeed the logical mind of man and the logical necessities of " nature " are engaged in a constant strife for superiority. In matters of health and disease of homo sapiens the doctor utilizes or com- bats the doings of nature. By caring he cures. Curing has long ago lost its literal meaning.*' It is healing. What I mean by prevention — I may say prevention of death — in acute febrile diseases may find a brief illus- tration in the roborant and stimulating treatment ot pneumonia. During health, the innervation and force of the heart are not easily disturbed, but every pul- monary disease taxes its powers. There is no pneumo- nia that may not require cardiac stimulation some time or other, for the heart is sure to suffer within a few days from dilatation, first of the right side. To what extent cannot be foreseen. The principle of waiting for symptoms to turn up is a bad one. If medication were injurious by itself, that would be an excuse for not resorting to it. When heart- failure or collapse, however, has once set in, our remedies are mostly too late. Then to busy ourselves with our subcutaneous, medicinal or rectal hot- water injections or a perfunctory dose of digitalis, not " ut aliquid fias, " but " ut aliquid fieri videatur," is preposterous. The weakness of the heart is by no means physical only, viz. : the result of the overexertion caused by the difficulty met by the blood in its passage through the lungs, but it is dynamic and physiologic. Like all other infectious fevers, pneumonia acts probably by its toxin on the functions of the heart-structure, and by impeded circulation the heart is certainly injured in its own nutrition. As far as the facilitation of pulmonary 6 " Curare." 31 circulation is concerned, it is not inipro1)Hl:»Ie that stro- phanthus acts even better than digitalis ; at least phys- iologists like Gushing tell us so. The inference is that whenever we require an improvement of the pulmonary circulation for the purposes of oxygenization and of the aortic circulation in behalf of nutrition, and of the ra- pidity of circulation in order to facilitate the elimination of toxins, we shall do well to use strophanthus and digi- talis in combination. Should medication begin when collapse is setting in, or has occurred? This procrastination, with its sad re- sults, may be illustrated by some comparative proced- ure. It is parallel to the plan of estimating the value of feeding by giving nourishment when inanition is complete, and not before. When the donkey of the gospel disappears in a ditch on Sunday, make haste to pull him out on Monday. Allow the child to drown in your well, and be sure to cover it up — the well, I mean, on the day of the funeral. Build earthworks quickly when the enemy is in your camp. That is the theory on which antitoxin is injected on the fifth day, instead of the first or second, alcohol is refused in cases of sepsis, digitalis in dilatation and weakening of the heart, ice in peritonitis, morphin in alcoholic delir- ium, or venesection in acute overdistention of the right ventricle. These are not cases in which, as Musser says, " possibilities for good or evil cannot be estimated ; " they belong to that very large class in which it is "nec- essary to invoke remedies directed to the removal or counteraction of a definite cause." Statistics are said to prove that pneumonias will get well without medication. Which pneumonia, and whose? It should be a great satisfaction to a man dying of pneumonia to learn that his neighbor got well without medication, if stimulation in time, perhaps venesection, might have saved his own individual life. / 32 It is the duty of tlie physician to judge of and to treat liis individual case, and not the pneumonia of Louis and of Dietl, and of other statisticians. Treat the man who is sick, and not a Greek name. Prevention by medication and other treatment can be easily demonstrated by some such instances as follow : Most of the non-congenital diseases of the heart in the young and old are rheumatic. Endocarditis is liable to start quite early in acute rheumatism ; indeed, in some cases it precedes the joint- affection. The physician is either called, or arrives too late to prevent endocarditis. My order is invariably, after a single attack of rheum- arthritis has occurred, to go to bed, for one or more days, on the slightest recurrence of pain, and to take a num- ber of doses of sodium salicylate, which are kept ready for use. No delay should be permitted. Thus many a case of endocarditis, or return of endocarditis, is pre- vented. Relapses of ulcers of the stomach are often prevent- able. I do not claim that all those which depend on embolisms during a chronic endocarditis, or on cir- rhosis of the liver, can be greatly influenced, but the frequent form observed in young anemic persons may be prevented by antacid medication. It is self-under- stood that a careful and restricted diet, mostly milk, slow eating and small meals, are the sine qua nons of treatment. The treatment of the intestinal tract is partly dietetic, partly mechanical, partly medicinal, as of most diseases of other organs or systems. Disorders of the bowels, which could have been removed, lead to disturbances of the temperament and the mind, to night-terrors and convulsions, to rhachitis, to intestinal absorption with fever and erythema and other skin-diseases, not quite rarely to peritonitis, to cystitis from the immigration of intestinal bacteria, and to toxic nejihritis; in other not 38 uncommon cases to visceral abscesses. I need not go into particulars before this audience. Most of what I have mentioned is preventable by medicinal and dietetic treatment ; and the old physicians, with their maxim " qui bene purgat, bene curat," hit the nail quite fre- quently. Rhachitis has a tendency to get well ; that is, under favorable circumstances the softened bones grow hard. Moderate curvatures disappear, or nearly so, after years, and the flabby muscles become strong and active. Should we let it alone, and not employ air, and proper food, and cold water, and phosphorus, and iron iodid, and codliver-oil in mild as in bad cases ? What we have to expect, or to fear, in every case of rhachitis, are stunted growth, deformities of the extremities, the trunk, and pressure by the chest-wall on the chest; and secondary hypertrophy of the heart, subacute and chronic bronchial catarrh, with bronchopneumonia and the possibility of tuberculosis ; laryngismus stridulus, with possibly sudden death ; hydrocephalus and im- becility or idiocy. These serious consequences of rhachi- tis may be prevented by treatment. The hyperemia of the rhachitical skull and brain tends to physiologic irritation and growth ; not infrequently, formerly the rhachitic children were the best scholars, and amongst the geniuses of history there are many rhachitic heads. But, if the physiologic hyperemia is permitted to become pathologic, the result is meningitic effusion and insufficient or faulty growth. To treat rhachitis in time means to add beauty and brightness and intel- lectuality to the world. Phosphorus, mentioned already in connection with rhachitis, may be utilized as a preventive in other direc- tions.^ The structure of the blood-vessels may l)every defec- ' See my " Thcriipeutics of Infancy and ChiUlhooci." 2(1 Ed., p. 530. 34 tive, their walls being thin, fragile and pervious. In such cases hemorrhage, small or copious, is a common symptom. The frequency of hemorrhages in the newly born, leading, when in the cranial cavity, to asphyxia, convulsions, idiocy, or early death, is caused besides by the lack of coagulability of the infant's blood, by the thinness of the vessel-walls, whose tissue has not yet quite evolved from its embryonal state. This or a simi- lar condition may continue for life. This hypoplastic state, however, is not, of necessity, general ; it may be local. The early nose-bleedings of some, though they have no heart-disease, and the congenital tendency to aneurysm in places where the elastic tissue, either from arrest of local development, or by microbic destruction, is either scanty or absent (mostly at the origin of branches), prove the occasional occurrence of these cir- cumscribed and local defects. That thinness which predisposes to fatty degeneration of the intima and media, to sclerosis of the adventitia, to atheromatous endarteritis, and to the formation of aneurysm at an early age has not been made the subject of active treat- ment, so far as I know, except by myself. The number of such cases is naturally small compared with the total number of a large practice or clinic ; but I feel convinced that the administration of phosphorus — not phosphates of any kind — with its stimulant effect on the growth of connective tissue in general, has rendered me good ser- vice in habitual tendency to cutaneous, mucous and internal hemorrhages. Hemophilia of a moderate degree and local, as it frequently occurs, appeared to improve under its use, and the children to be safer and better developed. Nasal catarrh is apparently one of the mildest, as it is one of the most frequent affections of infants and young children. Their narrow nares, their creeping on the floor, and poking their sweet, dirty fingers into 35 every accessible cavity have far-reaching dangers. Nasal catarrh, with its hyperemia and soreness of the mucous membranes, predisposes to and causes chronic hypertrophy, adenoid growths,tumefaction of submental and submaxillary lymph-bodies, invasion of diphtheria and tuberculosis, and occasionally meningitis. That is so true, that adenoid growths of moderate size will get well without operation, solely by regular nasal irrigations. The latter alone will prevent and mostly heal the ma- jority of the consequences mentioned. The hyperplas- tic, so-called scrofulous swellings of the neck in children, when not too old, will disappear when the original seat of the infection and irritation is attended to. Many a bacillus-hunt would not be required if other preventives of diphtheria were employed in time. The same should be said of the mouth. Hypertrophy of the tonsils, man}'' forms of stomatitis, diphtheria, probably also most of the rare forms of tuberculosis and neoplasms of the pharynx can and should be prevented. I have always made it a rule to keep all the integuments clean. At least once a day a physiologic solution of saltwater is poured through the nares of every infant or child over whom I have control. Big adenoids should be removed, large tonsils resected. Tliere is more dan- ger in a dirty nose than in an unwashed face. Only do not be satisfied with merely ordering it. I have met with many a " trained " nurse who did not know how to inject or to irrigate a nose. A mother or a child's nurse should be instructed by yoifi personally how to do it. Here, as everywhere, when two do the same thing, it is by no means the same. There are many cases of nasal diphtheria, such as are most likely to re- sist the influence of antitoxin, which are still spared a fatal termination by persistent and correct irrigation of the nares and naso-i)harynx. What is our verdict in the case of a medical man 36 who would refuse artificial respiration to a drowned person, or water to one afflicted with gravel or gall- stones, or an antidote to a chemical poison, or antitoxin in bacillary diphtheria, or mercury, or potassium iodid in syphilis, or quinin in malaria ? That death, or long suffering, or life-long invalidism is prevented by appro- priate treatment in these extreme cases is well under- stood ; but the principle underlying all this holds good everywhere. Let me select a few more instances only. A baby with hereditary syphilis is kept "under treatment for several months, gets well, and is discharged. The child grows up and develops symptoms of syphilis at about the period of puberty, or about the twentieth or even the thirtieth year. These are the cases of so-called " retarded syphilis. " There are but few mothers with large families, growing old in hard work, that are en- dowed with a sufficient memory to recollect the illness of the baby born long years ago; and there are, in large cities where syphilis is mostly seen, but few medical men who see the same patient when a baby and when grown up. That is why, when syphilis is seen about the fifteenth or the twentieth year, it is easily believed to be its first appearance, unless there be a history of the disease. Personally I have seen but few such cases in which I could not trace this retarded syphilis back to the infant-eruption, so that the assump- tion of hereditary syphilis in the adolescent or adult not preceded by that of the infant, has become rather doubt- ful in my mind. Now, what is the lesson taught by such cases ? It is in the same way that you insist upon protracted treatment of acquired syphilis in the adult, and allow, for instance, no matrimonial alliance, unless the person has been free from the last symptoms for years, that the baby with hereditary syphilis should be kept under treatment and observation for years to pre- vent relapses and consequences. 37 These relapses and consequences need not be char- acteristically syphilitic. They may be — as Fournier calls them — parasyphilitic, and exhibit symptoms of all sorts of dystrophy of early or late rhachitis, of scrof- ula, or of tuberculosis. The constitution undermined by syphilis, the tainted blood, the impaired mucous membranes and slightly swelled lymph-bodies furnish ever so many inlets to invasion of different kinds. Be- sides, there is a peculiar class of cases with which we have a great deal to do. They occur in children of from 5 to 8 years, who are reported as having never been sick, but never well. They are not always listless, and lan- guid, but they are anemic, thin, pale, under-weight, and easily tired. You find no organ diseased, and the blood-count is not pathognomonic. If you leave them alone, and with the consolation that the seventh or the fourteenth year will set matters all right, you leave death or life-long invalidism alone. Many of these children have syphilitic fathers in whom the disease was, or was believed to be, extinct when that child was conceived. In those cases think of syphilis. No arsenic and no iron, no country air or hydrotherapy will do them any good before they have been treated carefully and persistently with mercury. These are the cases in which mercury adds to the number of red blood-cells in a remarkable manner. It has often ap- peared to me that the absolute belief amongst our predecessors in calomel, which was considered indis- pensable in all the diseases of infancy and childhood, was in part founded on the frequency of just such cases. Pertussis is a self-limited disease. Nature will get through with it ; but in many cases with the child also. As long as whooping-cough lasts there is danger from hemorrhages, from convulsions, bronchopneumonia, and perhaps connected with it, from tuberculosis ; cases of ence])halitis, spastic spinal })aralysis, liemiplegia, 2)08t- » 38 hemiplegic chorea, and paralysis of the abducens have been observed. Some of these direct results are liable to occur during the height of the disease. If we shorten the duration of the illness we prevent its opportunities for mischief. One of the first con- vincing experiences of this kind I had when a young practitioner. An infant with whooping-cough had a severe convulsion with every attack. Three days and nights either I, or a substitute, sat by, chloroform in hand, which had to be administered dozens of times every day. There is no doubt in my mind that by this active treatment I prevented either death or cere- bral hemorrhage, with idiocy or epilepsy. In gonorrhea of the male, or female, what do we prevent by active treatment and great care ? Stricture and epididymitis may not count for very much, and aspermia in the male may not be estimated a great misfortune, but there are many here who have seen gonococcal arthritis and polyarthritis, endocarditis septicopyemia, and death, or at least, ankylosis and long suffering. And the woman who is the victim of a man that was insufficiently treated over the apothecary's counter, or by his medical adviser, and perhaps thought himself freed of his gonococcal tenants ! We have all seen from that cause endometritis, salping- itis, peritonitis, parametritis and perimetritis ; and if not death, or lifelong invalidism, both of which do happen — at all events, sterility. Most, or all of these could have been prevented. Fine principles, when put to the test of daily practical experience, lose sometimes much of their ornamental glitter, and much of their usefulness. We hear the saying, and pass it on, that simplicity is of the greatest value in practice, and that a compound prescription is the damnation of the practitioner. If there be one in- dication, or one alleged indication, there should be one 39 remedy. Here is an example : In a case of collapse, lowering of the head is a good remedy ; compression of peripheral blood-vessels another; hot-water injections into the rectum a third ; salt-water infusion, either sub- tutaneous or intravenous a fourth ; the hypodermic use of alcohol, of camphor, of strychnin, of digitalis, of caffein, a fifth, sixth, seventh, eighth and ninth, the internal use of musk a tenth, and many more. If there be any simplicity and one remedy preacher who means to live up to his own notions and teachings, let him decide as to the single one of the indicated remedies he will select. There are only a few things that are quite simple and uncomplicated; one is a corpse, and the other a coffin. Who is it that made the rule that a prescription must contain one drug only, not two, nor three, though they chemically be ever so compatible, if not the nihilists who preached that there is nothing in medicine but autopsies, and that medicine is a science and not an art ; or, perhaps, it was only exaggerated antagonism to the yard-long theriacs of the Middle Ages. If there is in illness an uncomplicated condition, give an uncompli- cated drug ; but be sure that the organ to which you direct your remedy is also simple and uncomplicated. Is there such a thing? Let me again take the example of the heart. When we speak of heart-failure, or a de- bilitated heart, does that not mean something more than the flabbiness or overextension of an Indian-rub- ber bag ? A heart is composed of muscular, intercel- lular, fatty, elastic tissues ; it supplies all the organs with blood, and is itself thus supplied. Its circula- tion is pulmonary and nutrient. Its blood-vessels are exposed to the anomalies of all of the rest of the blood- vessels. In its nerve-supply there are sympathetic ganglia and fibers ; there is the pneumogastric, there are fibers coming from the medulla, and in the medulla 40 there is the head center of the circulation. Its normal innervation is that of the contracting muscle and of in- hibition besides. If this compound body fails in its co- operative action, is it probable that a single drug will restore it in all instances ? In some, certainly, for the strengthening of inhibitory power is often sufficient to gradually restore the disturbed equilibrium ; but in many cases the circumstances are not so simple. Digi- talis acts in many ways; according to Traube the slowing of the heart's contraction is its main effect; but aconite has a similar effect without any muscular influence. Digitalis increases arterial pressure, so does strychnin : digitalis causes diuresis by raising tension in the renal arteries ; it has that eflect in a lesser degree than stro- phanthus, which influences the arterioles less markedly. Digitalis also raises the blood-pressure, and thereby improves the nutrition of all the tissues, that of the heart included. To its action on the heart, and also of the arteries, is due the rapidity of circulation ; when, how- ever, its contracting influence on the small arteries is too intense, that rapidity is stopped. To restore it ni- trites are employed. Strychnin increases arterial pressure without an in- hibitory effect. That is why when only a moderate amount of inhibition, but competent pressure is required, small doses of digitalis should be combined with good doses of strychnin. Inhibition is rather paralyzed by atropin ; that is why rather large doses of digitalis are both tolerated and beneficial when combined with atropin. Spartein has little direct action on the heart- muscle and depresses the inhibiting pneumogastric ; that is why digitalis, when its muscle-effect is demanded, is borne when combined with spartein, in fair doses, foV a long time in succession. Such combinations are not only ])ermissible ; they are requisite. I give such combinations, say of 4 decig. daily, of digitalis or its 41 equivalent with half the amount of spartein for six weeks with perfect safety without going to see the patient, and with no cumulative eflfect ; the latter can- not always be avoided when digitalis is given alone. Though I must be brief, I should not conclude however, without the remark that the combinations of so-called heart-stimulants may be much more various. Like strychnin, ergot affects the medulla and the spinal-cord centers. Caffein, camphor and ammo- nia stimulate both the heart and the vasomotor centers ; hydrastis both the vasomotor centers and the peripheral vasomotors. Adonis appears to be almost identical with digitalis in its cardiac and arterial effects ; stro- phanthus, with its modified action on the heart and principally on the arteries, finds its associates in con- vallaria and apocynum. Fragmentary though these remarks have been, there is but one conclusion to be drawn from them, viz. : That it is sounder practice not to rely on a single remedy when the disorder is multiple, and the tissues complicated. To win battles and to render war the reverse of ridicu- lous, you want the cooperation of brave troops, of well informed and conscientious officers, an experienced commissariat, expert engineers, and an effective med- ical administration ; not a single one of them only. In addition, you want to be sure of the condition of your armamentary — be they rifles or drugs. It is true, here as everywhere, that brains come in handy for guidance. In closing, allow me to thank you for your patience in listening to the many fragmentary remarks I took this opportunity to make. The stand I take in the midwife-question from a social and a sanitarian point of view will probably be shared by many who will acquaint themselves with the ever-increasing necessities of the crowded millions of a large city or of the forced hermits of the backwoods. Nor will much ol)jection be 42 raised to what I presented in connection with premature senility. I am, liowever, not quite so certain about the universal approval of my views on therapeutic pre- ventives in the different camps of medicine. Indeed I am quite aware that many of those to whom we are under great obhgations for services rendered to the ad- vancing medical sciences, will quickly disagree. Anatomists, physiologists, chemists, bacteriologists — all these pillars of etiology and diagnosis — should, how- ever, suspend judgment. What I said was in the inter- est of the man, woman, or child not yet on the autopsy- table. The demands of actual practice in hospitals and at the private bedside cannot dispense with the results of the labors of those mentioned ; but clinical medicine requires more than the knowledge of morbid changes and their causes ; it demands means to prevent, to relieve, or to heal. That is what creates the superiority of clinical medicine over the special branches of study, and its standing as the first of all humanitarian sciences and arts. When this will be fully understood by the hosts of medical students and young practition- ers, therapeutics in all its parts, diet, hygiene, and drugs, will receive greater attention. The latter deserves it more from year to year, with the increasing results of laboratory-research, which adds to accuracy and safety. It is a queer spectacle to notice that the use and abuse of drugs is growing with the actual or pretended indifference of medical men in regard to them. More than $200,000,000 annually are spent on proprietary medicines in this country. The pirates of the single-pill persuasion are ably seconded by the wholesale manufacturers, who supply you not only with their wares, but with the formulae of your prescriptions. The contempt in which we are held by some of them is perhaps best shown by the way in which they show their conviction of our absolute ignor- 43 aiice. It is only a few days ago that I received a cir- cular in Avhich I was taught a prescription for sub- dividing a certain quantity of a synthetic drug and white sugar into twelve powders. As our medical schools are to furnish not only scien- tific specialists, but the physicians and the sanitarians of the country, I trust the time will come when, like the present anatomic, physiologic, histologic, and bacterio- logic instruction, a course in a pharmaceutic laboratory will be compulsory. 