Lachesis mutus

Lecture III — The Ophidia — Lachesis

In considering the remedies derived from the animal kingdom, first I shall speak, in extenso, of the large family, formally called Ophidians, or snakes proper. Of those we use in medicine, we have first the Lachesis trigonocephalies. This was proved by Dr. Hering, sixty years ago. Next we have the Crotalus horridus. There is also a South American species, proved by Dr. Muir, the Crotalus cascavella. This has a few symptoms which will not yield to the administration of the other species. Then there are the Naja tripadians, one variety of the cobra, and the Elaps corallinus, so called from the shape of the scales on the back, which have something the appearance of coral. Lastly, there is the Bothrops lanceolatus, a remedy which, for a year or more, I have vainly tried to procure. It causes symptoms similar to that peculiar condition known as aphasia. Of these poisons, the first four are commonly used in medicine.

The poison of the snake is generally held in a little sac behind the fangs. On the under surface of the fangs is a small groove, into which empties a little tube that conveys the poison from the gland. When they are not in use they lie back on the roof of the mouth. If the animal is excited, it opens its mouth, the fangs are pushed forward, and at the same time, by muscular action, a drop of the poison runs down the canal and into the punctured wound. Now, what follows? That depends on various causes. The poison is more potent at some times than at others. The more angry the serpent is, the more active is its venom. If, in inflicting the wound, the fang passes through the clothing, some of the poison may thus be absorbed. Again, the power of resistance of the individual has some effect.

Thus, you may divide the effects of the snake-poison into three sorts: First, that which may be compared to the action of a stroke of lightning or a dose of Prussic acid. Immediately after the bite the patient starts up with a look of anguish on his face and then drops dead. This represents the full, unmodified, lightning rapidity of the poison. In the second form, commonly, the part bitten swells and turns, not a bright red, but rapidly to a dark purplish color, the blood becomes fluid, and the patient exhibits symptoms like those characteristic of septicaemia. The heart-beat increases in rapidity, but lessens in tone and strength. The patient becomes prostrated and covered with a cold clammy sweat. Dark spots appear on the body where the blood settles into ecchymoses; the patient becomes depressed from weakness of the nervous system, and then sinks into a typhoid state and dies. Or there follow nervous phenomena. Vertigo; dark spots before the eyes; blindness; a peculiar tremor all over the body; face besotted; dyspnoea, or even stertor. Or the process may assume a slower form. After the vertigo or trembling the patient remains weak, and the wound turns dark or gangrenous. All the discharges, the sweat, the urine and the faeces, become offensive. Dysenteric symptoms of a typhoid character show themselves. The patient goes into a low state, and finally dies. These are all phases of the action of these powerful poisons on the blood and the nerves.

The Ophidia, as a group, are characterized by their paralyzing action upon the nerves. They directly weaken the brain and heart action. Then follow decomposition of the blood, changes in the muscular tissue and local death from gangrene. At first there is developed a condition of anxiety, mental excitability and oversensitiveness of the brain, with hallucinations, anxious fear, etc. Afterward arises nervous depression, varying from such a debility as is observed in severe or protracted disease and advancing old age to mental confusion, stupor, low delirium and paralysis. Constrictions are noticed, as in the throat, larynx and sphincters in general. Haemorrhages, which are usually dark, decomposed, oozing from every orifice of the body; thus, also, ecchymoses. They are most marked under Lachesis and Crotalus, less in Elaps, least in Naja. Face sickly, pale, anxious; bloated, dark red or bluish. Special senses altered; dim vision, excitability of brain and spinal cord, accounting for the mental restlessness and bodily sensitiveness. Predominant, even with the pains, are torpidity, numbness, twitchings, formication.

You already see in what class of diseases you will find these poisons curative: Inflammations and fevers of low, destructive type, such as gangrene, malignant ulcerations, diphtheria, typhoid, pyaemia, carbuncles, etc. With all there are tendency to faint, muscular prostration, trembling as in drunkards, irregularities in circulation, flushes of heat, apoplectic congestions, paralysis.

Nerves especially affected by the snake-poisons seem to be the pneumogastric and spinal accessory; consequently, you expect to find, as eminently characteristic, symptoms of the larynx, of the respiration and of the heart. All of the Ophidia cause choking, constrictive sensation coming from irritation of the pneumogastric. All of them have dyspnoea and heart symptoms.

Moreover, the Ophidia produce a yellow staining of the skin. This is not jaundice, and must not be confused with that affection. It comes from the blood, and is due to the decomposition of that fluid, just as we find in yellow fever, typhus or pyaemia, and not to the staining of the skin with bile. This is most marked in the Crotalus. Again, you may find that the skin is dry and harsh, as if there was no vitality in it, or it may be clammy, more characteristic of Lachesis. The discharges are foetid, even the formed faecal stools of Lachesis are horribly offensive. As the heart is weakened by all, we find as characteristic, running through them all, weak heart, cold feet and trembling—not the trembling of mere nervousness, but the trembling of weakness from blood-poisoning. The cold feet are not indicative of congestion, as you find under Belladonna; they are attendant upon a weakened heart.

The heart symptoms of Naja resemble greatly those of Lachesis, but its cardiac symptoms point more markedly to the remote effects of cardiac valvular lesions; those of Lachesis more to the incipiency of rheumatic disease of the heart. In Naja there is a well-marked frontal and temporal headache with the cardiac symptoms; the heart beats tumultuously. The patient awakes gasping for breath. Naja causes more nervous phenomena than any of the snake-poisons.

Under Belladonna the head is hot and the feet are cold, because the blood surges toward the head. Under the snake-poisons the feet are cold, because the heart is too weak to force the blood to the periphery. All of the snake-poisons cause inflammation of the cellular tissue. Accordingly, we find them valuable when cellulitis arises in the course of typhoid fever, diphtheria, etc. The color of the affected part is dark red, purple or black, like gangrene.

In diphtheria Crotalus has had more clinical confirmation in the persistent epistaxis.

Elaps claims attention in cases of haemoptysis, when the blood discharged is dark in color, especially when the right lung is affected. Antidotes for these poisons are numerous. There is no doubt that alcohol is a powerful antagonist to the snake-venom. It is remarkable how much alcohol can be swallowed by persons bitten by serpents, without the manifestation of the usual physiological effects. Dr. Hering recommends radiating heat as an antidote. The part bitten should be held close to a hot fire. Ammonia and permanganate of potash have been recommended as antidotes, and cures have been claimed for each.

IvACHESIS.

Now let us consider Lachesis. First of all, in order that you may comprehend the subject, I wish to refer to those symptoms which are universal. We notice that Lachesis is especially suitable to persons who have a peculiar sensitiveness of the surface of the body. Even if the patient is lying in a stupor and you touch him, as when you try to feel his pulse, he will show that he is disturbed thereby. Hard rubbing or pressure may cause no trouble at all. Dr. Hering, who first proved Lachesis, could never tolerate tight clothing about his neck. He always wore his collars loose. He noticed that, during the proving, this symptom annoyed him more than usual, so he faithfully made note of the occurrence, but did not place much value on it. Since then the symptom has been confirmed many times in practice, and has been found true, not only as a local symptom of the neck, but as a symptom of the body universally. The explanation seems to be that there is an irritation of the peripheral nerves; and because of this the patient cannot bear touch or slight pressure. It is no evidence of inflammation, and must not be confounded with the inflammatory soreness of Aconite, Arnica or Belladonna. The sensitiveness also differs from that of Apis, which has a bruised, sore feeling more acute than that of Arnica. It also differs from the sensitiveness of Nux vomica and Lycopodium which have it about the waist only after a meal.

Next we find that the drug is prone to affect the left side of the body. Homoeopaths have been criticised for attributing to drugs the power of acting upon one side of the body in preference to the other. The simple fact that disease chooses sides ought to be enough to lead one to believe that drugs may do the same. The left side of the body is more apt to be affected by drugs having a depressing action, because that side of the body is weaker.

Another peculiarity of Lachesis, arising, probably, from its action on the pneumogastric nerves, is its influence on sleep. This is a universal symptom, that the patient is worse from sleep; he sleeps into an aggravation. If it is true that Lachesis has an influence on the centres of respiration, and is a weakening drug, we can understand why sleep should aggravate. During our waking hours we have some control over respiration. During sleep this voluntary control is lost. It is when this change takes place that the weakening effect of Lachesis is asserted. Lachesis is a very valuable remedy at the climaxis, especially in the woman who has exhausted herself by frequent pregnancies and hard work. In this worn-out condition there occurs a sudden cessation of the menses. Suppression or non-appearance of discharges always makes the Lachesis patient worse. Perhaps previous to the climaxis she was worse before the flow than during it. The pulse is weak and tremulous. There are the peculiar headache, and the annoying symptoms of the mind, hot flashes, and nervous symptoms characteristic of the drug.

Now, let us consider some of the symptoms of Lachesis in detail. First, as to the mental symptoms. The patient is nervous, anxious, loquacious, jumping from subject to subject; sometimes with fear of being poisoned, which causes him to refuse the medicines you offer. Interesting stories excite immoderately and even intensify the bodily symptoms. Sometimes the anxiety assumes a peculiar type, and he imagines that he is dead, and preparations are being made for the funeral. The loquacity may be accompanied with sleepiness, and yet inability to sleep. Ideas chase each other so rapidly through the mind he cannot write them down. He sits up late at night, mental activity then being unusually increased. But this stage of excitement is commingled w rith another, which soon entirely supercedes it. The mind is weakened. The patient is able to think only with difficulty. He has to stop to think how words are spelled, like Sulphur, Lycopodium and Medorrhinuni. There is vertigo, w Torse on closing the eyes, or on sitting or lying down. Vertigo with deathly paleness; syncope. In this vertigo, fainting, etc.. you may compare Theridion, which has dizziness worse with the eyes closed; but, as a distinctive feature, you will find that under the latter remedy, vertigo, pains and nausea are intensely aggravated by noise. Both remedies are useful in sunstroke. Arsenic, Hydrocyanic acid, Digitalis, Veratrum album and Camphor, you should compare in vertigo and fainting from cardiac weakness.

Laurocerasus or Hydrocyanic acid may be needed in long-lasting faints; there seems to be no reactive power; the face is pale and blue, the surface cold. If fluids are forced down the throat, they roll audibly into the stomach. If the syncope is attendant upon some poison in the system, as scarlatina, the symptoms are similar, the eruption being livid, and, when pressed, regaining its color very slowly (cf. Ailanthus) . Digitalis also rivals the Ophidians in syncope, with the antecedent dim vision; the pulse is generally very slow, and the patient complains of nausea and deathly weakness in the epigastrium. Camphor and Veratrum album display coldness and cold sweaty skin; in the latter remedy, the forehead is cold and sweaty. The face may be red while lying, but if raised, it turns pale and the patient faints; the pulse is thready.

Camphor has icy surface, sudden sinking, as in Laurocerasus , and although so cold, he throws off the clothing as soon as he is strong enough to move, even though he be still unconscious.

Heaviness of the head on waking, with nausea and dizziness, as in sunstroke. In ill-effects of the heat of the sun, compare Glonoine, Belladonna y Natrum card, and Theriolion (see above). The first two, with bloated red face, paralytic weakness (Glon.), unconsciousness, etc., resemble Lachesis, but the latter displays the effects of heat upon one already exhausted. All the Ophidians are intolerant of warm, relaxing weather, and so we find many ailments returning in spring and summer. In the Lachesis case, the patient may be an inebriate or one prostrated by mental fatigue. The sun's heat makes him languid, dizzy, faint, or, if congestions ensue, the face is dark red, and looks at the same time sunken and cadaverous; the extremities are cold. Here Camphor may be demanded if vitality is ebbing away, the fainting spells growing worse, and the body icy cold and bathed in cold sweat. Both Lachesis and Natrum carb. are useful when hot weather fatigues, in which case you should compare, also, Selenium and Natrum mur. Returning now, after this digression, to the mental symptoms of Lachesis, we find that the delirium is of a low, muttering type. At other times the patient seems to be going deeper and deeper into a torpid state, with coolness of the extremities and trembling of the hands and body. When asked to protrude the tongue, it comes out tremblingly, or catches in the teeth, and is usually coated dark brown, sometimes with little blisters on the tip. The lips crack and ooze dark blood. Loquacity is commonly followed by depression, and by weakness which amounts to a typhoid state; then comes delirium, but not of the violent Belladonna type.

These symptoms show Lachesis to be an invaluable remedy in typhoid fever, and in fact in all diseases of a typhoid type. The loquacity just referred to is particularly characteristic. Another mental state which these typhoid patients may have is the delusion that they are under some superhuman power. Diarrhoea is usually present, and the stools are horribly offensive, a strong characteristic of Lachesis, which will also aid you in diphtheria, scarlatina and other diseases of this type. Even when the stools are formed, and in every way natural, they give forth this horrible odor. Lachesis may also be indicated late in the course of typhoid fever, when the patient lies in a stupor with dropping of the lower jaw, and other symptoms indicative of impending paralysis of the brain.

Let me now speak of some of the concordant remedies of Lachesis in these conditions. In the loquacity just mentioned Lachesis should be compared with Stramonium, Agaricus, Mephitis, Actea racemosa and Paris quadrifolia.

Stramonium you will distinguish from Lachesis by the red face and the other evidences of great sensorial excitement.

Agaricus exhibits great loquacity associated with convulsive movements of facial and cervical muscles; merry, incoherent talk. In Mephitis it is as if one were drunk.

Under Actea racemosa the loquacity is usually associated with menstrual suppression, with puerperal mania or as a part of delirium tremens, for which Lachesis also is a useful remedy. Actea cures wild imaginings of rats, etc., sleeplessness, wild crazed feeling about the head, incessant talking with continual change of subject; the patient must move about. Lachesis has more marked trembling of the hands, diarrhoea and greater exhaustion with the loquacity and hallucinations. Paris quadrifolia causes a garrulity which is much like that produced by tea, a sort of vivacity with love of prattling. In these typhoid types of fever you may compare Lachesis with Opium, Hyoscyamus, Arnica, Lycopodium, Apis, Muriatic acid, Baptisia and Rhus toxicodendron . Opium is indicated in typhoid fever with this threatening paralysis of the brain, but the sj Tmptoms under it refer to a very different condition from that of Lachesis. The symptoms which indicate Opium, in addition to this dropping of the lower jaw, are unconsciousness, stertorous breathing, and a dark or brownish-red hue of the face. The darker red the face the more is Opium indicated. With Lachesis the cerebral condition is due to the effect of the typhoid poison on the brain. With Opium it is a secondary effect of the intense congestion of that organ.

Hyoscyamus is perhaps more like Lachesis than is Opium. Here we find the lower jaw dropped; the patient is weak and trembling, and there is twitching of the muscles. This last is a necessary symptom of Hyoscyamus. Here, too, there is snoring breathing, as in Opium, with involuntary stool and great prostration.

Arnica is also indicated when there is great congestion of the brain. The patient lies in a stupor, with lower jaw dropped and eyes fixed, but, even in stupor, as if the bed was too hot and hard. The face is dark red, and stool and urine are passed involuntarily. In addition to these symptoms, we find under Arnica a symptom which differentiates it from the drugs just mentioned, namely, dark spots here and there on the body, irregular in outline and having a black and blue appearance—ecchymoses, as they are called.

Lycopodium is the complement of Lachesis, and is, therefore, more apt to be indicated after it than any remedy I have mentioned. The symptoms which indicate Lycopodium are these: The patient lies in a stupor, with lower jaw dropped and rattling breathing. There is a rattling of phlegm in the throat during both inspiration and expiration, and the eyes are fixed and set, and are filled with mucus. Lycopodium is the most important remedy we have in impending paralysis of the brain; by that I mean to say that it is the most frequently indicated.

Apis has not so markedly the dropping of the lower jaw, but resembles Lachesis in muttering delirium, trembling tongue, etc. The bee-poison, however, causes a nervous fidgetiness with sleepiness and inability to sleep; later, muttering delirium; happy, strange expression; abdomen swollen and extremely sensitive, hands and forearms cold, involuntary stools. This sensitiveness is a bruised feeling, differing from the hyperesthesia of Lachesis.

Muriatic acid displays a sunken face, tongue smooth as if deprived of papillae, or brown, shrunken and hard; sliding down in bed from muscular weakness.

Baptisia has dark, besotted face, drowsiness and stupor, goes to sleep while answering questions; discharges from the bowels dark, fluid and very offensive.

Rhus tox. may simulate Lachesis in one phase of its action, namely, when drowsiness appears and there are muttering; dry, cracked tongue, sordes and involuntary stool. In degree the snake poison is undoubtedly lower than Rhus, and, therefore, other things being equal, comes in later. Rhus has a well-marked restlessness with relief from motion; loquacity is not prominent; the tongue has a red, triangular tip, and the discharges are never so offensive as those of the former remedy. You must bear in mind that Rhus is an erethistic remedy, and must be very similar to existing symptoms if it is to be continued after torpidity sets in without erethism.

Leaving the mental symptoms of Lachesis and the indications of it and its analogues in typhoid fever, we will next consider its head symptoms. We find that it produces a pulsating headache usually in the left temple and over the eyes, with mental confusion before the development of a coryza, relieved as soon as the coryza appears. This is a universal characteristic—as soon as a discharge is established the patient feels better. I have relieved dysmenorrhea with Lachesis when there was a headache preceding the dysmenorrhea, but relieved as soon as the flow was established. At the menopause there is burning in the vertex.

In catarrhal and rheumatic headaches you may compare Mercurius, Cinchona, Pulsatilla, Bryonia and Gelsemzum.

Mercurius relieves headache from suppressed coryza when there is pulsating headache with pressure towards the nose, worse when warm in bed and from damp, windy weather. Cinchona, when the pain is worse from the least draught of air. Bryonia and Pulsatilla come into use when the checked catarrhal secretion is thick, and yellow and green, respectively. Gelsemium, when motility is lessened and the patient is drowsy, with neuralgic pains from occiput to forehead and face.

The headache may also arise from disordered stomach or bowels, or may be an accompaniment of fevers and of diseases of zymotic origin. The patient has an upward tendency of the blood, with throbbing in the head, dark redness of the face, puffed face, confusion of the mind, all the way from simple confusion to absolute stupor, often accompanied, too, by partial blindness, palpitation of the heart, and fainting. The pains about the head are briefly as follows: Sharp sticking, which seems to concentrate at the root of the nose; at other times the pains go from the zygoma to the ear. This direction of the pains is characteristic. As a parallel of this shooting pain from the zygoma to the ear we have pains from the head going down through and into the eyes. These are all characteristic pains of Lachesis. There is an additional one that I will now mention, which is probably of rheumatic origin; pains in the head, going down into the shoulders and neck of the affected side, and often accompanied by slight stiffness of the neck, either catarrhal or rheumatic.

You may have Lachesis indicated in severer forms of the head trouble; for instance, in inflammation of the membranes of the brain; sharp pains in the head, making the patient scream out; tongue showing papillae; strawberry tongue; patient rolls the head from side to side, and bores it into the pillow. Particularly useful is Lachesis when an exanthem, like scarlatina or erysipelas, has not developed or has been repercussed. The patient is at first very drowsy, but unable to sleep; there is trembling or palpitation of the heart. Soon stupor ensues, and he becomes heavy and sleepy, and you can rouse him only with difficulty.

In intense head pains, as in meningitis, you should remember the relation between Belladonna and Lachesis, the difference between these drugs being rather one of degree. Both are suited to meningitis from erysipelas, to scarlatina, to apoplexy, etc. ; but the former represents the initial stage of these diseases, or the state in which, even though there be stupor, there are still evidences of irritation and not wholly of depression. Thus, under Belladonna, the patient often starts from his heavy sleep, cries out, grinds the teeth, awakens frightened, etc. His pulse is usually strong and the surface congestions are bright red, or if more intense, deep red and livid. If there is an eruption, as in scarlatina, it is red, even if sparse, but vitality is not so low that the extremities are cold or the rash bluish, and the cellular tissue infiltrated and threatening an unhealthy suppuration, as in the snake-poison. Often, however, after the use of Belladonna we find evidence of cerebral exhaustion, or blood-poisoning, or impending paralysis, in which case Lachesis may be required. The patient still cries out in sleep or awakens frightened, the tongue still shows elevated papillae, the head is hot, and the face is red; but the pulse is quicker,and more feeble, the feet are cold, the surface heat is irregularly distributed; the mind is more befogged and drowsiness is stealthily creeping on, the inflamed part or the pseudomembrane or the eruption, as the case may be, is becoming more purplish—these indicate the change.

Considering the action of Lachesis on the special senses, we find the eyes to be affected by the drug. Dim vision, worse on awaking; dark spots appear before the eyes; sight suddenly seems to fade away; feeling of faintness and palpitation of the heart; with these, nervous trembling. Lachesis is one of the leading remedies for dim sight as an evidence of heart disease and vertigo. We may also use it with good effect for what we may term retinal apoplexy. There it acts very well in causing an absorption of the blood.

The nearest remedies to Lachesis in this condition of the retina are Crotalus, Phosphorus, Arnica, Belladonna and Hamamelis. Scrofulous ophthalmia calls for Lachesis when the symptoms are decidedly worse after sleep. There are gr:at photophobia and pains of a burning, stitching, shooting character, extending to the temples, top of the head and occiput. There are also itching and stinging in the eyes and lids, worse from touch. Vision is misty, with black flickering before the eyes.

Crotalus may also be called for in keratitis when there are cutting pains around the eyes, lids swollen in the morning, ciliary neuralgia with these cuttings, worse during menses.

In the diseases of the ear, Lachesis ma}' be remedial for roaring and singing in the ears, and other sorts of tinnitus aurium, which are relieved by putting the finger in the ear and working it. This shows that the tinnitus is not congestive, but of catarrhal origin, especially from occlusion of the Eustachian tube. The wax is altered in quality and becomes pasty and offensive. There is swelling between the ear and the mastoid process, with throbbing pain and stiffness. You can here compare Nitric acid, Capsicum, Auruni, Hepar, and Silicea. Elaps and Crotalus also have an action on the ears. Elaps, like Lachesis, produces a catarrh with black cerumen, buzzing in the ears, and otorrhcea. In Elaps, the discharge is yellowish-green, liquid and bloody. Only Lachesis seems to have the Eustachian stoppage, better from shaking the finger in the external meatus. Crotalus causes a stuffed feeling in the ears, worse on the right side, associated with a feeling as if hot ear-wax was trickling out. The face in the Lachesis patient varies, of course, with the condition that obtains in the system at the time. In many of the diseases in which the remedy is indicated the face has an earthy pallor. In exanthematic diseases it is apt to be bloated or puffed, and bluish-red; if the eruption comes out, it appears sparsely and is of a dark color. Anxious and painful expression with the stupor; face disfigured, puffy, hot, red and swollen, as after a debauch; blue circles around the eyes. With abdominal troubles, as in ague, the face is earthy gray.

Lachesis also has convulsions of the face; lockjaw; distortion of the face; stretching the body backward; screaming; feet cold and itching. Sudden swelling of the face.

For swollen face, you may compare: Apis, Belladonna, Arsenic, Lycopodium, Hyoscyamus, Rhus tox., Pulsatilla, Stramonium, Kali carb., and Phosphorus.

For sickly, pale, or earthy complexion: Arsenic, Bufo, Lycopodium, Carbo veg., Rhus tox., Cinchona, Phosphorus, and Phosphoric acid. Blue around the eyes: Arsenic, Cuprum, Phosphorus, Secale cornutum , and Veratrum album.

Debauched look: Baptisia, Hyoscyamus, Carbo veg., Nux vomica, Sulphur, Opium, Nux moschata.

In facial convulsions compare: Nux vomica, Hyoscyamus, Belladonna, Hydrocyanic acid, Lycopodhim, Cicuta, Camphor, Phytolacca, Arsenic.

Apis, Arse7iic, and Kali carb. agree in puffing of the face even without any redness. In the first, there are also smarting of the eyelids, and a sensation of stiffness. In the second, the swelling is noticed about the eyes, glabella and forehead (also Natrum ars.). Kali carb. has the well-known sacs of the upper lids, and also sudden swelling of the cheeks.

The expression, complexion, etc., of Arsenic are very similar to those of the snake-poisons. The anxiety and pain are marked by more restlessness, irritability, fear of death, etc., and the sunken face is more completely Hippocratic, with pointed features, sunken eyes and cold sweat. When yellow or earthy, it is cachectic. If trismic symptoms are present, the patient will be found lying pale, and as if dead, yet warm. Suddenly he arouses, and goes into severe convulsions, only again to relapse into this sort of cataleptic rigidity. The eyes are partly open, with gum on the conjunctiva.

Lycopodhim has pale or yellow face, deeply furrowed, looking elongated. The convulsive movements are unique. All through the provings of this remedy you will note an alternation of contraction and expansion. And in the face you note the tongue pushed out and withdrawn, spasmodic trembling of the facial muscles, angles of the mouth alternately drawn up and relaxed, alse nasi alternately expanded and contracted. The eyes may be partly open and covered with mucus — a bad symptom, generally being indicative of brain exhaustion. Phosphorus has a pale face, but it is distinguished by its ash}-, anaemic appearance. This should be remembered, since this remedy, like the Ophidia, has puffy face, sunken features, blueness around the eyes, and blue lips.

Hyoscyamns is very similar to Lachesis in facial expression and in the convulsive phenomena. It has a marked stupid, drunken look; the face is distorted and blue, or swollen and brownish red; starting; twitchings of single groups of muscles are noted. Hunger appears before the attacks.

Stramonium is readily distinguished by its swollen, turgid face, fright on awakening, renewal of spasms from light, and contracted gloomy expression, with wrinkles of the forehead.

Hydrocyanic acid closely agrees in convulsive symptoms and in the color of the face. As in Llaps, fluids roll audibly into the stomach; but in the latter it is more as a spasmodic contraction of the sphincters, followed by sudden relaxation. In convulsions, the surface, in the acid, is pale blue, and the muscles of the face, jaw, and back are affected. Suddenly a shock is felt, which passes like lightning from head to foot, and then comes the spasm. Here, the remedy is more like Cicuta and Helleborus than Lachesis. But Cicuta has, like the snake-poisons, great difficulty in breathing from spasm, and, more than any remedy, it produces staring; the spasm is followed by disproportionate^ severe weakness.

Camphor is readily distinguished from Lachesis by the coldness and by the withdrawing of the lip, showing the teeth.

Lachesis is indicated in erysipelas of the face. Characteristically, the disease will be most marked on the left side. The face at first may be bright red, but it soon takes on a dark bluish hue. There is considerable infiltration into the cellular tissue, so that we have puffiness of the eye of the affected side. Now the characteristic bluish face is due to the accompanying weakness. Kven in the beginning, while the skin is still red, the pulse, though accelerated, is weak, the feet are apt to be cool, and the head is affected sympathetically, so that the patient readify becomes drowsy, with muttering delirium; or the opposite condition of pseud o-excitement—the loquacity w Thich I have already mentioned—obtains.

You must now distinguish this erysipelas of Lachesis from that of the remedies which are akin to it; among these is Belladonna . In its early symptoms, Belladonna bears no resemblance to Lachesis. But in the course of the disease, when the inflammation is so intense that the bloated face grows bluish red, threatening gangrene, or when the brain becomes affected, differentiation is necessary. Here, both have hot head and cold feet, delirium, dry tongue, etc. But Lachesis suits when the cerebral symptoms fail to yield to Belladomia, and the excitement gives way to muttering stupor. The pulse is weak and rapid, and the cool surface of the limbs is plainly due to failing vitality rather than to the upward tendency of the blood. Crotalus holds the same relation to Belladonna.

Apis mellifica is indicated in erysipelas when the affected parts exhibit a tendency to become cedematous. If the face is involved, the eye-lids protrude like sacs of water. The face is usually of a pinkish hue, or it may be dark purplish, but it never has the deep bluish-black hue of Lachesis.

Although there may be a similar destructive tendency, the condition of nervous irritation produced by the bee-poison is very different from that of any of its congeners. It is a fidgety, nervous state, a fretted feeling, which deprives the patient of sleep, although he feels sleepy. Rhus toxicodendron is suited to the vesicular form of erysipelas. The patient is drowsy, as under Lachesis, little blisters form on and about the face, and the face is dingy red, not the bluish-black of Lachesis nor the purple of the intensified Apis case.

If vesicles form in the Lachesis case, they quickly fill with pus. Speaking relatively, Rhus produces more vesiculation and burning, stinging and itching, with more aching of the limbs and restlessness; Lachesis, more bluish-red inflammation, with gangrenous tendency. Euphorbium, since it causes gangrene with erysipelas, anxiety as from poison, apprehensiveness, dim vision, etc., deserves your notice. The right cheek is of a livid or dark red hue, vesicles form as large as peas, and are filled with a yellow liquid. The pains are boring, gnawing and digging in character, and extend from the gum into the ear, with itching and crawling when the pains are relieved.

Lachesis may be indicated in prosopalgia when the pain is worse on the left side, and when there are tearing pains above the orbit and digging and screwing pains around the malar bone. Delirium appears as soon as the eyes are closed.

The teeth decay and crumble. The gums are swollen and bluish, with throbbing pains. Lachesis may be successfully used in periodontitis and abscess at the root of a filled tooth (compare Mercurius, Hepar, Silicea, Lluoric acid and Petroleum.

Of the allied remedies in toothache none is so similar as Mercurius, which, like Lachesis, relieves when the gum is inflamed and the tooth decayed, with abscess at the root. It is said to have a direct action on the dentine. The pains are tearing and pulsating, and shoot into the face and ears. In Lachesis the gum is swollen, and at the same time dark red and livid, or it is tense and hot and looks as if it would crack. Mercurius is markedly worse from the warmth of the bed. Lachesis often follows the latter, or is needed at once if the patient has been previously salivated. Only Mercurius has dirty gums, with white edges.

In sore mouth, aphthae, etc., Lachesis should be compared with Baptisia, Nitric acid, Muriatic acid, Arsenic and Apis; while Mercurius compares more with Carbo veg., Staphisagria, Kali chlor., Iodine, Sulphuric acid, Nit} ic acid.

Baptisia has blood oozing from the gums, which look dark red or purple, salivation,foetororis, offensive stools, and thus far is precisely like Lachesis. Both, too, are indicated in the stomacace attending the last stages of phthisis. Decide by general differences and also by the tongue, which, in the former, is yellow or brown down the centre, with red, shining edges. In the latter, it is red, dry and glistening, especially at the tip, and has its sides and tip covered with blisters. Nitric acid causes an acrid saliva ; the pains in the mouth are pricking in character, as from a splinter; the aphthae and gums are usually whitish; there are raw places, with shooting pains.

Muriatic acid presents deep, bluish ulcers, with dark edges; the mucous membrane is denuded in places, the raw spots being dotted with aphthae.

Arsenic looks very much like Lachesis, with livid, bleeding gums, edges of tongue blistered, or ulcerating diarrhoea. The burning is more intense, and is associated with restlessness, compelling motion in spite of the weakness. In gangrena ofis it causes more acute pain and heat in the mouth; both have bluish or black sloughing ulcers. Arsenic has more mental irritability.

Apis has blisters marking the border of the tongue, or in clusters. The mouth is usually rosy-red, swollen, and there are marked stinging pains; the margin of the tongue feels scalded, as does the mouth generally.

Carbo veg. , Staphisagria and Sulphuric acid agree more with Mercurius; the gums are white, spongy, ulcerated, rather than livid. Staphisagria may cause sores, which look bluish-red or yellow; especially is it needed after abuse of Mercury, or in syphilitic cases when the general debility is marked with sunken face, blue around the eyes, etc. Sulphuric acid produces great debility, yellowish-white gums, yellow skin; the patient is nervous and hasty, and constantly complains of trembling, which, however, is not observed by others.

Salicylic acid causes the common canker sores, with burning soreness and foetid breath.

Lycopodium produces similar sores near the fraenum of the tongue, Lachesis at the tip, and Nitric acid, Phytolacca, Natrum hydrochlor. on the inner sides of the cheeks.

Phytolacca has some systematic resemblance to Lachesis here as well as in the throat (see next lecture). Both cause great weakness, dim vision, sunken face, blueness around the eyes, sore mouth, tongue blistered along the edges, tip of tongue red, roof of mouth sore, profuse saliva. The poke-root may be distinguished by the great pain at the root of the tongue when swallowing. These pains are a part of the tired aching and soreness which are general over the body. Helleboi'us produces canker in the mouth, but the sores are yellowish, with raised edges.

Returning to the subject of decayed teeth, it may be noted that Kreosote cures pains extending from teeth to left side of face; teeth decay rapidly, gums bleed, the blood being dark; but the accompanying facial pains are burning, and the patient is excitable, nervous, even, as in children, thrown into convulsions.

Thuja causes a decay just at the border of the gums, leaving the crown apparently sound. Gums dark-red in streaks. Teeth turn yellow and crumble.

Lecture IV (continued)

Lachesis (conti?iucd)

Next we take up the action of Lachesis on the nose, throat, and chest, so far as catarrhs are concerned. Lachesis produces watery discharge from the nose, which is often preceded by throbbing headache, worse in the left temple and forehead, and relieved as the coryza establishes itself. Accompanying this coryza sometimes are vesicles about the nose, redness, puffiness of the face and lids, creeping chills over the body, palpitation of the heart, and great relaxation of the whole system; hence it is suitable for a cold which occurs in relaxing weather, consequently in the spring of the year. Lachesis may also be used in ozsena of mercurial or syphilitic origin. Here you may compare Kali bichromicum, which follows Lachesis well; and also Aurum, Nit) ic acid, Mercmius, and Lac caninum. The last-named drug cures syphilitic ozsena and angina when the corners of the mouth and alsenasi are cracked.

The cold may extend to the throat, and then we will find that the tonsils are enlarged, particularly the left one, or the inflammation may tend to spread from the left to the right tonsil. The throat, when examined, exhibits a red hue, not bright or rosy-red, but bluish. The patient complains of a sense of constriction, as though the throat were suddenly closing up, or a sensation as though there were a lump in the throat which he must constantly swallow, but which as often returns. Pains in the left side of the throat extending to the tongue, jaw, ear. Rawness and burning. The throat externally is exceedingly sensitive to touch. Unless the tonsils are going on to suppuration , there is relief from swallowing solids, while swallowing of liquids and empty swallowing increase the pains. I except suppurating tonsils because, when they are large and stop up the fauces, nothing can be swallowed; then the attempt to take anything is followed by a violent ejection of the food, through either the mouth or the nose. But with the ordinary catarrhal sore throat, when the tonsils are not parenchymatously swollen, the swallowing of food often relieves the irritation for a time. The cold may travel farther down and involve the bronchial tubes, when a different class of s3 rmptoms develops. The patient may suffer from tickling, irritating cough, which is especially apt to come on as he drops off to sleep, arousing him as if he were choking. He can bear nothing to touch the larynx or throat, so that he loosens his neckband. These, briefly, are the catarrhal symptoms of Lachesis. But suppose, while we are considering this locality, we look to more serious affections which may manifest themselves in these parts, diphtheria, for example. Lachesis may be indicated in diphtheria of one or all of these parts. Symptoms for which you will be called upon to prescribe it are mostly those that I have already given you, with these points in addition: The discharge from the nose is thin, sanious, and excoriating; a really dangerous objective symptom. The throat is, if anything, a darker red than in the catarrhal state. The membrane is more marked on the left tonsil, or has an inclination to go from the left to the right. It early develops that gangrenous state which obtains in diphtheria, with the attendant foetid breath, and the increased danger of systemic infection. The tissues surrounding the throat are often infiltrated so that you have swelling of the glands about the neck, and also of the cellular tissue. The swelling may be so great that the neck becomes even with the chin and sternum. The lymphatic glands are swollen, too, and have a dark purplish hue, and threaten suppuration. When pus does form, it is not a laudable pus. The child is drowsy, even though feverish; the heart, though beating more rapidly than normal, is evidently greatly weakened, as is shown by the feebleness of the pulse and coolness of the extremities. This is the kind of diphtheria in which you can hope much from the use of Lachesis. The diphtheritic deposit may extend down into the larynx, and the remedy still be indicated. You must not infer from this that Lachesis is the remedy for laryngeal diphtheria; but when it has the characteristic symptoms which I mention, it may be needed; the patient arouses from sleep smothering, and has a diphtheritic, croupy cough. Crotalns and Naja, like Lachesis, have relieved in diphtheria. The former has been selected when the epistaxis is persistent; blood oozes from the mouth, not merely coming from the posterior nares but escaping from the mucous membranes of the buccal cavity.

Naja has helped in cases just like Lachesis, when the larynx is invaded; the patient grasps at the throat, with a sensation of choking, the fauces are dark-red; there is foetid breath, and short, hoarse cough, with raw feeling in larynx and upper part of the trachea. Lac caninum is very similar to Lachesis in diphtheria, but is readily distinguished by its peculiar habit of alternating sides. Starting on one side, frequently the left, the soreness and swelling, and even the membrane, suddenly shift to the opposite side, only to return, in a few hours, to the starting point. The membrane is grayish-yellow and curdy, and if ulcers form, they shine like silver-gloss. Lycopodium, which also resembles Lachesis, has aggravation of the symptoms from 4 to 8 p. m. The right side is mostly affected; the child awakes from sleep frightened or cross and angry.

Apis is to be distinguished by the oedema of the throat, the stinging pains, the blisters on the border of the tongue, etc.

Again, you may find Lachesis of great service in affections of the lungs. We ma)- use it in asthma when there are present one or more of these few symptoms. The patient arouses from sleep with the asthmatic paroxysm, and cannot bear the least pressure about the neck or chest; finally, he coughs up a quantity of water}- phlegm with great relief. This last is a neglected characteristic of Lachesis in asthma. I have succeeded with it in relieving an incurable asthmatic for months. In pneumonia Lachesis may be useful, but not in the early stages of the disease. There is nothing in the provings of Lachesis to suggest that it will be useful in pneumonia. It does not cause the engorgement of the lungs, the fever or the fibrinous deposit. But it ma)- be indicated in the later stages of the affection, when it assumes a typhoid form, especially when an abscess forms in the lungs. Brain symptoms, such as low muttering delirium and hallucinations, appear. The sputum is frothy, mixed with blood, and purulent, and the patient is bathed in a profuse sweat.

Sulphur is, perhaps, the better remedy to prevent suppuration when there are no typhoid symptoms, but be careful how you give Sulphur if tuberculosis has been developed by pneumonia. To do so is almost like giving a person running down hill another push. It will only hasten the end.

In chest affections Elaps is sometimes of great service. It affects the right more than the left lung, but both may be diseased. In the morning there is pain in the right side severe enough to prevent the patient's getting up. There is a feeling of coldness in the chest after drinking. The cough is accompanied by intense pains in the chest, worse in the right apex, as if it were torn out, and the sputum consists of black blood.

You may use Lachesis in phthisis, not necessarily to cure, but to relieve. Remember it when, in the course of typhoid fever or pneumonia, tubercles have been deposited in one or the other lung. You may use it in the advanced stages of tuberculosis of the lungs when the patient has a retching cough, which arouses him from sleep, and which ends in expectoration of tough, greenish muco-purulent matter, which causes gagging, and is vomited rather than clearly expectorated; when the patient sweats during every nap, the sweat being most copious about the neck, shoulders and chest, and when the strength is greatly reduced and the pulse indicates extreme prostration. Next we turn our attention to the alimentary canal from the mouth down. I referred to the tongue in speaking of the typhoid condition. Lachesis is useful for weakness of digestion in patients who, from some vicious habits, from abuse of Mercury, or of Quinine, or of alcohol, have so exhausted their stomachs that even the plainest food causes indigestion. Acids especially disagree, aggravating the stomach symptoms and causing diarrhoea. Sometimes a gnawing pain is relieved by eating or improves immediately after a meal, but soon a heavy pressure, as from a weight in the stomach, and other symptoms of indigestion show themselves. There may be a craving for coffee and oysters, which may not disagree.

The liver is affected by Lachesis. Like all the snake-poisons, it causes jaundice. Even when abscesses form it may be useful by reason of the tenderness on pressure, intolerance of clothing, and deep throbbing in the right hypochondrium.

The bowel symptoms are not numerous, though they are important. We find diarrhoea caused by the drug, with watery, horribly offensive stools; diarrhoea during the climaxis; diarrhoea of drunkards. Especially may Lachesis be used in chronic diarrhoea with great debility and aggravation in spring weather. The tongue is smooth, red and shining {Kali bi.). The abdomen is bloated; very sensitive to touch about the waist. Constant tormenting urging in the rectum, but not for stool. It is merely a spasmodic condition of the bowels with an unduly irritable sphincter. The rectum protrudes and is held by the constricted sphincter; after stool there is often a sensation in the rectum as from the beating of little hammers. These symptoms are common enough in dyspeptics, particularly in those who have, abused alcohol. They are not infrequently associated with large, protruding haemorrhoids, which are worse at the menopause, or with scanty menses, with stitches upward at each cough or sneeze. They occur also in connection with constipation. The patient attempts to strain at stool, but must desist on account of pain in the sphincter. Unsuccessful urging; the anus feels closed. Stool hard, like sheep's dung, and excessively offensive.

In dyspepsia Lachesis is very similar to Hepar. The latter remedy, however, has relief of the symptoms from the use of condiments. Under Hcpar the plainest food disagrees. The cravings are unique. As if knowing instinctively what will "tone up" the stomach, the patient longs for condiments or wine. Eating relieves the relaxed feeling, but food annoys as soon as the digestive process begins its slow and imperfect work. The bowels move very sluggishly, even when the stools are soft.

Cinchona, too, enfeebles digestion and induces great weakness and languor after meals. It also has a craving for coffee-beans. Fruits induce diarrhoea with intestinal fermentation. Both cause fulness after eating, but only in Cinchona is the fulness so severe as to cause pain, with little or no relief from belching. Bitter eructations and bitter taste belong to each; the latter has the altered taste after swallowing, food retaining its normal taste while being masticated. The discharges from the bowels and the flatus are offensive; yellow watery stools, undigested. But the marked aggravation at night, after a meal, and the resulting prostration, are not at all like Lachesis. In dysentery, etc , when putrid or gangrenous changes occur, the choice is more difficult. Both have cadaverous smelling discharges of a chocolate color, with coldness and great debility. And, although Cinchona is far preferable if the disease is of malarial origin, such a complication does not contra-indicate the snake-poison. The apparently close similarity is also enhanced by the nervous excitability in both. Light touch is distressing, the epigastrium is sensitive, and clothing annoys in each remedy. But this in Cinchona is an increased general sensibility, while in Lachesis there is general torpor, with hyperesthesia of the cutaneous nerves. The former is suitable when the offensive discharges follow a severe, rapidly exhausting inflammation, or when the frequency and quantity of the evacuations have greatly reduced the vitality, thus favoring retrogressive changes. If hectic symptoms are present, the choice is rendered more certain. In addition, we may also refer to the well-known anaemic symptoms of Cinchona, paleness, ringing in the ears, easy fainting, etc., which show at once how it affects the blood.

Mercurius presents many points of similarity with Lachesis. The latter frequently follows the former, and also antidotes its abuse. There are loss of appetite, coated tongue, nausea with oppression, and epigastric tenderness. Pressure in the pit of the stomach produces a deadly faintness. The stomach hangs heavily, even after a light meal of food of ordinary digestibility. The sensitiveness of the stomach to the clothing is a part of a symptom which is completed by a similar tenderness over both hypochondria, with fulness and upward pressure from the abdomen. The patient cannot lie on the right side. If hypochondriacal, he is suspicious, anxious and restless at night, with vascular erethism and sweat. In fact, this erethism is directly contrary to the torpid Lachesis.

In abdominal inflammations with suppuration, as in typhlitis, both remedies are useful and follow each other well. Mercurius has its ever-present perspiration without relief; stools slimy, or much straining, with or without stool. Lachesis follows when the symptoms threaten a typhoid condition. The patient can lie only on the back with the knees drawn up; if he turns to the left side, a ball seems to roll over in the abdomen.

In the rectum and anus, Mercurius has more persistent tenesmus; protrusion of the rectum, which looks inflamed and blackish; Lachesis \ more spasmodic tenesmus, with constriction of the anus, which tightly constricts the prolapsed rectum. Both have chronic constipation. The former induces much straining, with tenacious or crumbling stools; chilliness during defecation.

Arsenicum intensifies the gastric and systemic weakness to which we referred in the remedies just considered. While it is true that the patient does not fully realize his want of strength, and hence does not care so much to lie quietly, nevertheless the actual amount of his vitality is seriously reduced. In a word, he is excessively weak without feeling so fatigued. Any exertion produces fainting. Taste is lost, or is bitter, sour, and putrid. The stomach feels swollen as if full of water. Craving for acids and for coffee; the latter, as in Lachesis, agrees with the patient. There are burning feelings, red rough tongue, and anxiety and distress after eating, as in subacute gastritis, which no remedy pictures better. Nausea is frequent, and often periodical (12 p. m.) and is accompanied by great prostration. The vomiting is of manykinds, but is distinguished from the bilious, slimy, or bloody emesis of Lachesis by its irregular convulsive character, indicative of gastric irritability. Lachesis is adapted to the nervous weakness and trembling of drunkards; spasm of the stomach, spasmodic constrictions, relieved temporarily by eating; vomiting of bile or mucus; Arsenic is adapted to burning periodical pains, with sour acrid vomiting; violent thirst, but vomits the water.

Cadmium sulph. has nausea, } Tellowish or black vomit, saltish rancid belching, cold sweat of the face, burning, cutting in the stomach; cramps after beer, griping in the lower part of the bowels. Both this remedy and Lachesis induce marked sensitiveness to touch upon stomach or abdomen, spots of burning soreness here and there over the swollen abdomen (peritonitis); offensive, bloody, chocolate-colored discharges, as in dysentery, with constriction in the bowels; cutting pains in bowels. But in Arsenic there is more lamenting with agonized expression; restless moving despite the pains. The constriction of the intestines is torturing; the patient declares he cannot stand it, and rolls about in agony, despairing of his life. The extreme tenderness of the pit of the stomach denotes a more positive state of acute inflammation than Lachesis causes.

In the vomiting of yellow fever Lachesis has, in addition, brown coating on the teeth and abdominal tenderness.

Arsenic has also spasmodic protrusion of the rectum; very painful tenesmus with burning; haemorrhoids, especially in drunkards; they protrude at stool with burning. Alvine discharges are offensive, dark, sometimes involuntary, with great weakness and coldness. But Lachesis has less tenesmus recti, the distress there being attributable to a constriction of the anus not found in the other drug. Arsenic, moreover, causes more acridity of the stools, with rawness and excoriation of the anus.

All that I have here stated regarding the difference between these two drugs might be tersely stated thus: One causes intense irritability and acnte inflammation of tissue, mental anguish, and extreme prostration; the other, torpidity, with loss of vitality, but associated with nervous excitability, constrictions, and cutaneous hyperesthesia. Still, some minds require more attention to detail; and every one retains general mental impressions more accurately if they are formed with due attention to particulars.

When there is ulceration of the bowels, tendency to sloughing, with offensive, purulent, or bloody discharges, the two remedies are very nearly allied. Vitality is at a very low ebb; blood oozes from the cracked lips and tongue, and the extremities are cold. But even here the best distinctions are the mental irritability of Arsenic, and the intolerance of pressure of Lachesis.

Carbo vegetabilis resembles Lachesis in weak digestion, complaints of drunkards, flatulent asthma, constriction of the oesophagus, annoyance from clothing about the waist, offensive, bloody, decomposed, purulent stools, collapse, etc.

There is craving for coffee, but it does not relieve. Milk disagrees in both remedies, but only the snake-poison has craving for it. Carbo veg. has aggravation from fats, tainted meats, fish, oysters, foods causing flatulency, ices, vinegar, and sour cabbage—the latter principally on account of the flatulency it causes. Eructations are sour, rancid. Both drugs have relief of flatulent distension from belching, but Lachesis has an ill feeling in addition, which is relieved. Both drugs experience freer breathing after belching. In Carbo veg. this is expressed as the lessening of a tension and upward drawing which marks the costal attachments of the diaphragm; in Lachesis there is a relief after eructations which seem to suffocate him. They come rapidly, and induce the ever-present Lachesis constriction of the throat. The latter remedy also has empty eructations, which intensify the pains.

Carbo veg. has heaviness, fulness, sleepiness after eating, with fulness of the abdomen, almost to bursting. Burning in the stomach is also increased. This heaviness is very characteristic, and is noted likewise in the abdomen, which seems to hang heavily; also in the head, which feels as heavy as lead. The burning is attended with a creeping feeling up to the throat. In Lachesis, the fulness and pressure is as from a load, and the sense of repletion induces lowness of spirits. There is, also, a feeling as if a lump were forming in the stomach and also in the bowels; burning, with hard abdominal distension, and a feeling as if a stone was descending; he must stand still or step cautiously. This lump is presumably a part of the Lachesis constriction, which we have so often designated as highly characteristic. In Carbo veg. the flatus is more rancid, putrid, or, when passed per anum, burning, moist, offensive. Its incarceration with burning is a cause of many of the symptoms, and it is more in quantity than in the snake- poison. It also causes a bearing down upon the bladder and sacral region. Lachesis relieves a gnawing gastralgia, when eating lessens the pain; Carbo veg. cures when there is burning, with a constrictive cramp, bending him double; the pains are paroxysmal and take his breath. The burning spreads up to the chest and down into the abdomen, seemingly following the sympathetic.

Tenesmus recti is most prominent in Carbo veg., anal constriction in Lachesis It is this latter symptom which explains, as we have before observed, the ineffectual urging to stool; while in Carbo veg. the urging is fruitless on account of the pressure of flatus. Both have bluish, protruding piles, as after debauchery. This constriction distinguishes them, as do also the headache and diarrhoea In each there is throbbing headache, but Carbo veg. has more of the heaviness, and the diarrhoea is thin.

In typhoid conditions, whether the specific fever, or as a sequel to peritonitis, dysentery, etc., Carbo veg. causes the more perfect picture of collapse, while in Lachesis the cardiac debility, drowsiness, cool extremities, etc., indicate failing vitality, but the patient is not so near death as in the former drug. Inthe collapse of Carbo veg. there are tympany; cold legs, especially to the knees; filiform pulse; cool breath; absence of discharges from the bowels; or involuntary, putrid, bloody, purulent diarrhoea.

In hernia, Carbo veg. has anxiety, as in Arsenic, but with uneasiness rather than restless change of place; and it resembles Lachesis in the annoyance of the clothing, foulness of the parts, if strangulated, etc. There is, however, more meteorism and foetid flatus. Graphites has anxiety, melancholy; tip of the tongue blistered; feeling of a lump in the left side of the throat, over which the food seems to pass with difficulty; on empty deglutition, a constrictive retching from the oesophagus up to the larynx; must loosen the clothing after eating; gastralgia, relieved by eating; chronic gastritis, especially after abuse of alcoholic drinks. Sensation of a lump in the stomach; flatulent distension of the abdomen, with congestion to the head; foetid flatus. Suffocative spells arousing from sleep, must jump out of bed; compelled to eat something to relieve the pain. Offensive stools. But this remedy causes more flatulence than Lachesis. The gastralgic pains are burning and griping, and the feeling of a lump in the stomach is accompanied by a constant beating; the heartburn is rancid. The suffocative spells are usually worse after 12 p. m. instead of during or after a sleep at any time; and the constriction noticed on falling asleep is of the chest instead of the larynx. The offensive movements from the bowels are half-digested, dark and pappy, indicating the imperfect digestion which is so characteristic of this remedy.

There is some resemblance in the constitutional symptoms of Graphites and Lachesis, since both are needed at times in phlegmatic patients; but the former is related to a distinguishing type; fat, cold and costive; skin herpetic, rough and disposed to crack and ooze a glutinous fluid. Aside, then, from a few resemblances to the snake-poison, Graphites belongs more with Arsenic, Nux vomica and Lycopodium. It resembles the first two in gastritis and gastralgia; the latter in flatulency. Sulphuric acid resembles the snake-poisons somewhat, especially in the ailments of drunkards. Its corrosive effects, however, are distinctively prominent, as shown in the violent inflammation of the alimentary canal. But the nervous system is so involved that several symptoms look like those of Lachesis, as, for instance, epigastrium sensitive, constrictive feeling in the bowels, griping, cutting, twisting, with faint-like nausea; trembling, pale face, apprehensiveness; fluttering pulse; cramps in the pharynx; he cannot swallow; oesophageal stricture; great weakness, etc. Both, moreover, crave brandy. The acid acts well when the patient is weak, emaciated and complains of trembling, which, however, is more subjective than objective. He is anxious and restless; must do everything hurriedly. The face is pale, and sometimes presents dry, shrivelled spots, especially when the haemorrhoids are worse. Eructations are sour. The stomach feels relaxed and cold. Wine may palliate and distilled liquors aggravate, as in Lachesis; but the peculiarity of the acid is that the stomach rejects cold water unless it is mixed with brandy. The abdominal muscles are spasmodically retracted. Stools are yellow, like Lachesis, but present a chopped appearance, and are stringy; they are watery, diarrhoeic and very offensive. Piles are moist, burn, and may prevent defaecation.

As the acid causes croupous formations, it should be remembered with Lachesis when the stools indicate such a condition in the intestine. The acid also resembles Elaps; drinks feel like ice in the stomach; but only the former has the relief from the admixture of spirit. The Elaps diarrhoea resembles that of the rest of the order, but this remedy is particularly called for when the stools consist of black, frothy blood with twisting pains in the bowels.

Colchicum deserves mention here, especially since, like Lachesis, it causes coldness or cold feeling in the stomach {Elaps), intolerance of pressure of the clothing, burning in the stomach, vomiting and purging, spasms ofthe sphincter ani ', urging to stool, offensive flatus, offensive diarrhoea, sensitiveness to the least touch, very much exhausted, slow breathing, feeble pulse. But there is generally present nausea, worse from the smell of food; if the patient sits or lies very quietly, the vomiting is suppressed (like Veratrum) . Senses too acute; a bright light, touch or strong odors irritate him (like Nux vom.) . Vomiting and purging as in cholera morbus; the sphincter ani contracts after each stool, with fruitless urging. The similarity, then, exists chiefly in the sensitiveness to touch and the constrictions of sphincters with weakness, other symptoms being so different as to render a choice easy. (See also below.)

In cholera Lachesis has been employed when the vomiting was renewed by the least motion and the nausea was attended with a great flow of saliva. As Colchicnm has precisely the same symptoms other indications must decide.

In reflex irritation, as convulsions with variegated, slimy stools in teething children, and rolling of the head, Colchicum resembles Podophyllum.

Belladonna, Lachesis, Rhus tox. and Baptisia constitute a group serviceable in peritonitis, enteritis, etc.

Belladonna differs from all in the character of the inflammation. It is only when the affection becomes asthenic that the others are needed. Lachesis follows Belladonna when, especially in children with inflammatory diarrhoea, constipation suddenlj 7 sets in with abdominal swelling and tenderness, particularly at one spot, or if suppuration ensues and Mercurius fails, or, again, if gangrene threatens.

In peritonitis Lachesis is indicated late in the disease, when the fever still continues and is worse after i p. m. and at night. The slightest touch on the surface of the body is intolerable. Typhoid symptoms complicate the case. It may even be indicated when there is typhlitis after the formation of pus. It follows, particularly, Belladonna, Bryonia or Mercurius corrosivus. It is also similar to Rhus tox., but, having more typhoid symptoms, comes in later in the case.

Rhus tox. requires drowsiness, the fever remaining high or increasing; restlessness; tongue dry^, parched, brown, with red, triangular tip; diarrhoea slimy, watery or putrid, yellowish-brown and bloody, involuntary during sleep; generally it is accompanied by tearing down the thighs, while Lachesis has painful stiffness from the loins into the thighs. In typhlitis, in which affection either may follow Belladonna, Rhus tox. has relief from pressing the swelling gently from below upward; Lachesis, intolerance of touch.

In periproctitis Rhus tox. may be needed if the inflammation is of traumatic origin; Lachesis, if an abscess forms and fails to point, the surrounding tissues presenting a purplish hue.

Colchicum compares with Lachesis when the prostration is extreme, with coma, hot abdomen, cold extremities, and thready pulse; if raised, the head falls back and the jaw drops; the face is hippocratic, the tongue is protruded with difficulty, and the bowels move involuntarily. But the tympany is more marked in the former; and the stools contain white flakes or shreds; the tongue is either thickly coated brown or it is bright red, except at the root, where it is coated. According to provings and cases of poisoning, Colchicum does not cause sensitive abdomen below the epigastrium.

Aryiica develops a profound stupor, with blowing respiration, dry tongue, brown down the middle, distended abdomen, and involuntary faeces and urine. It may be distinguished by the ecchymoses and the bruised aching, inducing restlessness, which latter is relieved if the patient's clothing is smoothed down and his position changed. Among the remedies causing constriction of the anus, the following are worthy of notice: Bellad., Caustic, Nitric ac, Nat. mur., /gnat., Kalibi., Opium, Plumbum, Mezereum, Coccul.

The first has pressing and urging toward the anus and genitals, alternating with contractions of the anus; spasmodic constriction of the anus, as in dysentery.

The second, Causticum, causes fruitless urging to stool, with anxiety and red face.

Nitric acid causes sticking in the rectum, as from a splinter; the constriction occurs during stool and lasts for hours afterward; the rectum feels as if torn.

Natrum mur. has a sensation of contraction in the rectum during stool; the faeces tear the anus; frequent ineffectual urging; spasmodic constriction of the anus.

fgnatia induces a proctalgia; contraction, with cutting, shooting pains; contraction of the anus worse after stool. Symptoms are inconsistent, irregular, fitful, as in hysteria.

Kali bi. has a sensation of a plug, similar to Lachesis; diarrhoea of a brown, frothy water, spurting out in the early morning and followed by tenesmus ani.

In Opium the anus is spasmodically closed during the colic, with obstinate constipation. Plumbum is very similar.

But all these are readily distinguished from Lachesis by the characteristic symptoms of the latter: Tormenting urging in the rectum, but on account of constriction of the anus it becomes so painful he must desist; protruding piles, with constricted anus.

Much nearer, and indeed almost identical here, is Mezereum; after the stool, the anus is constricted around the protruded rectum. In other respects, however, the two remedies are widely different. Kali bichromicum must also be remembered as a relative of Lachesis in dysentery. Both have red, cracked, smooth tongue; blackish stools; hence both are useful in severe or typhoidal cases, and here they follow each other well. The offensive odor of the discharges distinguishes the latter; the jelly-like, sometimes stringy mucus, the former.

A peculiar feature of Cocculus is tenesmus recti after stool, with faintness, and yet peristalsis is lessened. (Compare Ignatia.~)

Lecture V (continued)

Lachesis {continued) .

Lachesis causes in the male an increased lasciviousuess with diminution of the physical powers. The mind is a prey to all sorts of allurements, but erections and emissions are imperfect. Upon the female organs, Lachesis acts very powerfully. It seems to have special affinity for the ovaries, particularly the left ovary; ovaritis, ovaralgia, and tumor, may be relieved when there are tenderness to pressure of the clothing and other characteristic symptoms of the drug. Menses scanty, feeble, blood lumpy, black, and very offensive; pains in the hips, bearing down in the region of the left ovary—all better when the flow is established. The uterus is also intolerant of the least pressure.

Lachesis may be used in puerperal metritis, especially when the lochial discharge is foetid. The face is purple and the patient unconscious.

It is indicated in ovarian tumors when the disease shows a tendency to extend from left to right, even when suppuration has taken place. It is especially called for after Hepar or Mercurius when there is great adynamia.

In syphilis, Lachesis is called for as an antidote to mercury or when the chancre becomes gangrenous. Its characteristics are found in its peculiar sore throat, the blue surroundings of the ulcers, nightly bonepains, violent headache, and the phagedenic chancre.

The syphilitic ulcers on the legs are flat and have blue surroundings; caries of the tibia; the parts are sensitive and livid; ulcers in the throat; bone-pains at night; all after abuse of mercury. The bluish ulcers ally it with: Hepar, Asafcetida, Lycopodium, Siticea, Arsenic; the pimples, blisters, or pustules surrounding the ulcers ally it with: Arsenic, Phosphorus, Lycopodium, Mercurius, Hepar, Siticea, etc.; the burning in the areola with: Arsenic, Lycopodium, Mercurius, Siticea; the offensive pus with: Arsenic, Asafcetida, Lycopodium, Silicea, Sulphur, Hepar; the ulcers, being flat, with: Arsenic, Asafcetida Lycopodium, Mercurius, Silicea, Phosphoric acid, etc.; if they become black or gangrenous, with: Arsenic, Secale. Silicea, Plumbum, Carbo veg., Euphorbium, Muriatic acid. But Lachesis has the burning most marked when the ulcer is touched. The surrounding skin is mottled. Ulcers on the legs tend to spread superficially (rather than deeply, as, for example, in Kali bi.), the discharge is scanty and the strength is failing. Dark blisters encircle the ulcers and the surrounding skin is dead. Sometimes the discharge ceases, the patient is stupid, cold, the leg becomes cedematous, and a bluishred swelling along the course of the veins shows that phlebitis exists. All this looks like Arsenic, Carbo veg., Bufo, Secale, Cinchona, etc. But Arsenic presents more vascular excitement and nervous irritability with the prostration. Carbo veg. induces still greater prostration than Lachesis, cold sweat, cool breath, collapse. The ulcer has a cadaverous odor. In mild cases there is no resemblance at all between the two, for Carbo veg. causes much burning, rawness in the folds of the skin; borders of the ulcer hard, but not oversensitive, as in Lachesis.

Hepar should be remembered as a concordant of Lachesis, especially because it is so useful after abuse of mercurials. The areola of the ulcer is very sensitive, but there is a sore, bruised feeling, together with hyperesthesia. And, although the suppurating part may turn bluish and the patient experience weakness, yet there are no evidences of loss of vitality and gangrene, such as suggest the later-indicated drug, Lachesis.

Lycopodium is here again a complement of the snake-poison. If syphilitic ulcers appear in the throat, they are dark grayish-yellow, worse on the right side. The forehead exhibits a coppery eruption and the face is sallow, often furrowed, but lacks the small red bloodvessels which shine through the yellow skin in Lachesis. Chancres are indolent. Condylomata are pediculated. Ulcers on the legs refuse to heal, with tearing burning, worse at night; they are made worse by poultices or by any attempt to dress them. The pus is often golden-yellow. There is flatulent dyspepsia.

Nitric acid, should it seem similar in phagedenic chancre, ulcers on the tibia, etc., may easily be distinguished by the irregular edges of the ulcer, which also presents exuberant, easily-bleeding granulations; and its mouth and throat symptoms may be differentiated by the cracks of the commissures of the lips, sensations of a splinter in the throat, etc.

Kali iodatum exhibits a very different train o£ symptoms from Lachesis. Gnawing, boring bone-pains; throbbing and burning in nasal and frontal bones; greenish-yellow, excoriating ozaena; papules ulcerating and leaving scars; rupia; chancres with hard edges and curdy pus; ulcers deep-eating; violent headache, much more severe than in the snake-poison, and causing hard lumps on the head. Tendency to interstitial infiltration of soft tissues and also of bones, thus more extended than with Lachesis, which infiltrates only the soft tissues. In the uterine and ovarian symptoms of Lachesis your attention is directed to the following comparisons.

Platina has profuse, dark menses instead of scanty flow, and the hauteur is much more pronounced. The nymphomania is accompanied by titillation and tingling of the genitals or with vaginismus. In ovarian affections this drug has relieved after Lachesis failed, as in suppuration of the ovary, the pus having been evacuated under the action of the latter. The pains are burning, with violent bearing down. Palladium has relieved induration and swelling of the right ovary, as has Lachesis. Mentally the two are widely different. The former develops an egotism which manifests itself in the patient's concern ior the good opinion of others, consequently her pride is often injured. Mental emotions aggravate the ovarian pains, as in the snake-poison, but in a different way. The Lachesis patient is ecstatic or at least excitable; the relating of stories moves her to tears. The Palladium patient is easily agitated in society; a lively conversation or some evening entertainment increases her pains and tries her mentally and bodily. In ovarian affections Apis stands closely allied to Lachesis, but it acts more on the right ovary than on the left. There is a bruised, sore feeling, or a stinging, burning. At other times the pains are described as lancinating.

In prolapsus uteri or during the menses the bearing down seems to be in the right ovary; pains followed by a scanty dark mucus. Both have pains from the left to the right ovary, but in Apis these are experienced while stretching. There is also a strained feeling in the ovarian region, very characteristic. The pains may ascend in either, but in Apis they are in the right ovaty, with pain also in the left pectoral region, and cough.

Mentally there is considerable similarity (see Mind). Both have jealousy, with talkativeness and increased sexual desire; restlessness, with bustling manners.

Arsenic affects the ovaries and uterus, and has metrorrhagia of dark blood, and increased sexual desire. But this powerful agent affects more the right ovary, with marked burning, tensive pains and restlessness, which is somewhat relieved by constantly moving the feet; menstrual colic, better from warm applications.

Lycopodium reverses the Lachesis direction of pains, shooting from right to left. Its gastro-enteric symptoms are also always present. Although Graphites more often affects the left ovary it will also relieve when pains in the right ovarian region are followed by a discharge from the vagina, but constitutionally- this drug and Lachesis differ. A marked symptom of Lachesis is the relief of pain when the blood flows. Compare Moschus, drawing, pulling at beginning of menses, ceasing with the menstrual flow; Ziricum, relief of boring in the left ovary (just like Lachesis).

Platina and Ammonium carb. have pains which continue with the flow, the former even with a profuse discharge, the latter with flow between pains. In Actea racemosa the more profuse the flow is the greater is the pain.

Now, the heart, circulation and fevers. Lachesis, as I have already intimated, affects the circulation markedly; it causes flushing of heat, as at the climaxis; rush of blood headward, with coldness of the feet; palpitation of the heart, with a feeling of constriction about the heart as if tightly held by cords. These latter symptoms, with the oppression of the chest, the dyspnoea on awaking, and the inability to lie down, have led to the use of Lachesis in hydrothorax and hydropericardium when dependent on organic disease of the heart.

Lachesis is indicated in general dropsy when the urine is dark, almost blackish, and contains albumen, and the skin over the cedematous parts is dark bluish-black. I remember a man, sixty years of age, who had just this sort of dropsy, and continued to live for six months under the action of Lachesis, and whose death, when it came, was painless. It is especially useful in the ascites following scarlatina and the ascites of drunkards, when the above symptoms are present. In renal and vesical affections Lachesis is to be selected more by the general than by the local symptoms. For instance, in albuminuria or morbus Brightii, the respiratory symptoms, aggravation after sleep, and blue surface are more characteristic than the urinary symptoms- In cystitis the drug is indicated when the offensive mucus introduces the universal characteristic of tendency to putrescence. And the more this offensiveness of the urine is disproportionately intense, when compared with the time of the vesical retention of the mucus, the more likely is Lachesis to be the remedy.

In haematuria the drug, like its powerful rival Crotalus, is called for when the symptoms occur as an evidence of blood degeneration, as in low fevers; hence there is the characteristic deposit of disintegrated blood-cells, of fibrin, etc., presenting the appearance of charred straw. In albuminuria after scarlatina there is dropsy from delayed desquamation, and the urine is black or contains black spots. This spotted appearance is precisely like Helleborus. Other remedies causing black urine are Colckicum, Natrum mur., Carbolic acid and Digitalis. Apis, Ammonium benz., Arsenicum, Benzoic acid, Arnica, Opium, Carbo veg., Kali carb. and Terebinthina produce dark turbid urine. Lachesis alone, however, has the foaming urine and the general characteristics already discussed.

Helleborus is to be distinguished by the sensorial apathy, muscular weakness, pale puffed face and jelly-like, mucous diarrhoea which accompany its dropsy. The patient may breathe better when lying down, which is the converse of Lachesis and Arsenicum.

Digitalis, with blackish, scanty, turbid urine, faintness from weak heart, with bluish face, looks very much like Lachesis here. In the latter there is more laryngeal constriction, as well as oppression and constriction of the chest; in the former the suffocative constriction is as if the internal parts of the chest had grown together. Digitalis has also sinking or faintness at the stomach, as if life was becoming extinct.

Terebinthina, has smoky and turbid urine, depositing a sediment like coffee-grounds. It is often.indicated in dropsy after scarlatina. The sediment contains disintegrated blood-corpuscles; haematuria. Dyspnoea; the patient must be propped up in bed. There is great drowsiness. The tongue is dry and glossy. Clinically, Terebinthina has proved useful in the early stages of renal disease, when congestion predominates, that is, before renal casts appear in any great quantity. It causes more intense burning and pain in the back than Lachesis, and the urine may have a violet odor. In typhoid fever both renal and alvine discharges resemble those of Lachesis. Foetid stools, haemorrhages from the bowels, caused by ulceration; the blood is dark, sooty and looks like coffee-grounds. Foetid urine; disintegrated blood in the urine. In addition, Terebinthina causes stupor, dry, smooth, glossy tongue and great weakness. But it is distinguished by a preponderance of tympanites, with burning, which is accompanied by a smooth tongue, as if it had lost its papillae.

Apis simulates Lachesis in post-scarlatinal dropsy, for both remedies have albuminuria, scanty urine, which is dark from decomposed blood, and dyspnoea. But Apis usually requires thirstlessness, pale waxen skin and an eruption here or there resembling nettle-rash, red pimples or an erysipelatous rosy appearance of the anasarcous limbs. Arsenicum is needed in cases of renal disease when the urine is scanty and albuminous without blood, the remedy being required on account of its well-defined heart symptoms or its mental restlessness, etc. Thus far it needs no differentiation here. But if the urine is dark, turbid, blood-mixed, depositing a coffee-like sediment, if there is orthopnea with cold legs, bronchial catarrh, great difficulty in breathing until phlegm is raised, spasmodic constriction of the larynx, the choice may demand further comparison. Arsenicum cures when the urine looks like dark dung-water, and renal casts are abundant. The dyspnoea is noticed more when the patient attempts to lie down in the evening, and again it arouses him after 12 p. m.; it is relieved by the expectoration of mucus. In Lachesis the dyspnoea is worse when, after lying down, he drops off to sleep, relief follows the hawking loose or coughing up of a small amount of thick adherent mucus, and there is far more annoyance from the contact of the clothing than there is with Arsenicum. In the latter the clothing is torn loose lest its pressure smother the patient; in the former there is added a cutaneous hyperesthesia.

Colchimin causes an intense congestion of the mucous membrane of the stomach and bowels, and also of the kidneys. The urine is dark, turbid, albuminous, bloody and as black as ink. There is dropsy. But Colchicum is readity distinguished from Lachesis by the prominence of irritation of the sphincter vesicae with tenesmus of the bladder after urination. It is especially indicated in gouty patients, who at the same time suffer from a nervous weakness, which is combined with hypersensitiveness. If this latter symptom seems to resemble Lachesis, we may readily distinguish by the general effects of Colchicum, namely, oversensitiveness to touch (except perhaps the tympanitic abdomen); senses too acute, especially over-affected by strong odors; gastric symptoms are prominent; mental labor fatigues, causing inability to fix the thoughts or to think connectedly; headache, the skin of the scalp feels tense; coated tongue; nausea; great weakness, yet easily irritated by external impressions. A peculiarity of Colchicum is that if there are copious salivation and urinary secretion, the stools are scanty and attended with tenesmus, and vice versa.

I need not dwell upon the fevers of Lackesis, because I mentioned them in speaking of the mental symptoms of the drug. I may, however, speak of the intermittent fever which recurs in the spring-time in spite of the use of quinine in the fall. The chill comes on at one or two o'clock in the afternoon. During the chill—and here is a symptom which is characteristic—the patient feels that he-must have clothing piled on him, not so much to keep him warm as to keep him still. He wants to be held down firmly to relieve the shaking and the pains in the chest and head. The fever is characterized by burning pungency, by the oppression of the chest and the heart, and by the associated drowsiness and loquacity. Desire to be held down during chill is also characteristic of Gelsemium.

Carbo veg., like Lackesis, has annual return of the paroxysms, loquacity during the hot stage, thirstlessness during the fever, oppressed breathing. The patient is very weak from protracted disease and abuse of quinine. But the thirst is greatest during the chill, not before it, and the chill is often accompanied by cold breath, coldness of the knees, even when wrapped up in bed. Flushes of burning heat in the evening attacks, without thirst. Flatulency. One-sided chills, left side generally. Collapse more marked.

Capsicum agrees in thirst before chill, desire for warmth, chill beginning in the back; irregular, intermittent pulse. But with the red pepper the chill commences in the back and spreads thence; the thirst continues into the chill, and drinking aggravates (see Elaps). The patient is relieved by hot applications, as by a hot water-bottle applied to the back.

Menyanthes is preferable when the disease manifests itself as a coldness of the tip of the nose, the ear-lobes, and the tips of the fingers and toes. Feet to knees icy cold. Hands and feet icy cold, rest of the body warm. When Lachesis is called for in such irregular cases, with cold nose, etc., the livid skin and great weakness, as shown by the filiform pulse, are sufficiently distinctive.

Agreeing more accurately are the following remedies, all of which produce weak or thready pulse, coldness orblueness of the skin, and, of course, great prostration: Carbo veg. (see above).

Veratrum album, but in this drug the chill is associated with thirst, and (if internal) runs downward, not upward. Skin blue, cold, inelastic; hands blue; face, mouth and tongue cold; breathing oppressed and labored; heart weak; cold, clammy sweat, worse on the forehead. Heat has no palliative effect.

Arsenic, external heat relieves; mouth and tongue cold; face blue; single parts of the surface blue. Anxious restlessness despite the great debility; cold, clammy sweat. Suffocative attacks of breathing. Camphor, icy-cold surface, but hot internally, so he throws off the clothing; face deathly pale; limbs blue; breath generally hot. Spasms, or, if conscious, voice altered. Sopor follows.

Hydrocyanic acid, marble-like coldness of the whole body. Pulse feeble or imperceptible. Long-lasting faints. Drinks roll audibly down the oesophagus. Clutches at the heart as if in distress. Spasms; especially muscles of back and jaw are stiff.

Helleborus, muscles relaxed; suddenly he falls, with coldness, cold sweat on the forehead; slow pulse. Horrible convulsions, with extreme coldness. Rheumatic pains in the knees.

Digitalis, like the snake-poison, weakens the heart. The skin is very cold. Copious sweat, but the heart symptoms are not relieved. Pulse intermits every third, fifth or seventh beat; very slow pulse. It will be remembered that Lachesis has oppression of the chest, with cold feet. As the latter become warmer the oppression lessens. Secale, cold surface; sunken, pale face and blue lips. Will not be covered. Tingling in the limbs; holds the hands with the fingers widely spread apart. Cold, clammy sweat. Speech feeble, stuttering. Hyoscyamus resembles Lachesis in the chill up the back, objective coldness of the body, convulsions, delirium. But the chill is worse at night, and spreads from the feet to the spine, and thence to the neck. The lowering of the temperature is accompanied hy slow arterial action, drowsiness, or by delirious and excited talk; picks at the bed-clothing, fears being poisoned, hallucinations, fibrillary twitchings, etc.

Lachnanthes, like Lachesis, causes glistening eyes during the chill, icy coldness of the body, relieved by warmth. But only the former has brilliant eyes and circumscribed red cheeks with the fever and delirium.

Lycopodium follows Lachesis. It is needed in fevers when the patient becomes drowsy or stupid; coldness, as if lying on ice. One foot warm, the other cold—an important symptom. Feels as if the blood ceased to circulate.

In intermittent fever the chill begins in the back, as in Lachesis. It is worse from 4 to 8 p. m., or at 7 p. m. ; hands and feet numb and icy cold. Sour eructations or vomit are almost invariably present, especially between chill and heat. Thirst mostly after the sweat. Desires hot drinks only.

Apis here, as in many other instances, favors the snake-poison. Both are suited to old or maltreated cases; afternoon chill, oppression of the chest, nose cold, pulse fluttering, skin of hands and arms blue, and general appearance of collapse. But the bee-poison has aggravation from heat, Lachesis has not; the former has much more marked oppression of the chest, with consequent smothering. The tongue is red, raw, and covered on tip and borders with vesicles. Thirst during and not before the chill. Urticaria.

Cuprum combines coldness with convulsive phenomena. Icy coldness of the whole body. Severe cramps in the extremities, with cold sweat, blue surface; also collapse. Urine suppressed. Employed successfully in the cold stage of cholera, after Camphor, but also useful in other forms of collapse. For instance, it has antidoted snake-bite, with cramps, delirium, and finally torpor.

L^achesis may also be indicated in scarlet fever, but not in the Sydenham variety of the disease, but in those forms which have a malignant tendency. The child is drowsy and falls readily into a heavy sleep. The rash comes out very imperfectly or very slowly, and has a dark purple hue. It may be interspersed with a miliary rash. It is apt to be complicated with a membranous deposit in the throat having the character I have already described to you when speaking of the remedy in diphtheria. The cellular tissue of the throat is inflamed and threatens suppuration. The cervical glands are swollen. On looking into the throat you find it to be dark red with a dirty white deposit on the tonsils, especially the left. The tongue is coated dirty yellow at the base, and the red papillae show prominently through this coating. The pulse is weak and the surface of the body cool. There is apt to be dark blood oozing from the mouth and nose.

The majority of physicians make a mistake in beginning their treatment of scarlatina. A mistake in the beginning means one of twothings, either a long, tedious illness, or a short one, ending with death. The mistake made is to give Belladonna in every case. Let us look for a moment at the differences between Belladonna and Lachesis. Both remedies have the strawberry tongue, the throbbing headache, the red face and the high fever. Belladonna is indicated only in the sthenic type when there is an active delirium, the throat is bright red in color, the pulse is full and bounding, the rash is bright red and smooth. Lachesis on the other hand, is suitable where asthenia predominates, with purplish, tardily-appearing rash, drowsiness, marked swelling of the cervical glands, and other symptoms of malignancy above enumerated .

In carbuncle and cancer we think of Lachesis when the surrounding area is swollen and purple or blackish, and pus forms very slowly. Lachesis given under these circumstances increases the quantity and improves the quality of the pus, and the patient's strength improves also.

When giving Lachesis for malignant pustule you should accompany the remedy with brandy. That is an experience of Dr. Dunham. I will next say a few words respecting the modalities of Lachesis- Modalities, as you know, express the mode or manner by which symptoms are qualified. They are therefore important in the study of drugs and especially in differentiating allied remedies. Two medicines, for instance, may induce supraorbital pains of a shooting character. But if one has the pains modified by pressure, the other by sleep, we are thus enabled to distinguish them in practice. Modalities, then, qualify symptoms and are as essential as adjectives to nouns. Care must be exercised, however, that they be not substituted for the symptoms they modify. Too often we see cases reported, the only homoeopathic resemblance between which and the remedy selected is a mere modality, as, for instance, worse after sleep.

The modalities of Lachesis, then, are as follows:

Worse.— During sleep, especially the throat symptoms, choking, which arouses him; worse after sleep, especially in the morning. Time of Day.—Generally worse from noon until 12 p. m. ; still there are some prominent symptoms aggravated in the morning and forenoon. This is partly owing to the bad effects of awaking, but, as some symptoms appear later in the morning, we may ascribe them to causes then at work. For instance, the patient has vertigo on awaking, yet this returns, on closing the eyes, at 11 a.m. Headache in the left frontal eminence in the morning. Weakness in the morning on rising. Finger tips numb. On sitting up quickly in the morning, breathing becomes slow, difficult and whistling.

In the evening and before 12 p. m., we find the following especial exacerbations: Throat sensitive; diarrhoea; dry, hacking cough. Chill beginning some time between noon and 2 p. m., but fever is marked in the evening and night; worse before 12 p. m. Temperature, Weather, etc.—Worse in the cold air, from change of temperature and from the warmth of the bed (see below under Motion, etc.); worse from getting wet, wet weather, windy weather; worse before a thunderstorm; worse from the sun; worse in the spring. Better often from warmth, wrapping up, near the stove, etc. Excessively cold or excessively warm weather causes debility.

Motion, Rest, Position, etc.—Worse on and after rising from bed; worse while sitting and better after rising from a seat; better lying in bed on the painless side, but worse from the warmth of the bed (see above under Temperature) and from lying on the painful side. Some symptoms are better from moving, but not if continued long. Touch, Pressure, Injuries, etc.—Almost invariably worse from touch, however slight. Useful for the bad effects of injuries, as penetrating wounds, with much haemorrhage or gangrene.