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CLINICAL LECTURES
VARIOUS
IMPORTANT  DISEASES;
          BEING A COLLECTION OP



THE CLINICAL LECTURES DELIYERED IN THE MEDICAL

    WARDS OF MERCY HOSPITAL, CHICAGO.



               BY Y /

    XATIIAX S. T3AYIS/A.M.,M.D.,
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE, AND CLINICAL MEDICINE,
          IN CHICAGO MEDICAL COLLEUE.



      Edited by FKAXK H. DAVIS, M.D


          SECOND EDITIOX.
<Z
'~9%/>-
   PHILADELPHIA:
HENRY  C. LEA,
       18T4. 
ll.                    PREFACE.
want  of uniformity  that may be observed  in  the  manner

of writing  the prescriptions,  or in the  naming of medi-

cines.   With no  pretension  to  completeness,  as a course

of Clinical  Lectures on  practical medicine,  it  is  never-

theless  hoped  that  the contents  of  this volume  will  be

found  of real  value, especially by the  younger class  of

practitioners.
                                            F.  H. D.

  Chicago, 792 Wabash Ave., )
       March 17th, 1873.      ) 
CONTENTS.
                     LECTURE  I.
                                                    PAGE.
CONTINUED FEVER. — Cases of Typhus and Typhoid
   Fever.—Bad Effects of Cathartics. —Value of Strych-
   nia in  Certain Stages. — A Case of Typho-Malarial
   Fever,     ....--...-7

                     LECTURE II.
CONTINUED FEVER.—Cases Complicated with Emboli,
   Bronchitis, Broncho-Pneumonia, Hypostatic Infiltra-
   tion, Intestinal Ulceration, etc.,  -    .    -    -       27

                    LECTURE III.
CASES OF PERIODICAL FEVER. —Chronic Ague and its
   Sequels,..........5°

                     LECTURE IV.
RHEUMATIC FEVER. —Acute Articular Rheumatism.—
   Muscular and  Bronchial  Rheumatism. — Rheumatic
   Inflammation of Spinal Nerves. — Intestinal Rheuma-
   tism. — Chronic Rheumatism, etc.,.....60

                     LECTURE V.
SCARLATINA AND  RUBEOLA. —Renal  Dropsy. —Sup-
   pression of Urine. — Convulsions. — A Case of Rubeola,   74 
iv.                  CONTENTS.
                    LECTURE VI.
                                                    PAGE.
RESPIRATORY AFFECTIONS. — Diphtheria. — Croup. —
   Chronic Bronchitis.—Rheumatic Bronchitis.—Asthma.
   — Pleurisy, etc.,     -----               4

                   LECTURE VII.
PULMONARY  TUBERCULOSIS. —Cases Illustrative of
   the Incipient, Suppurative, and Excavated Stages.—
   Diagnosis. — Treatment,......-ioo

                   LECTURE  VIII.
DISEASES OF  THE ALIMENTARY  TRACT. —Gastritis.
   — Scirrhus  at the Pyloric Orifice of the  Stomach. —
   Chronic  Inflammation of  the  Stomach. — Chronic
   Army Diarrhcea,  Chronic Diarrhcea  Sequel of Typh-
   oid Fever. — Acute  Dysentery,    -    -    -    -    -  114

                    LECTURE IX.
INTESTINAL  AND UTERINE  IRRITATION. —Bilious
   Colic.—Tobacco Enemas. — Hydrate  of Chloral and
   Belladonna Enemas.— Inflammation, and its Treatment-  129

                     LECTURE  X.
SUMMER COMPLAINTS OF CHILDREN. —Diarrhcea.—
   Cholera Infantum, etc.,  ----___

                    LECTURE XI.
SUMMER COMPLAINTS OF  CHILDREN.— Their Path-
   ology and Treatment,.....
139 
CONTENTS.
v.
                    LECTURE XII.
                                                    PACK.
DROPSY. — The  Pathological Conditions  that give rise
    to it. — Differences in Location and Progress,  -    - 165

                     LECTURE XIII.
CAUSES OF CARDIAC DISEASE. — Diabetes Mellitus.—
    Anaemia and Anasarca. — Biliary Calculi,   -    -    -177

                    LECTURE XIV.
NEURALGIA.— An Obscure Case. — Sciatica. — Neuralgia
    of the Rectum, -    -    -......192

                    LECTURE  XV.
NERVOUS  AFFECTIONS. — Spinal  Irritation. — Hemi-
    plegia. — Partial  Hemiplegia. — Paraplegia. — Progres-
    sive Locomotor Ataxia,.....-    -210

                    LECTURE XVI.
AFFECTIONS  OF THE BRAIN. — Epilepsy. — Probable
    Softening of the Brain. — Chronic Hydrocephalus,  - 227

                    LECTURE XVII.
CEREBRO-SPINAL  DISEASE. —Symptoms, Progress and
    Treatment,.....:    -    -    -241

                   LECTURE XVIII.
CUTANEOUS DISEASES. — Their Classification and Diag-
    nosis. — Cases of  Psoriasis. — Prurigo. — Porrigo. —
    Eczema, etc.,.........25r 
vi.
CONTENTS.
                   LECTURE XIX.
MANIA A POTU AND CHRONIC DISEASE OF THE BRAIN.-
   Delirium Tremens with Fatty Degeneration.—Chronic Dis-
   ease of the Brain.—Anomalous Nervous Symptoms,  -   263

                    LECTURE XX.
PNEUMONIA. — Double  Pneumonia. — Sthenic  and  Typhoid
   Pneumonia,   ---------    274 
LECTURE  I.
CONTINUED FEVER. —Cases of Typhus and Typhoid Fever.
   — Bad Effects of Cathartics. — Value of Strychnia in Cer-
   tain Stages. — A Case of Typho-Malarial Fever.
    Gentlemen: — The  case  before  you is  a female,  aged
about  twenty years, a  native of Ireland, and a resident of
this country only a few weeks.   Some  ten days since she
came to my office  complaining of  pain in her head, with
some pain also in the  back and limbs; a sense of oppres-
sion or tightness across the chest; looseness of  the bowels;
loss of appetite, and lightness or dizziness of the head.   She
presented an anxious  expression of countenance;  dryness
of the lips; a thick, dirty white coat on the middle and
posterior part  of the tongue;  some tremulousness of both
tongue and lips; skin dry, harsh and congested; pulse soft,
weak, and about no per minute.  She had been complain-
ing about one week, during which  time she had taken two
doses of salts  and senna, each operating freely as  physic,
and  during the  two days that had  intervened since the
second dose, she  had continued to have four or five copious,
thin, intestinal discharges  each day.   I advised the  patient
to go home, keep quiet, take  bland nourishment, and effi- 
8
CONTINUED FEVER.
cient anodynes to control the intestinal evacuations.   About
one week after, she was brought to the hospital, and  she is
consequently now near the end of the second week of her
fever.
   The symptoms that I wish you to notice carefully, at
present, are the following:  The whole cutaneous surface is
dry,  harsh, and  warmer than natural;  eyes suffused, and
expression dull;  respiration short, accelerated, and accom-
panied by strongly-marked dry bronchial rales all over the
chest, and occasional rough cough; dullness, on percussion,
over the lower and posterior part of the  chest; but very
little expectoration; pulse 115 per minute, small and weak;
abdomen tumid, inelastic, but only moderately tympanitic;
three or four thin, brown intestinal evacuations each day;
tongue  and lips dry, dark red, and tremulous;  slight sub-
sultus ;  and hearing dull.
   Such are the more important symptoms presented by the
patient.  What are the pathological conditions indicated by
them ?  The somnolency, the dullness of hearing, the sub-
sultus, and the frequent mental wanderings, point  directly
to a strongly depressed condition of the nervous functions.
The dryness of the skin, the lips, the mouth, and the mucous
surface of the bronchial tubes, and the scantiness of urine,
equally indicate  a depressed  or retarded condition of the
secretory functions.  The moderately congested and livid
hue  of the skin,  the congested  condition of the lower and
posterior portions of the lungs, as indicated by dullness on
percussion, and the soft, weak pulse, indicate general feeble-
ness of capillary  circulation.
   Thus the three great functions of inervation, circulation,
and secretion, are much impaired, producing  all the phe-
nomena of a low type of fever, while the enfeebled capillary
circulation has led to a serious degree of infiltration  of the
pulmonary  tissue, and in the  mucous membrane  of the 
CONTINUED  FEVER.
9
 lower half of the intestinal tube, to a scarcely less danger-
 ous degree of effusion, constituting the liquid stools, and a
 tendency to softening and ulceration  of Peyer's glands.
    A further inquiry now arises, of great interest, but less
 easily answered, namely:   What causes the well-marked de-
 pression of all the functions  just named ?  Is it some mor-
 bific  agent or fever poison acting primarily on the nervous
 centers, depressing nerve  force, and through this influencing
 the vascular and secretory functions ?  This was essentially
 the doctrine of Cullen, and of a majority of writers on prac-
 tical  medicine, from  his day to the  present  time.  A more
 modern, and somewhat more popular doctrine, at the present
 time, alleges that the supposed  fever-poison acts primarily
 upon the constituents of  the blood  by a zymotic  or septic
 influence, and that all the important functional disturbances
 are consequent on the deteriorated condition of that  fluid.
    A few, like Virchow and Addison, who make all the phe-
 nomena of life depend on cell action, would  make the phe-
 nomena of fever depend on the primary modifying influence
 of the fever-poison on the functions of the cells, both in the
 blood and in the tissues.    Careful study and extensive clin-
 ical observation will show you, however, that all these theo-
 ries are defective and unsatisfactory.
    My own opinion has often been expressed, both here and
 in the lecture-room.  It is, that  the initial steps of morbid
 action constituting fever,  are neither in the  nervous, secre-
 tory,  or vascular structures  or functions separately, but in
 the elementary properties common to all the  tissues.  But it
 is no  part of my purpose, at  this  clinic-hour, to dilate upon
 the essential pathology of fevers.  The  symptoms of the
patient lying before us are of the  most serious import.  The
universal depression of vital  properties, with  the extensively
engorged condition of the lungs, rendering  respiration im-
perfect, and the continuance of the frequent  intestinal evac- 
IO
CONTINUED  FEVER.
uations, renders the prognosis extremely unfavorable.  The
deteriorated condition of the blood always existing in typhus,
is here increased by the diminished interchange of carbonic
acid gas for oxygen, through the lungs, and there is danger
of a suspension of life before any change can be effected, by
which  a more healthful impression of the blood upon the
capillary and secretory structures can be made.
   Still, the  rational indications for  treatment are  plain.
They are to repress the intestinal evacuations;  to arrest the
further engorgement of the pulmonary tissues, and to sus-
tain  the functions of the nervous and vascular systems.  To
accomplish the first, there' is probably no remedy more effica-
cious than oil of turpentine combined with a certain propor-
tion of tincture of opium.  It not only exerts a peculiar action
on the  mucous  surface  of the intestines, by which the tone
or contractility of the capillaries is increased and the accu-
mulation of blood consequently diminished, but it also in-
creases the activity of  the  whole capillary vascular system.
Hence it not only fulfills the local indication, but aids mate-
rially in accomplishing  the third object named.  To  devise
remedies that will relieve the extreme congestion in the lungs,
and  promote  re-absorption of  the dark  blood infiltrated
into the posterior and lower parts of these organs, is  no
easy task.
   The immediate cause of this condition of the lungs is a
failure  in the susceptibility of the capillaries and their con-
sequent dilation.  When this state of bronchial and pulmo-
nary congestion commences  early in the  progress  of the
fever, I have found no remedy for its relief so  reliable as
small doses of tartrate of antimony and potassa, given in
combination with opium  sufficient to  prevent  any danger
of acting on the bowels.  Given in the early stage, it lessens
the general febrile action, promotes perspiration, and renders
respintion and  expectoration much  more free.  But  V> 
CONTINUED  FEVER.              n
 the  patient, as  in. this case, has already advanced to that
 state when the pulse is small and weak, the skin relaxed, the
 abdomen tympanitic, and  bowels very loose, with much
 dullness on percussion over the middle and lower part of
 the lungs, and somnolency, you can expect no benefit from
 so  direct a sedative  as antimony.   The principal reliance
 must then be placed on such remedies as tend to sustain the
 sensibility and action of  the  nervous and  vascular systems,
 and prevent the further deterioration of the blood.   We will
 give the  patient ten drops each, of oil of turpentine and
 tincture of opium, in the form of an emulsion, every four
 hours, and  the sixteenth  of a grain of strychnia, with four
 drops  of nitric  acid dissolved in sweetened water, between.
 We  will also dissolve  two drachms each, of chlorate of
 potassa and gum arabic, in a tumblerful of cold water, and
 have the patient take a tablespoonful every three hours.   She
 must also be fed regularly every two hours with two or  three
 tablespoonfuls of a porridge made of sweet milk and wheat-
 flour or oatmeal.  Seeing the  subsultus, the weak pulse, the
 oppressed breathing, the  dingy or leaden  hue of the  skin,
 and the mental  dullness exhibited  by the patient, you  may
 ask why I do not order brandy or other alcoholic stimulants?
 I answer, that nearly thirty years of careful observation at the
 bedside of the sick, has satisfied me that, under such circum-
 stances, strychnia is a far more reliable remedy for sustaining
 the nervous functions than alcohol;  while  the effects of the
 latter,  in diminishing the  decarbonization  of the blood,
 makes  it positively detrimental to  the already seriously em-
 barrassed condition of the lungs.
   Before leaving the subject suggested  by this patient, I
 must add a few words of caution in regard  to the use of
harsh evacuants in the early stage of these continued fevers.
Since the epidemic of erysipelas, in the  fall and winter of
 1863, a large proportion of our attacks of continued  fever 
12             CONTINUED  FEVER.
have presented, prominently, the symptoms of typhus rather
than those of enteric typhoid fever.  That is, the first stage
has been  accompanied by more intense headache;  more
restlessness; more frequent pulse  and respiration ;  often a
semblance  of  constipation;  a thick whitish coat on  the
tongue, with less tendency to change to red and dry; and
the much more frequent appearance of a mulberry or flea-
bite-rash early in  the  second stage.  The apparent torpor
of the bowels, coupled with  the coated  tongue and intense
headache, in the early  stage, has often led the patient—and
sometimes under  the  direction  of his  physician—to  use
active cathartics, and, in a few instances,  emetics.   I have
known of no  instance in which such a course has not been
productive of very bad consequences.   It often induces an
early and excessive prostration, coupled with a fixed conges-
tion of the intestinal mucous membrane, greatly  favoring
softening of the membrane and intestinal hemorrhage in the
more advanced stage of the fever.   Several cases  have come
under my observation  illustrating  this tendency.
    A few weeks since I was called to see  a young man, in
consultation  with his  physician,  who  had been attacked
severely with typhus fever.  The bowels not being  loose in
the early stage, the physician gave him several  compound
cathartic pills, which did not seem to operate harshly;  but
soon after a pitcher of lemonade was prepared, with half an
ounce of chlorate of potassa dissolved in it, intending to
have  the patient use it sparingly as a  drink.  The nurse,
however, allowed the patient free access to the pitcher, and
he  drank its contents all  in one  night.  This was imme-
diately followed by such copious intestinal evacuations, some
of  them tinged with  blood,  that  the  patient was almost
hopelessly prostrated in a few hours, and died  during the
succeeding week.
   Another case was that of a man aged about twenty-five 
CONTINUED  FEVER.
n
years, who had recently come to this city.   He first  called
to consult me at my office.   I noticed, at once, an unusually
haggard expresssion of countenance; tremulousness of the
lips  and tongue;  a very  soft and frequent  pulse;  with
unsteadiness of gait in walking.  I learned that he had been
laboring under all the  symptoms of the first stage of con-
tinued fever for ten days, during which  time he had taken
repeated doses of active  physic, to  remove what he  called
"biliousness."   I explained to him the nature of his sick-
ness, prescribed  some anodyne and astringent medicine to
check the excessive intestinal discharges, and urged  him to
keep quiet in bed.  He  persisted, however, in keeping up
three or four days longer, at the end of  which time I found
him in bed, with the same tremulous lips and tongue ; the
same haggard  countenance;  a  still weaker pulse,  and a
peculiar tawny hue of  the  skin, as  though  the hematine of
the red corpuscles had  become diffused in the serum of the
blood and stained all the tissues.   His mind was dull; hear-
ing impaired;  urine  scanty and  turbid, and  bowels  still
moderately loose.  In  a  few days petechial spots appeared
over the chest and abdomen; and in about ten days from
the time h'e  took his  bed he passed, at once,  a chamber-
vessel  half-full of dark,  offensive, and partially-coagulated
blood.  The discharge was repeated three or four times
within thirty-six hours, producing collapse and death.
   The last case I shall mention, was a young man  aged
twenty-three  years, sanguine temperament, and usually in
good health. While on  a business tour in the country, during
the latter  part of August  and first part oi September, he
was taken with the usual symptoms of the forming-stage of
continued fever, viz.:  severe pain in the head, back,  and
limbs;   loss  of  appetite;  furred tongue;  dryness  of the
skin  and mouth, etc.   On  arriving at one of the towns on
the Mississippi river, he felt so unwell that  he was induced
       2 
14
CONTINUED FEVER.
to take  a warm foot-bath, accompanied by an emetic, and
followed by an active  cathartic.  The remedies  produced
excessive vomiting and purging, but in no degree dimin-
ished the headache and fever.   With some assistance on the
way, he reached his home in this city on the third day after
he took the evacuants.   His face was flushed ; eyes watery
and  dull; skin dry  and moderately hot;  tongue covered
with a white fur, and red at the edges;  lips and mouth dry;
pulse no per minute, small and weak.   He complained of
a  general sense  of heaviness  and oppression; constant
thirst,  and  severe, dull  pain, with a  sense  of dizziness
through the whole head, but more severe in the cerebellum
and base of  the brain.   Since  he took the emetic and cath-
artic, three days previously, he had  retained nothing on his
stomach, more than a very few minutes.  A single spoonful
of cold water would be  promptly ejected by vomiting.  I
endeavored  to overcome the irritability of the stomach by
giving a solution  of bicarbonate of soda, one drachm, and
sulphate of  morphia, one grain, in two ounces of water, in
doses of a  teaspoonful every hour.  Sinapisms  were  also
applied to  the epigastrium, and cold  applications to the
head.  On  the second day, finding the irritability of the
stomach only partially allayed,  while all the other symptoms
were  unchanged,  I  gave,  in   addition  to  the  soda  and
morphia, a powder of calomel, two  grains every four hours,
until it should induce a movement of the bowels.  I did this
because  the continued intense suffering in the head with
fullness of the temporal and carotid  arteries, and heat above
the rest  of  the  body, caused a fear that a low grade of
meningeal inflammation might complicate the case.  After
four powders  had been given the  bowels moved, and the
irritability of the  stomach was so far relieved that liquids
were  retained, if  taken in small quantities; but the pain
and sense of confusion  in the head continued unabated    d 
CONTINUED FEVER.             15
 there was much mental wandering.  The pulse was frequent,
 small, and weak;  respiration hurried ;  some subsultus.  I
 ordered a solution of permanganate of potassa, one grain to
 the ounce of water, to be taken in doses of a tablespoonful
 every three hours, and a tablespoonful of thin milk-porridge
 every hour.  On the following day, finding less heat in the
 head, but more subsultus and mental  wandering, I gave one
 grain of valerianate of quinine in sugar-coated pill, between
 each  of  the  doses of  the permanganate,  and doubled the
 quantity of milk-porridge for nourishment.  He continued
 this treatment three days, during which  the general symp-
 toms  underwent  but little  change, except that the pulse
 became a  little less frequent,  the  fever  less active, and a
 characteristic typhus eruption appeared quite copiously  over
 the trunk of the body.   The hearing also became dull, and a
 large bullae or vesicle, filled with purple or bloody serum, ap-
 peared on the outside  of the right thigh, and  another on
 the scrotum, while  the bowels  became slightly  relaxed.
 Owing to these  symptoms, an emulsion of  oil  of turpentine
 and tincture of opium was given in the place of  the solution
 of permanganate of potassa;  and the doses of valerianate of
 quinine were increased to two grains.   Under these  reme-
 dies, with as much simple nourishment as his stomach could
 bear, he continued to  progress favorably, though changing
 but slowly, for three days longer, when there  occurred  one
 pretty copious  discharge of dark blood  from  the bowels.
 I immediately gave  him a  powder containing tannate of
 quinine, two  grains, pulverized geranium  root,  five grains,
 and pulverized  opium, one  grain, and  repeated it every two
 hours, with ateaspoonful of the turpentine emulsion between.
 After  three doses had been given, and no  movement of the
bowels occurring, the interval between the doses of  medi-
cine was lengthened to two  hours.  When twenty-four hours
had elapsed without further  evacuations, the powders were 
i6
CONTINUED  FEVER.
discontinued, and the valerianate of quinine again given in
their place.  From this time the patient began  slowly to
convalesce, and has since fully recovered.
   These cases strongly illustrate the evil effects of active
purging in the early stage of continued  fever,   Such prac-
tice not merely prostrates the patient, but it directly increases
the irritability of  the mucous membrane, with the aggregate
glands of Peyer, which so  generally constitute an important
pathological condition in all varieties of continued fever. I
think I have never known a case of typhoid or typhus fever,
in which active emetics or purgatives were used in the early
stage, that did not run a protracted and dangerous course.
   The next patient to which I shall direct your  attention
is this  young man, who was admitted to the hospital October
17th.   He was then reported to  have been sick in bed one
week, but we could learn nothing reliable concerning either
his symptoms or  treatment during that  time.*   At the time
of admission, his expression of countenance was  dull; the
surface, especially of the face, hands,  and neck, was dry,
and suffused with a dark, dingy redness ;  temperature mode-
rately  increased;  pulse 120 per minute, quick and weak;
lips and mouth dry ; tongue  covered with a thick coat, dry
and brown along the middle of the dorsal surface ;  abdomen
moderately distended,  tympanitic, and  presenting a  few
small red papules on its surface.   He was reported to have
had five or six thin intestinal evacuations per  day, for two or
three days past.   The chest was resonant and natural except
dry bronchial rales over both sides ;  the mental  faculties
dull,  drowsy,  and  wandering—so much so as to render him
incapable of  giving any reliable intelligence.  His  muscular
movements were unsteady and tremulous.
   He was directed to have two or three tablespoonfuls of
sweet milk and wheat-flour porridge every two or three hours
for nourishment, with whey, bread-water, or milk-and-water 
CONTINUED  FEVER.
*7
for drink, and an emulsion of turpentine and laudanum, of
the same strength, and in the same doses, as was directed for
our last  patient.  He continued  this treatment two days,
during which time his bowels remained quiet; but his urine
passed involuntarily,  and  he continued to exhibit all the
symptoms of a  strongly  marked  typhus  condition.  The
abdomen was full and tense, the pulse very soft and frequent,
and the mind somewhat wandering.
   On the evening of the  19th an enema of warm water was
administered, which was followed by a moderate evacuation
of faecal matter, and some flatus.   During the latter part of
the night he had another large evacuation in bed, which was
thin, and freely intermixed with blood, and  the urine con-
tinued to pass, without his notice.  On the 20th, we found
the whole cutaneous surface  dingy, with slowness of capil-
lary circulation ; the mouth and tongue very dry, with con-
stant tendency to  gather dark sordes on the lips and teeth;
mind very somnolent; respiration slow and  irregular, with
sharp, dry, bronchial rales ; pulse 128 per minute, and weak;
but less distention of  the abdomen than previously.  It was
evident that  the depression of the  excito-motory nervous
centers—as indicated by the  slow and irregular  respiration,
feeble  circulation  and  relaxation of the sphincters—was
directly threatening the life of the patient; while the copious
intestinal discharges, largely intermixed with  dark blood,
indicated a  condition of the mucous membranes scarcely
less critical.
   To counteract, as  far as possible, the first  of these pa-
thological conditions, the patient was directed to have a tea-
spoonful of the following mixture every four hours:
       5.—Strychnise.......—.................gr. i.
           Acid, nitric-----„„-,--_.------------l\.
           Tinct. opii.....---------............3 iii.
           Syrupi *impl. )  a__________________^ iss
   M.      Aqusb,      '2* 
i8
CONTINUED FEVER.
   To aid the mineral acid and  opium  in  restraining the
further  intestinal discharges, the  emulsion  was continued
between each of the doses of this solution.  Nourishment
was continued the same, only giving the porridge somewhat
oftener, and occasionally substituting in its  place the same
quantity of  beef-tea, well salted.   No  further intestinal
evacuations  occurred, and after about thirty-six  hours  he
ceased to dribble his urine in bed, and voided it regularly.
   After following this treatment punctually for three days,
he became less somnolent, and exhibited less muttering and
subsultus, but his skin remained  dry;  pulse soft, frequent,
and weak; tongue dry, with dark sordes on  the  lips and
teeth; bronchial rhonchi over both sides of the chest, with
dullness over the lower  and posterior parts; and abdomen
tympanitic.
   The same treatment was continued, with the addition of a
warm water enema, which procured a slight movement of
the bowels, until the 27th of October.  During  the 25th,
26th, and 27th, the  patient gradually passed from his state
of somnolency and muttering to that of morbid vigilance,
or constant wakefulness, with less subsultus,  and a slight im-
provement in  the condition of the mouth and tongue; but
the mind still wandering; pulse soft, weak, and frequent;
and commencing bed-sores over the sacrum and trochanters.
Thinking that the  change from  mental drowsiness  to con-
stant wakefulness might be the result of the continued action
of the  strychnia on  the nervous centers,  directions were
given  to  have the interval  between  the  doses  extended
to six hours, and fifteen grains  of bromide of ammonium
to be given at  bed-time; all other directions  the same as
before.
    On the 28th, it was found that the bromide had failed to
procure sleep, although  the  dose was  repeated a  second
time, and the patient appeared in all respects  more exhausted 
CONTINUED FEVER.
l9
and unfavorable than on the day previous.   The emulsion
and the strychnia solution were again given, at intervals of
four hours—or two hours apart—and instead of trying fur-
ther the bromide, to overcome the morbid vigilance, fifteen
drops of chloroform were added to each dose of the emul-
sion,  the nourishment  to be continued as before.   This
treatment was continued until November  ist, with a very
gradual but marked improvement in the condition of the
patient.   The febrile heat had diminished;  the skin was
better color; sordes gathered less  rapidly on his lips and
teeth;  the edges of the tongue were moist—though the mid-
dle was still dry and fissured—the mind less wandering, with
intervals of quiet sleep.   The bowels had not moved, except
when excited to action  by enemas, which  had been given
about once in three or four days.   The last enema was fol-
lowed by an evacuation of firmly-consistent, healthy-look-
ing fasces.  The strychnia solution was still continued every
four hours; but six grains of Dover's powder, and four of
pulverized gum  camphor, were given instead of the emul-
sion of turpentine.
    Two days later,  it was found that the symptoms of con-
valescence had vacillated, being much more prominent every
alternate day, and  two  grains of  sulphate of quinia were
given between the doses of the strychnia  solution, while the
Dover's powder and camphor were limited  to a single dose
at night.
    I have passed thus in review the prominent features of
this case, because I consider it a rather unusually instructive
one ; and, although the patient has been here  for a considera-
ble time, your attention  has not before been called to him.
At present—November 9th—convalescence seems to be fully
established.   The bed-sores over the  sacrum and trochan-
ters have been treated by an application of the tincture of
the chloride of iron, daily, and are improving.  The patient 
20
CON TIN UED  FE VER.
still remains very feeble, however.  The solution containing
strychnia and nitric acid will be continued every six hours,
with the quinia between.
   This patient has been  in the hospital  about ten days.
Six days  previous to his entrance he was  attacked with a
chill, so decided as  to  make him  think  he had the com-
mencement of an intermittent fever.   He  had felt  unwell
during the preceding three or four  days.   When the chill
occurred, he called a physician, who gave  him some pow-
ders, and followed them  by a cathartic.   The latter operated
freely, and during the succeeding three days he had from
twelve to fifteen intestinal discharges per day.  It was at the
end of these three days  that he was brought to the hospital.
On examination, we found himlaboring under all the symp-
toms of continued fever, with great exhaustion.
   He was first  given the turpentine emulsion every three
hours, until the intestinal discharges should  be stopped, with
milk-and-flour  porridge  for nourishment.  The following
day his bowels had become quiet, but he  presented every
symptom of  profound typhus;  countenance dull; color of
skin  brown, or  dingy;  capillary circulation feeble ; pulse
124 per  minute, soft and  weak; abdomen slightly tym-
panitic, and bowels  quiet;  some subsultus, and constant
delirium;  and once,  haemorrhage from the nose.  A slight
papular eruption was discernible over his chest and abdo-
men.   The  emulsion was   continued  three times   a day,
and, in addition, a teaspoonful  of the solution of strychnia,
nitric acid, and tincture  of  opium, given every four hours-
same  proportions as already given in previous cases- and
the same strict attention enjoined to the giving of bland
nourishment.
   The further increase  of prostration  was  arrested  in
twenty-four hours ; but the same treatment has been contin-
ued for the past week, during which  time a slow but steady 
CONTINUED  FEVER.             21
improvement  has taken place.  The emulsion will now be
discontinued, and  the  strychnia solution given only every
six hours, with two grain doses of quinia alternated with it.
   The patient lying in this next bed is a native of Ireland;
aged twenty-seven years; a laborer; had been sick four weeks
previous to admission here on yesterday.  He now presents a
dull  expression  of countenance ; skin dry, congested, and
above the natural temperature ; lips thin, retracted, and teeth
covered with dark sordes;  tongue covered with a dark brown
dry coat, fissured; mouth dry; mind dull and wandering;
much subsultus; the hands trembling constantly, and the
tongue so tremulous that he can  neither run it out nor speak
plainly.  His urine dribbles in bed ; and a somewhat extensive
superficial  bed-sore has  formed over the sacrum.   The
abdomen is neither distended nor tympanitic; but he has
from one to three  faecal  evacuations daily.  Pulse  130 per
minute, soft, and weak; respiration accelerated, but no tho-
racic dullness, or bronchial rales.
   In this case, impairment of the functions of the nervous
centers, and the general exhaustion, are so prominent, that
we shall  order, at once, the same strychnia and acid  solu-
tion, to be given in doses of a teaspoonful every four hours;
and five grains each of pulv. Doveri  and pulv. gum camph.
at night; also the prompt attention to nourishment.
   On the third day this patient  had  so much improved that
he could speak plain, protrude his tongue readily; and there
was but  little tremor  of the extremities.   The  strychnia
solution was then  diminished to once  in six  hours, and a
powder consisting of sulph. quinia, two grains ; pulv. Doveri,
five grains;  pulv. gum  camph., three grains, was ordered to
be given alternately with it.   He continued steadily to im-
prove, and in eight days after his admission into the hospital
(five weeks from the commencement of his fever), his  con-
valescence was fully established. 
22             CONTINUED FEVER.
   We have here another patient, aged twenty-seven years;
native of Ireland; laborer; who was admitted into the hospital
eight days since, with all the symptoms  of a severe form of
enteric typhoid fever, then in the middle of the second week
of its progress.  The tongue was dry and brown, with redness
of the tip and edges ; the abdomen tympanitic ; face suffused
with redness;  pulse  120 per minute; skin moderately  hot
and dry; intestinal evacuations  eight  or ten  times in the
twenty-four hours, thin, and dark brown; urine  less than
natural;  respirations short, and  twenty per  minute, with
some cough, and harsh respiratory murmur in the upper and
anterior part of the chest, and deficient murmur with dull-
ness in the lower part of the left side.   Mind dull, but not
much wandering.
   To arrest  the progress of the  abdominal lesions,  and
also aid in giving tone to the capillary circulation generally,
he was  put upon  moderate doses of oil of turpentine  and
tincture of opium, in the form of an emulsion, every three
hours; and to  counteract  the tendency to pulmonary con-
gestion, he was ordered one teaspoonful of the following pre-
scription three times a day :
        IJ.—Ammon. hydrochl_____________________3 iii.
            Antim. et potass, tart__________________grs. ij.
            Morphise sulph_______________________grs. iij.
    M.     Syr. glycyrrhiz____..........________^iv.
   His nourishment, administered regularly, consisted of
sweet milk  and wheat-flour  porridge, alternated with beef-
tea.   During the first five  days of this treatment, all the im-
portant symptoms improved.   The temperature diminished;
the cough ceased; the pulse gradually fell to  100; abdomi-
nal tympanites diminished; and the  intestinal  discharges
were reduced in frequency to two in twenty-four hours.   But
the tongue remained dry, and the mental faculties dull.   On
account  of the  diminished frequency  of  discharges   the 
CONTINUED  FEVER.             23
emulsion  was given  only every four  hours;  otherwise  the
treatment was not altered.   During the  sixth and seventh
days after admission, which would be about  the middle of
the third week after  the patient  had  taken to the bed, the
symptoms rapidly assumed a more unfavorable aspect.   The
pulse increased to 130 per minute, and was quick, soft, and
weak; the mind more wandering; and the intestinal  evacua-
tions more frequent and partially involuntary.
    This  state of the  pulse, and  intestinal  discharges, indi-
cated a dangerous degree of depression of the functions of
the nervous  system, especially that part  of it denominated
excito-motory, by Marshall Hall.   As before stated, we know
of no remedy as direct and efficient for sustaining the nerv-
ous functions of organic and animal life as strychnia.  When
the muscular contractions  of the heart become weak, and
the sphincter muscles give indications of relaxation, in the
advanced stage of typhoid fever, we always resort to its use
in the combination before mentioned.*
    This patient was  admitted to the  hospital some four or
five days ago.  He had had several paroxysms of intermit-
tent fever during the latter part of August and the month
of September, in consequence of which he had become pale
and somewhat debilitated, but  was recovering until about
two weeks since.  He  was then attacked with a chill, fol-
lowed  by a  paroxysm  of fever, which  abated after a  few
hours, but has not since entirely disappeared.   He says that
he  took  some  quinia and other medicines, but instead of
having the progress  of the  fever  interrupted, it was  only
modified in its severity.   There has been no distinct  repeti-
tion of the chill, but  a paleness and sense of  weakness each
   * About five days later the attention of the class was again called to this patient,
and he then presented all the symptoms of commencing convalescence.  The treat-
ment had been continued without change, except to lengthen the intervals between the
doses of the medicines. 
24             CONTINUED FEVER.
day during the morning hours, with  increased heat, quick-
ness of pulse, headache,  restlessness, and general febrile
symptoms  during  the afternoon and  evening; and in all
parts of the day and night, a swimming, unsteady feeling in
the head when in the upright condition ;  dryness of the lips
and mouth; tongue covered with a dirty, white coat; pulse
ioo per minute ; abdomen moderately full and  tympanitic;
bowels relaxed; and the mind dull.   He  has no appetite,
and only moderate thirst.  The patient is  now evidently
affected  by a mixed grade of fever.   The early history of
the case, together with the  existing paleness of skin, and
exacerbating character  of the  febrile  phenomena,  show
the  existence  of  a malarious  influence; while the  dull-
ness  of mind, dryness of lips  and mouth, sense  of gid-
diness in  the  head,  together   with  symptoms  of  diar-
rhcea and  abdominal tympanites, clearly indicate a typhoid
condition  and   tendency.  In  other  words, the case has
become  one of typho-malarial  fever, of moderate  sever-
ity.   This mixed grade of fever had been very prevalent in
the city from the  early part of August to the present time
(November, 1872), while in  the surrounding  country dis-
tricts, purely malarious or periodical fevers have  been unusu-
ally prevalent.   Many  of the typho-malarial cases in the
city have  commenced with  such  distinct chills and exa-
cerbations of fever, as to lead the patient and practitioner
both to regard them  as simple malarious cases, and to
confidently expect their full  interruption by anti-periodics.
In a few, the deception has been increased  by an interrup-
tion of the paroxysms for two or three days  after  the first
induction  of the effects of quinia, so  fully that the patients
have gotten up,  and supposed themselves convalescent.
Yet there has remained with  them a dull, unnatural feeling
in the head; a dry or gummy feeling in the mouth ;  obscure
achings in the back and  limbs, especially in  the afternoon, 
CONTINUED  FEVER.
25
with indifference to food ;  and after a period  ranging from
three to five days, the face  would become suffused with red-
ness ;  the  lips  dry;  the  tongue coated;  more dullness,
swimming and pain in the head ; and more general derange-
ment of secretions.  The  pulse from ioo to  no, and tem-
perature from ioo° to 1030 in  the afternoon, but so much
less as to constitute a remission in the morning.  From this
time on, every day generally adds to the predominance of the
typhoid symptoms, and some of  the cases run a protracted
course of  from four  to six  weeks.    If, when  the  fever
returns, after the first apparent interruption by quinia, that
remedy be  again resorted to, and  the doses increased, with
the expectation of again arresting, at  once, the further pro-
gress of the case, it generally produces no other  effect than
to stupefy  the  sensibility  of the  patient, and  add to the
giddiness and confusion in  the head.   The method of treat-
ment which we have found most  beneficial  in these cases,
when  called to them in  the  early  stage,  has  been rest;
a bland, simple  diet;  milk-whey for  drink;  sponging the
surface with luke-warm water, when hot and dry in the
afternoon ;  and the exhibition of a mixture of carbolic acid,
gelseminum, and camphorated tincture of opium, in moder-
ate doses, to counteract the typhoid elements, and moderate
anti-periodic doses of quinia in  the  morning remission to
destroy malarious influence.  Four or five days since, when
the present patient  was admitted to  the hospital, he was
ordered the following prescriptions :

       5.—Acid, carbol. cryst....................grs. vj.
           Glycerinae (purae)----------..........§ ss.
           Tinct. gelsemii-----.................3 iii-
           Tinct. opii camph.........----------§ iss.
           Aquae___........-.......------.....% iss.
   M.  Give one teaspoonful every four hours.
       3 
26             CONTINUED FEVE
       -,   „ .  .    , ,                  ___grs. xxiv.
       5.—Quiniae sulph_________.......----    &
           Hydrarg. chlor. mit...-.......-------6rs- n>
           Glycyrrhiz. rad. pulv------------.....Srs- VJ'
    M.  Fiant pulv. vi. Give one at six and ten o'clock each morning,

    He has continued these medicines steadily until the pres-
ent time, and with a gradual improvement  in all the febrile
symptoms.  He will  now continue the carbolic acid solu-
tion every  six  hours,  and  take only  one  powder  of the
quinia, etc., each morning.
    This  case will  probably require no other treatment ex-
cept the  gradual withdrawal of his present medicines, as
convalescence becomes established, and the allowance of a
more liberal diet.
  When  cases  of  this mixed fever assume greater severity,
and, after the second week, present more prominent typhoid
symptoms,  the  treatment must be more  fully that which
is adapted to   the  advanced  stage  of idiopathic typhoid
fever. 
LECTURE  II.
CONTINUED  FEVER. — Cases  Complicated  with  Emboli,
   Bronchitis, Broncho-Pneumonia, Hypostatic Infiltration, In-
   testinal Ulceration, etc.
    Gentlemen :—The patient before you is a laboring man,
 aged about  thirty-six years,  a native of Canada, and  a
 resident of this city only a few months.  About one week
 since he called at my office for advice.   His expression of
 countenance was dull; face moderately flushed;  skin dry
 and warmer than natural;  pulse about ninety per minute
 and soft; respiration natural; tongue covered with a dirty,
 white fur,  thicker along  the  median  line; mouth moist;
 thirst moderate ; no  appetite ;  bowels slightly  relaxed ; and
 complained of dull pain in the  head, back and  limbs, with
 swimming  or giddiness in  walking, and  a great  sense of
 muscular weakness.   These symptoms had been gradually
 developing for three or four days, and  clearly indicated
 the forming  stage of typhoid fever.  He was directed to
 go  home  and keep  quiet,  take only  light food, and  for
medicine, ten grains of. sulphite of soda  with eight  drops
of tincture of  gelseminum, every  four hours,  and  a pill
containing three  grains  of quinia  and one of blue mass 
28
CONTINUED  FEVER.
every morning.  Two  days later a message was left at the
office, and Dr. F. H.  Davis visited him at his boarding.
house in Charles street.  He found the patient presenting
all the ordinary symptoms of typhoid fever, except in rela-
tion to the skin, which, instead of being dry, was thoroughly
wet with perspiration.   Owing to the relaxation of the skin,
and some  looseness of the bowels, he directed the  quinia
without the blue mass  to be given  three  times a day; and
instead  of  the sulphite of soda solution, gave  an emulsion
containing oil of turpentine and tincture of opium.   About
forty-eight hours later, I saw him in consultation.  His skin
was still wet with perspiration ; his countenance dull, with
dryness of the lips and mouth, as in ordinary typhoid fever;
mind dull, but not wandering; pulse  small, weak, and 120
per minute; respiration nearly natural;  urine scanty, and
passed with some pain; three or four thin evacuations from
the bowels had occurred during the preceding twelve  hours;
and he  was complaining of extreme  pain in  the region of
the lower end of the fibula of the right leg.   There was no
swelling, no redness, no visible change in  the appearance of
the leg, except it was paler, or more bloodless, and entirely
cold.   The coldness was  as perfect as though the limb was
dead.   We could find  no pulsation either in  the femoral or
posterior tibial arteries.  All the  extremities were cool; and
the patient looked very depressed.  He was living in a very
damp, badly ventilated place, entirely below the level of the
street.   He was directed powders of sulphate  of  quinia
and morphia, both, to  relieve the severity of  his pains and
prevent further intestinal discharges ; and dry  warmth to the
extremities.
  In looking at the patient, as he lay in his low, damp room,
with feeble pulse, cool  extremities, relaxed skin, and copious
intestinal  discharges,  the  question came up  in the mind
whether we had a case of pernicious  chill, or, as it is more 
CONTINUED FEVER.             29
generally termed, congestive  intermittent.  But  the  quiet,
dull  expression of countenance,  the absence of  paroxysms
of restlessness and tossing, the  quiet respiration,  and the
marked disparity in the temperature of the lower  extremi-
ties,  served to negative the idea of a chill of any kind; and
the'  conviction  was forced  upon  me  that  some serious
mechanical obstruction existed in the arteries supplying the
right leg.  The  cardiac sounds were natural in rhythm, but
weak.  This fact, with the quiet breathing, led to the con-
clusion that the obstruction was  in the iliac  or femoral
artery, rather than in the  heart  or lungs ;  and as there was
no tumor discernible  in the abdomen or groin, it was pre-
sumed that  the obstruction  was from  emboli or fibrinous
clots.  The  next  day  the attending physician, finding him
no better, advised his removal  to the  hospital, which was
done yesterday.
   If you examine the  present condition of the patient, you
will see a dull, typhoid expression of countenance;  the
upper lip is  retracted; the  exposed parts of the  teeth are
dry  • the tongue coated; the skin dry, but not hot; respira-
tion natural; pulse soft, weak and 115 per minute ; abdo-
men soft • bowels moved three  or four  times in  the twenty-
 four hour's ;  urine scanty ;  and both lower extremities cold ;
 the  left retains some warmth in  the upper part of  the thigh,
 but all below the knee is cold  and pale.   The  right  leg is
 cold throughout, and mottled  with purple  spots from the
 foot to the knee, showing commencing gangrene.  But there
 is no swelling and no  paralysis, as he  moves both limbs at
 will  This is a very unusual case.  A laboring man, in the
 early period of vigorous manhood, residing in the city only
 a few months, and boarding in a low, badly ventilated place,
 is attacked  with the  ordinary  symptoms of typhoid  fever,
 and in four or five days suddenly loses  all circulation in the
 right extremity, which progresses to the development of dry 
3°
CONTINUED  FEVER.
gangrene; and in two or three days more the same state of
things takes place in the left.  It would seem from the pro-
gress of the coldness and arrest of circulation, that com-
plete obstruction occurred  first, in either the external or
common iliac artery of the right side,  and gradually extend-
ed upward to the abdominal aorta, and to the common iliac
of the left side; thus completely interrupting the circulation
to both lower extremities.
   That the obstruction is in the arterial trunks is evident
from the fact  that  there is no  swelling or oedema of the
limbs.   If the venous trunks  were  obstructed,  the  blood
would  continue to flow into the limbs through  the arteries;
but not returning through the obstructed veins, its accumu-
lation would necessarily be speedily  followed  by  swelling,
and  more or less serous infiltration  into the tissues.  You
see,  however, the reverse of all this in the present  case.
But  what is the nature of the obstruction in the arteries?
The absence of all signs of cardiac and pulmonary disease,
and  also the  entire freedom from any abdominal tumor,
leaves  us only the emboli or fibrinous clots as  the probable
cause of interrupting the flow of blood to the lower extremi-
ties.   That the fibrine, and perhaps more or less of the albu-
men of the blood, does sometimes  spontaneously solidify,
forming masses or emboli of greater or less size, which are
capable of lodging either in the cavities of the heart  or in
the blood-vessels, and thereby mechanically obstructing the
circulation, is a fact familiar to the profession.  The  exact
pathological  condition of the blood, which favors or gives
rise  to such solidification, however, is not well understood.
The subject is one that needs an  additional amount of
careful study, more  especially by adding microscopic and
chemical analysis to  our  clinical  observations.   The  latter
so far as my experience goes, appears to show  that the for-
mation of emboli  occurs chiefly in patients with impaired 
CONTINUED  FEVER.             31
vital activity or molecular change, with accompanying cir-
cumstances  such as. would favor deficiency of free  salts in
the blood.   It is generally conceded that the albumen, and
probably also the fibrine of the blood, is held in solution in
the living body by the free  alkaline salts, more especially
of soda and ammonia.   Let us see whether these views will
aid us in unraveling the pathology of the case before us.
The patient is  a  laboring man who, at work  in the  heat of
summer, had, for two  or three weeks previous to being
taken  down sick, drank profusely of water, and more or
less of beer  and ale.  At my first interview with  him, he
acknowledged  that he  had drank two or three quarts of
fluid per day, and had  sweat  correspondingly profuse.  A
little reflection  will show you how rapidly the" composition
of the blood must be changed, in some important respects, by
such a process.   All know thai perspiration contains a nota-
ble quantity of saline matter, especially salts  of soda; while
neither water nor the beer drank supplied these elements.
Hence, his  excessive drinking  and consequent  excessive
perspiration  rapidly exhausted  the free alkaline  salts, and
left these solvents of the albumen and fibrine deficient  in
the  blood.   But  the  evil did  not  stop  here.  A normal
proportion of saline matter in the blood is necessary to give
it the  capacity for absorbing and holding the oxygen gas
furnished in  the air-cells of the lungs;  or,  in other words, to
render complete  the  change from venous to arterial blood.
This defective  arterialization resulted in diminished inner-
vation; muscular weakness ; a leaden hue of the lips.; a soft
weak pulse,  and  feelings of decided general  debility.   Add
to  these board and lodging  in damp, ill-ventilated  apart-
ments, with the  accompanying impurities of a city atmos-
phere, and you have a fair view of the influences that were
at work, effecting the important pathological changes frpm
which our patient suffers to-day.  The same causes,  acting 
32
CONTINUED  FEVER.
with less  intensity, perhaps, affect thousands of the inhab-
itants of all our cities and populous towns.  The changes
produced  in the blood by the excessive use of  drinks, and
the resulting excessive  perspiration, constitute  very impor-
tant pathological conditions, and have more to  do with the
production  of  attacks of diarrhcea, cholera morbus,  and
typhoid fever than is generally supposed.   If  the circum-
stances to which  we have alluded, or indeed  any others,
have so far influenced the blood of the patient before Us as
to give rise to emboli that have  completely obstructed the
passage of blood  to  the  lower extremities, and caused the
present appearance of incipient gangrene, it is not likely
that any course of treatment will avert a fatal result.  It is
not likely that any remedy can be safely introduced into the
blood, in  sufficient quantity to re-dissolve a fibrinous clot
large  enough to block up the iliac arteries.   If the deficien-
cies in the composition of the blood had been corrected by
a  supply of pure  air, and a judicious use  of the chlorine
salts,  during the preliminary or forming-stage of the attack,
it  would  probably have prevented both the fever and the
arterial obstruction.  But in the present state of the patient,
the prognosis is entirely unfavorable.   He should be sus-
tained as much  as possible with good nourishment, and such
medicine as will help sustain the vital properties  and nervous
force.   Carbonate of  ammonia and  camphor, alternated ■
with small  doses  of  strychnia, would probably afford the
patient as much benefit as anything we could suggest.
    The formation  of emboli in  the  cavities of the heart is
not very unfrequent; and  it occasionally  happens, that a
patient laboring under disease of  such nature  as to cause
diminished  innervation and cardiac  weakness,  has life ter-
minated suddenly, and unexpectedly, from this  cause.
    A  few years since I attended a man in feeble general
health, who was attacked with dysentery.   His discharges 
CONTINUED  FEVER.
33
 were largely mixed with blood; but they had continued only
 about twenty-four  hours when he suddenly presented signs
 of syncope, and almost immediately expired.  A post mortem
 examination revealed a tenacious white fibrinous clot occu-
 pying the right ventricle, and extending several inches into
 the pulmonary artery.  It adhered quite closely to the edges
 of the tricuspid valve as well as to the columnar carnae.
    Within a few days, a neighboring practitioner was attend-
 ing  a case of typhoid dysentery which had presented no
 unusual symptoms, but  was apparently progressing favor-
 ably, when there  suddenly  supervened feelings of  great
 exhaustion, bordering on syncope;  the sounds  of the heart
 became muffled and obscure; the pulse extremely feeble,
 and extremities cold.   He passed directly into complete
 collapse, and died  in about twelve  hours.  Although no
 post mortem examination was  allowed, yet I have no doubt
 but a cardiac embolus was the immediate cause of the fatal
 result.
   While speaking of these unusual complications  I am
 reminded of a case recently seen several times  in consulta-
 tion.   The patient, a laboring man, aged about twenty-five
 years, was  attacked with a chill, followed by an exceedingly
 severe pain in his back and loins, with fever of a distinctly
 remittent type.   The  urine  was scanty  and high-colored ;
 stomach irritable;  the  bowels costive, and the pain in the
 back so severe as to cause the  attendant to fear direct inflam-
 mation of the lumbar portion of the  spinal cord.  After a
 few days of treatment, chiefly with anodynes and alteratives,
 during the febrile exacerbations; quinia and  morphia in
 the remissions; and active revulsives and counter-irritation
 to the  spine, all the more active symptoms subsided.   The
patient remained  quite comfortable for  two  or three days,
though not'entirely free from dull pain and soreness, both
in the lumbar  region of the spine and in the direction of 
34
CONTINUED  FEVER.
the psoas  muscles.  The tongue remained coated, the urine
rather scanty, and a noticeable  increase of pain and fever
every alternate day, but no chills.  The continuance of these
symptoms, and  especially the  dull pain  and tenderness in
the psoas regions, led to a suspicion that  there might be
forming a psoas abscess.  ' But up to the time we now allude
to, there had occurred no rigidity or contraction of the psoas
muscles, causing the thighs to be flexed on the pelvis, as is
usual in cases involving inflammation or suppuration in  the
psoas regions.   While in  this state, about one week after the
commencement  of his sickness, there came, suddenly, pain
in the  left hip, thigh, and calf of the leg, accompanied by
diffuse swelling  of the whole  limb.   The swelling, tender-
ness and  pain were greatest on the  anterior and outer part
of the  thigh and in the calf of the leg.  There was no red-
ness or erysipelatous appearance of  the surface,  and  but
little, if any, increase  of  temperature.  Over the dorsum of
the foot and ankle there was  sufficient  oedema to present
pitting on pressure; but the calf of the  leg and the whole
thigh had a hard or semi-elastic feel, like that of phlegmasia
alba dolens.  The extent and character of the swelling; the
rapidity with which it had been induced, and the preceding
pain in the lumbar and psoas regions, led to the belief  that
some mechanical obstruction existed in the iliac vein; and it
was feared that rapid and diffuse suppuration would  take
place  in  the cellular tissue of both thigh and leg.   The
stomach of the patient being irritable and inclined to reject
whatever  medicine had been given, he was directed nothing
but a powder  of sub-nitrate  of bismuth,  six grains,  and
sulphate  of morphia, one-quarter of a grain  every three
or four hours,  and an emollient poultice of linseed meal
over the whole thigh  and leg.   Under this treatment,  with
mild nourishment, he became quite comfortable  the  pain
 gradually declined in  the limb, and  after two  or  three 
CONTINUED  FEVER.
35
days  the swelling began  to abate, and in  a week it  had
entirely  disappeared, without any vestige of suppuration.
The patient, though free from fever, remained weak and still
suffering from pain and lameness in the small of his back.
    You  will doubtless learn, at a future time, what becomes
of the poor patient before you.*
    This next case, gentlemen, to  which we now call your
attention,  is  that of a laboring man, aged about twenty-
eight years, naturally  spare in flesh, and  of nervous tem-
perament.  He came to me  about four weeks since,  in my
office, complaining of the  usual initial symptoms  of an
attack of typhoid fever. I directed him some medicine, and
proper  hygienic management,  and  saw  or heard nothing
more from him until he was brought into this ward  of the
hospital, about one week  since.   At the time of admission
his  case presented all the  symptoms  of a  grave form of
typhoid fever, in the advanced  stage of its progress.  His
skin  was dingy; countenance dull; lips retracted and dry,
leaving  the  upper teeth covered  with sordes ;  mouth and
tongue  dry ;  mind somnolent  and sometimes  wandering;
skin  dry and  rough, and above  the natural temperature;
muscular  movements  unsteady  and  awkward;  abdomen
tympanitic and full;  bowels moving five or six times per
day, the discharges being dark brown and thin ;  respirations
twenty per minute  and short, with dry bronchial rhonchi

    *This  patient continued steadily to fail, and died in about one week after he was
■admitted into the hospital.  The right leg had become entirely discolored from gan-
grene, and  the left partially so. A/ost mortem examination revealed no unusual patho-
logical changes in the abdominal or pelvic viscera, except in the abdominal aorta and
its branches.  Commencing about three-quarters of an inch above the bifurcation, a
tough, yellowish-white fibrinous clot occupied the vessel and extended through both
common iliacs, and on the right side through the external iliac to the groin, and the
internal iliac two or three inches ; also through the external iliac of the left side, but
only slightly into the internal iliac. Throughout the extent just mentioned the arteries
appeared full, round, and firm, as if injected, while above and below they were empty
and collapsed as usual.  The coats of the plugged vessels showed no  appearance of
inflammation. 
36
CONTINUED  FEVER.
over both sides of the chest, and some dullness on percussion
over the lower  and posterior parts.   The  pulse  was soft,
quick,  and varying from  120 to 130 per  minute.  If wu
suppose that at  the time when he called at my office he
was in the forming-stage of the fever, it will be  seen that
when  admitted into the hospital he  was at the end of the
third  week of the disease, and the symptoms  such as to
render the prognosis doubtful.
   The soft, frequent pulse, the mental dullness, the muscular
unsteadiness, the dark hue of the lips  and skin, all  indicated
that profound typhoid condition when  the  qualities of the
blood and the properties of the  tissues are  both  impaired,
causing all the resulting actions in the economy, such as
capillary circulation, secretion, nutrition, innervation, etc., to
be  performed feebly.   In the  more malignant  cases of
typhus and typhoid fevers,  these alterations in the qualities
of the blood and  properties of the tissues  are sufficient to
suspend the  organic changes,  and, consequently, to prove
the direct cause  of death.   In  addition  to the general
pathological  conditions, there  are  important  local changes
in the viscera of the chest and abdomen.  The dry, bron-
chial rhonchi over the whole anterior part of the chest, with
dullness on  percussion  over  the lower  and posterior part,
and the short inspirations, show that  the  bronchial mucous
membrane is in  a  state  of congestion, and the parenchyma
of the lower lobes so  occupied with hypostatic or passive
infiltration, as to  materially  diminish the capacity of the
lungs for air.
    This condition of the lungs, of course, lessens the oxygen-
ation  and decarbonization of the blood,  and thus  indirectly
increases the general impairment of function throughout all
the organs.   The tympanitic abdomen, with the frequent
thin reddish-brown and copious discharges from the  bowels,
indicate, in this stage of the disease, extreme softening, and! 
CONTINUED  FEVER.
37
perhaps, ulceration, of the aggregate glands of the ilium and
those of the mesentery.
   These local  pathological  conditions in the chect and
abdomen are frequently the most dangerous  developments,
during the  progress of  this variety of fever, sometimes  de-
termining a fatal  result in cases presenting  only moderate
primary changes in the  blood and  properties  of the tissues.
In the  patient before us, at the time of his  admission, the
symptoms,  as we have recalled  them, indicated much general
depression, with serious lesions both in the chest and abdo-
men.  Hence the special  indications for treatment were to
sustain  the general properties and  functions  by  plenty of
good air and judiciously  selected  nourishment; and  to
administer  such medicines  as would relieve  the congested
condition of the bronchial mucous membrane, on the  one
hand, and,  on the other, such as would arrest the process of
softening and disintegration in the glands of the ilium and
colon.   The first object was  secured by the size  of the
ward, its free ventilation, and the limited number of patients
in it;  and the  feeding of the  patient animal  broths well
salted, alternately with thin sweet milk and wheat-flour por-
ridge.   These articles of  nourishment, given in small quan-
tities, and at short  intervals, are capable of being taken up
by the absorbents and lacteals of the stomach and duodenum,
leaving the smallest amount of faecal residue to pass over the
diseased surface of the ilium and  colon.  To accomplish
the second purpose, we gave one fluid drachm of the follow-
ing mixture every four hours :
       ]$.—Ammon. hydrochl....................3 iii-
            Antim. et potass, tart.....------------grs. ij.
            Morphise sulph......-----------------grs-  iij-
    M.       Syr. glycyrrhiz.....-.....- -..........1 iv-

   To secure the  third object,  we  give one fluid drachm  of
        4 
38
CONTINUED  FEVER-
 the following emulsion every four hours, alternately with the
 foregoing prescription :
       3•—Olei.  Terebinthinse___...........----..'..
           Tinct. opii................---------- ^
           Acaciae g. pulv. )              _____ 3 iv.
           Sacch. alb.    )   ".....
           Olei. gaultheriae_.-......-...........gtts; xx-
           Misce. et add. aquae------------------ 3 U1-
    After these  remedies had been  used for three days, the
 dry bronchial  rhonchi  diminished, and were  partially re-
 placed by moist mucous rattles; the skin became less hot
 and dry; but the pulse  remained  weak and  frequent, and
 the mind more wandering.
    The emulsion was continued every four hours, and ten
 drops of chloroform added to  each dose.  The use of the
 solution of hydrochlorate of ammonia, etc., was diminished
 to one dose, morning, noon and evening.   The same nour-
 ishment was continued as before.
   Four days have  elapsed since any  alteration  has been
 made in his treatment.   If you now examine the  patient
 carefully, you  will find  the  skin but  little above   the
 natural temperature,  and more  soft;  the   countenance
 more  pale;  the  lips thin, and still  somewhat retracted,
 but the sordes  mostly gone from  the  teeth;  the  middle
 of the tongue  dry  and red, but  moist  and  white along
 the margins ; the respirations   shorter and more frequent
 than  natural, with  a moderate development of mucous
 rhoncus  over the  anterior part of the chest,  and some
 dullness on percussion  over the lower and posterior part.
 The pulse is  110 per minute, small  and soft.
  The abdomen is only slightly tympanitic, but the intes-
tinal discharges continue thin and light-brown, and average
from three to five  discharges  in twenty-four  hours.   You
will readily perceive that  some of  the  symptoms to which 
CONTINUED  FEVER.
39
your attention has been called indicate improvement, while
others  point to a more doubtful prognosis.  For instance,
the nearer approach to a natural condition of the skin, the
less appearance of sordes on the edges of the lips and teeth,
the moist condition of the margins of the tongue, and the
lessening of morbid sounds in the chest, all indicate the
commencement of convalescence.   But the continued weak-
ness and frequency of the pulse, with the quality and num-
ber of  the intestinal discharges, indicate the continuance of
a serious amount of disease in the ilio-ccecal portion of the
alimentary canal.  It happens, not very unfrequently, in the
severer cases of enteric or typhoid fever,  that all the general
symptoms of fever subside, and convalescence ensues, while
the patches  of aggregated  glands in the ilium, which had
become softened  or ulcerated during the progress'of the
fever, are still not cicatrized or much improved  in texture.
Your attention is  called to the fact  as one of much practical
importance.   If it be overlooked, and as soon as the patient
appears otherwise convalescent, all  remedies  designed  to
exext a soothing influence on this part of the mucous mem-
brane  are  withdrawn, and a liberal diet allowed, it will
sometimes happen that the intestinal evacuations will gradu-
ally increase in frequency, and  after a week of partial con-
valescence, the abdomen will again become  tympanitic,  the
mouth dry, the pulse frequent and  feeble,  with rapid loss of
strength, until a fatal  result is reached.  In a smaller  num-
ber of cases the general appearances of  convalescence con-
tinue, but the patient does not improve in  strength.  The
bowels do not become regular, sometimes moving three or
four times in  succession, and  then quiet  twenty-four or
thirty-six hours.  After  a time, varying from one to three
weeks, they are suddenly attacked with acute pain in some
part of the abdomen, followed rapidly by  abdominal disten-
tion, tenderness and prostration.  The  pulse becomes very 
4°
CONTINUED  FEVER.
rapid  and feeble,  the countenance hippocratic,  the  skin
covered with cold perspiration, and death follows in twenty.
four to forty-eight hours.  These are cases in which some
one  of the patches of Peyer's glands remained unhealed,
after the convalescence from the general fever;  and instead
of subsequent cicatrization, the ulcer slowly extended, until
the coats of the  intestines  were  perforated, inducing,  sud-
denly, peritonitis and death.
   Many years since, a marked instance of this kind  occur-
red in the person of a medical student, in this city.  After
an apparently mild course of typhoid fever he convalesced;
continued to be up a part of each day for a week, and began
to go to the table for his meals with other boarders, when
he was attacked suddenly with fatal peritonitis, from a per-
forating  ulcer in the  intestines.  In a much larger propor-
tion of cases, however, patients  convalesce from  typhoid
fever while numerous places in the mucous  membrane are
in a state of partial or complete ulceration.  They regain a
fair  degree of flesh and  strength, and often attempt to re-
sume attention to their  ordinary work.  But the intestinal
evacuations never become  regular.   In some,  there  will
occur from one to three or four  of these faecal discharges
per day, constituting what might be  styled a slight chronic
diarrhcea.  This  state of the system will continue in some
cases many months, and finally the patients  begin to lose
flesh and strength, and slowly reach a stage of fatal exhaus-
tion.
   In  other  cases  the  uncicatrized patches  appear to be
limited to the colon.  The patients recover a fair degree of
flesh, and resume attention  to business; but their intestinal
evacuations remain very irregular, usually going from two to
four days  without  any discharge, and then having six  or
eight in  a single day.   It  would seem  that the peristaltic
motion of the small intestines was  impaired,  and the faecal 
CONTINUED FEVER.             41
 contents were  carried forward only slowly ;  but as soon as
 they began to accumulate in the colon and come in contact
 with the patches of diseased membrane, an exaggerated mo-
 tion is started, which does not stop until the whole canal is
 emptied, when it returns  to  the  dormant state as  before.
 Patients have come to me often with this state of the bowels,
 and, on  carefully inquiring into their history, I have traced
 them directly back to an attack of typhoid fever, which had
 occurred,  sometimes, four or five  years  previously.   I am
 thus  particular in calling your attention  to  this point, be-
 cause  it is  one of direct practical importance.  Careful
 attention to the state of the  bowels, during convalescence
 from typhoid fever, will save many patients from trouble-
 some sequelae.
    The  patient before us gives plain evidence of commenc-
 ing convalescence ; but his bowels remain actively loose, and
 his pulse quick and feeble.   We shall therefore continue to
 give him the emulsion of ol.  terebinth, and tinct. opii every
 four hours, and  feed him  on sweet  milk and wheat-flour
 porridge, until   the  intestinal  discharges   become  more
 natural.
   A few days  since I directed your attention  to two cases
 of typhoid or enteric  fever, in this ward, each  complicated
 with serious pneumonic inflammation.   One of them is still
 occupying the bed in which you saw him, but is now conva-
 lescent.  He is  a native of Norway, aged about twenty-two
 years, and  had been sick for ten  or twelve days before his
 admission into  the hospital.  At the time your attention was
 called to his case, he was presenting all the symptoms of the
 advanced stage of typhoid fever; such as somnolency; de-
 lirium ;  dry tongue and  mouth; sordes on the lips  and
 teeth; dryness  of the skin, with congestion  of  the cutane-
ous capillaries ;  tympanitic abdomen, with five or six thin,
reddish-brown intestinal discharges daily.  Upon this  con-
                           4* 
42             CONTINUED  FEVER.
dition had rapidly supervened, during the three or four pre-
ceding  days, short  and  hurried  breathing,  with  loud
bronchial rhonchi over the whole anterior part of the chest;
a mixture of dry and moist rhonchi in the axillary and sub,
axillary regions; and in the  latter, dullness  on percussion.
There was cough, with a scanty expectoration  tinged with
dark  blood, and the pulse was  120  per minute, small, and
weak.   I then explained to you that the case presented all
the phenomena of typhoid fever, with the  enteric disease
peculiar to that grade of fever well developed, on which had
supervened universal congestion of the mucous membrane
of the respiratory passages, with pneumonic  infiltration of
the middle lobes of both lungs, constituting a most danger-
ous condition, yet  one  frequently met with in this climate
during the latter part of autumn and early spring.
   You will remember that we directed a blister to be ap-
plied  to his chest, while he took internally the emulsion of
ol. terebinth, and tinct. opii every four hours, and one of
the following powders between :
       R.—Pulv. opii-----............._________grs. vi
           Antim. et potass, tart......___________gr. i.
           Sacch. alb..............-------.....grs. xxx.
   M.  Fiant pulv. vi.

Under that treatment he soon began slowly to improve.
   The other case to which I directed your attention at the
same clinic, was one  of typhoid  fever,  presenting complica-
tions  of the  same nature, but  much more  severe.  The
patient—a German, aged about  twenty-five years—instead
of being somnolent, was affected with constant delirium and
subsultus;  the intestinal discharges were not only more fre-
quent, but they were mixed  with mucus and  blood, and
the whole right  lung, from the  clavicle to  the diaphragm,
yielded  complete  dullness on percussion, and  only a very 
CONTINUED FEVER.
43
slight respiratory or vesicular murmur by auscultation.   At
first a blister was applied to the right side of the chest, and
the same remedies given internally as in the case previously
alluded to.  After continuing this treatment two full days,
the intestinal  discharges  and abdominal  tympanites  were
much improved; but the delirium, the muscular tremulous-
ness, and the oppression of breathing, were much increased.
The pulse was small, soft, and frequent.  Thinking it very
desirable to lessen the nervous jactitation and delirium, so as
to induce some sleep, and finding the powders of opium and
antimony to fail, I caused  them to be  omitted, and fifteen
drops of  chloroform given in their place, every three hours,
alternated with  the turpentine emulsion.   In  twenty-four
hours after commencing the use of the chloroform, his pulse
and  respirations were slower,  the subsultus less, and  he
obtained short intervals of quiet sleep.   The  bowels also
remained quiet; consequently the same remedies were con-
tinued, only at a little  longer intervals.  On the  afternoon
of the second day, he  not only remained more quiet and
rational, with a fair amount of sleep, but  he  coughed less,
and there was decidedly less dullness  over the upper lobe
of the right lung, with  a corresponding increase of respira-
tory murmur.   The bowels had also remained without any
evacuation, and the abdomen only slightly tympanitic.  The
amount of chloroform was now reduced to ten  drops every
four hours, and an anodyne cough or expectorant mixture
given instead of the emulsion.  On the fourth day after the
first exhibition of the chloroform, the  patient  appeared so
much improved, in all respects, that I thought his convales-
cence had fairly begun.   He was consequently ordered to
have more nourishment, and the use of the chloroform  re-
stricted to ten  drops  each morning,  noon, and evening.
During the latter part of the following night, however, the
patient suddenly expired.  The death  was preceded by no 
44             CONTINUED  FEVER.
new symptoms sufficient to attract  the attention of the
nurses,  and no  post  mortem  examination  was permitted.
The immediate cause of the patient's death is therefore left
to conjecture.   It might have been syncope, from some un-
observed attempt to  rise from the  bed, or from the forma-
tion of emboli, or  fibrinous clots in the  cavities of the
heart.   The very small quantity of chloroform which he had
been taking during  the  preceding twenty-four hours, could
hardly be suspected of having induced excessive anaesthesia
of the nervous centers.  We have administered-that agent
in doses of from ten to fifteen drops, in several cases of
typhoid fever with pneumonic complications, in which there
was constant delirium and sleeplessness, and in all previous
instances; with the most satisfactory results.
    This patient  now  before  you is  a  German  by birth,
aged about twenty-five years.  He was admitted to the hos-  j
pital  three days  since, and was reported to have been sick
about two  weeks previously.   At my first visit, after his
admission, his face was  suffused with a dark red flush; lips
and tongue dry;  expression dull; skin moderately hot and
dry; pulse  112 per minute, small, and  weak; respirations
short, and accompanied by coarse, dry, bronchial rhonchi
over both sides of the chest, intermixed with a sub-mucous
rhoncus over  the middle and lower  part of the right lung,
with  considerable dullness, on  percussion, over the latter
region.  There  was also frequent  cough, with but little
expectoration.  The  mind was dull, and more or  less wan-
dering, and slight haemorrhage from  the  nose. The abdo-
men was quite full and tympanitic, and he had been having
from three to five thin, brown, faecal evacuations daily.  You
will recognize in this assemblage  of symptoms, as well as in
the present aspect  of the  patient, a well-marked  typhoid
condition, with the usual enteric  disease of the aggregated
glands, and, in addition, a dry, congested condition of the 
CONTINUED FEVER.
45
pulmonary mucous membrane, with considerable pneumonic
engorgement of the  middle  and  lower  lobe of the  right
lung.   To restrain the  intestinal  irritation and excessive
evacuations, I directed him to have a teaspoonful of the
turpentine and laudanum emulsion every four hours;  and
yesterday, finding the dry sounds still predominating in his
chest, and  the skin  dry, I ordered  one  of  the  following
powders to be taken  between  each of the  doses of the
emulsion :
       J^.—Pulv. opii.......................----grs. viij.
           Hydrarg. chlor. mit.....-............grs. vj.
           Antim. et potass, tart............-----gr. i.
           Sacch.alb._______--------------------grs.xx.
    M.  Fiant pulv. vi.
    The object of this was to induce such a change in the
functions of the skin and pulmonary membranes as would
result in  free secretion from both, and  thereby lessen the
congested condition of the pulmonary textures.
    The patient has taken the powders  just named,  alter-
nated with the emulsion, during the past  twenty-four hours;
and if you now step forward and examine him, you see his
face less  flushed, lips  and tongue less dry, though there is
still a dry, crusted strip through the middle of the latter, and
some  sordes on his lips.   The skin  is relaxed and univer-
sally  wet with warm perspiration.  His countenance is still
dull; mind  somewhat wandering; and you see a little blood
on the upper lip, indicating recent slight epistaxis.
    If you watch the motions of the chest, you see that the
respirations are short and too much abdominal.  If you now
take  the stethoscope and listen over the anterior and right
lateral part of the chest, you will perceive still more clearly
the imperfect  expansion of the chest by inspiration, while
you  find the dry, wheezing  sounds of  yesterday  replaced
with  moist or mucous rhonchi, intermingled with only an 
46             CONTINUED  FEVER.
occasional coarse, dry sound.  If you move the stethoscope
to the anterior margin  of the  axillary region, you will hear
less respiratory sounds of any kind ; but if the patient artic-
ulates sounds,  you will  have decided vibration  of voice,
indicating increased density of that portion of  the lung.
Now, what is the exact pathological condition of our patient,
and what  the indications for further treatment ?
   The typhoid condition of the patient is  strongly char-
acterized; and though  the  general febrile  condition is
improved, as indicated by the soft and  moist condition of
the skin, the less tympanitic condition of the abdomen, and
the more  quiet condition of  the  bowels, yet the pulse is
very soft, weak, and  115  per minute;  the respirations
are short, and the  patient  gives evidence of  a feeling
of. exhaustion.   He has  evidently arrived at a critical pe-
riod in his disease.  He is vacillating to-day, between a ten-
dency to  convalesce, on  the one  hand,  and such a general
depression of vital properties in his  tissues as would soon
cause a return of copious  intestinal discharges,  perhaps
mixed with blood, with a rapid  increase of infiltration  into
the pulmonary textures,  followed  by colliquative sweating,
involuntary discharges, and death.   Hence it is necessary
to adjust the further treatment with great care.  If we con-
tinue the ■ antimony and calomel  in the powders, we shall
increase the risk  of the latter alterative;  but  if  we can
bring to  our aid  some agent calculated to give increased
tone or contraction to  the capillary system  of vessels, with-
out restricting secretion,  we may decide  the progress of the
case in favor of convalescence.  With  this view, we shall
continue the turpentine  and laudanum emulsion every four
hours, and change the powders  by substituting sulphate of
quinia, two grains, and pulverized bloodroot, one grain, for
the antimony  and calomel, in each powder, leaving  the
opium as  before.  As thus altered, one to be given half-way 
CONTINUED  FEVER.
47
 between the doses  of emulsion.  Of course,  in all such
 cases, the patient is  carefully fed with animal broth, well
 salted, and a porridge of sweet milk and wheat-flour.*
    The  patient in this next bed is in  the second week of
 typhoid  fever, with a pulmonary  complication, which makes
 his condition quite serious.  The expectoration has been
 tinged with blood for two  or three days, and there is dull-
 ness over a part of  one lung, with severe bronchial cough.
 These symptoms led to the conclusion that  the  inflamma-
 tory action, which had existed  in the capillary bronchial
 tubes was extending  to some of the  lobules of the lungs.
 The typhoid depression was  considerable,  and the indica-
 tions were to sustain the circulation and innervation, and
 to induce freer secretion from the pulmonary mucous  mem-
 branes, and thus lessen the tumefaction and  admit a larger
 supply of oxygen to the blood.   The first indication is well
 met by the following prescription:

       IJ.—Ammon. carb_________.............3 ij.
           Quiniae sulph.....____..............grs. xx.
           Camph. gum__________......_......grs. x.
    M. Fiant pulv. x.   Take one every four hours.

    To accomplish the second object, the solution of muriate
 of ammonia, tartrate of antimony and morphia  in syrup of
 liquorice, was given every four hours, alternating with the
 other medicine.   A blister was also applied to the sternum.
 At present the pulse is fuller and less frequent, the expecto-
 ration more  abundant, and the  whole aspect of the case
 decidedly better.
    Here we have also another case of typhoid fever com-
 plicated  with capillary bronchitis, which has been on the
 use of the emulsion of turpentine and laudanum, and the

   * This patient progressed well under the last prescription, and  made  a good
recovery. 
48             CONTINUED  FEVER.
muriate of  ammonia  mixture.   The former medicine has
brought the bowels into a  satisfactory condition, but the
want  of innervation  has been so  great  that  the patient
was  in much  danger from the depression of the nerve-
centers.  To remedy  this he was given the following pre-
scription :

       5.—Strychniae_ _ _.....___________________gr. j-
          Acid, nitric.__________________________ 3 j-
          Tinct.  opii____________________________3 iij -
          Aquce______________________________•__ § jv.—M.
       Dose—One teaspoonful in sweetened water, every four hours.

   Now, after two days, the patient  is improved, the coun-
tenance  looking  better,  and the  mind clearer;  but the
typhoid depression  is still  considerable, and it is best that
the tonic  be continued.  The muriate of ammonia mixture
is also to be continued on  account  of the bronchitis.  On
examining  the  chest, the  spaces  above  the clavicles and
between the ribs are seen to sink at the beginning of each
inspiratory  act, and to  bulge  during expiration.   This is
evidently due to the difficulty in getting air into the air-cells,
on account  of  the obstruction  of  the capillary tubes.  On
the expansion of the chest  the  air cannot enter fast enough
to fill the cells, and a partial vacuum is produced; atmos-
pheric pressure from without then  presses in the soft tissues
at the intercostal spaces;   while  in  expiration the  air is
with equal  difficulty passed out of  the cells through the
obstructed tubes.  Thus forcible inspiration and slow expi-
ration  is the characteristic  respiration where the air-cells
are themselves permeable but  the capillary tubes  partially
closed. But when the  air-cells are infiltrated, the respiratory
acts are short.
   Sometimes, when there is typhoid depression, wandering
of the mind and  bronchial  tightness, chloroform is  useful, 
CONTINUED  FEVER.               49
and in  this case may be given with  propriety, according  to
the following formula:

        IJ.—Chloroformi............------......3 iij-
            Acaciae g____________________________3 vj.
            Sacch.  alb........,____.....--------3 vj.
            Aquae................--------------1 vj-
    Dose—A tablespoonful every four hours, alternately with the other
medicine.
5 
LECTURE   III.
CASES OF  PERIODICAL FEVER. — Chronic Ague  and its
    Sequelae.
    Gentlemen:—This patient was admitted to the  hospital
two days since.  He is a native of Ireland, aged about thirty
years, and  has  been working in a district of country where
periodical  fevers are of frequent occurrence.   He states
that he has had paroxysms of intermittent fever every alter-
nate day, with occasional  interruption for a week, during
the last three months.   He has had  one paroxysm, consist-
ing of a well-marked chill and fever, since  he came into the
hospital.    His skin and lips  are pale, indicating  an  im-
poverished or spanaemic state of the blood ; but the most
prominent  item of complaint on the part of the patient is
a severe pain in the left hypochondriac region, aggravated
by a short, dry cough, with loss of appetite  and  general
muscular weakness.  On making physical  examination, the
respiratory murmur is  found rough  and exaggerated, indi-
cating  slight bronchitis ; the left hypochondriac region is
fuller than  the right; decided  tenderness on percussion at
the lower margin of the ribs, with dullness extending  ver-
tically from two inches above the margin of the  ribs to the
crest of the ilium, and, transversely, from the left margin of 
PERIODICAL  FEVER.
51
the epigastric region to the spine.  With the patient on his
back, and the thighs flexed on the pelvis, you  can trace by
the touch, the hard rounded edge of a solid tumor, extend-
ing from the margin of the epigastric region downward and
to the left until  it nearly touches  the crest of the ilium.
Both percussion and the  touch show that the broadest part
of the tumor is upward, and  extending fully under the ribs
of the left side.  These facts show that the tumor is simply
an enlarged spleen.
    The  moderate  degree of  tenderness  existing in the
spleen, the recent  date  of the enlargement,  and the fact
that it co-exists with chronic ague, render  it probable that
it is caused by simple  inflammatory congestion with  semi-
plastic exudation into the texture of the organ.
    The treatment in such cases should have for its objects
both the permanent arrest of the intermittent paroxysms
and the removal of the local inflammation.  If the former
is not accomplished, each chill and febrile exacerbation will
renew the local congestion, and defeat all treatment directed
to that alone.  The patient  will be directed to have five
grains of sulphate  of quinia,  with  two of blue mass, each
morning and  noon for two  days,  then the  quinia  alone
every morning  for a week or more, at the  same time he is
to take  ten grains of hydrochlorate of ammonia, dissolved
in syrup of liquorice, every four hours, until  the  splenitic
enlargement  disappears.  The latter is an old  remedy for
visceral enlargements consequent on chronic ague, it having
been recommended by Dr. Eberle  in his work on practice.
After the intermittent paroxysms have ceased,  and  the local
symptoms  of inflammation have abated or disappeared, it
will be proper to keep the patient for some time on small
doses  of quinia in combination with a soluble salt of iron,
of which the citrate and phosphate are  the  best.  This
combination should be continued, with a mild, easily digested 
52             PERIODICAL  FEVER.
diet, and  moderate  out-of-doors  exercise, until the patient
regains his muscular vigor, and the  blood its natural  pro-
portion of red corpuscles.
   We would also call your  attention to the pale and rather
sallow complexion, the  empty veins and bloodless appear-
anee of this next patient, who has entered the hospital after
being  troubled  with ague  more or less for four months.
Malaria diminishes  the amount  of  red corpuscles, and, in
extreme cases, the thinning of the blood produces a tendency
to anasarca.   By examining the blood of patients who had
suffered from malaria, we • have  found the  red corpuscles
reduced from the normal 127. in 1,000  to 50 in 1,000.  This
is a regular concomitant of intermittents, and forms a marked
contrast with typhoid  fever.  It is uncertain whether the
red corpuscles  are  destroyed by the  direct action of the
malaria, or their development arrested  by some  change in
the organs by which they are matured.  But in treatment
the fact is to be remembered, especially in chronic cases.
    The physician who is called to stop the paroxysms of
intermittent fever frequently does nothing further, and there
is a relapse with which the  patient is  dissatisfied, or a new
disease may arise from the condition in which the intermit-
tent leaves the patient.  Intermittents  can be easily inter-
rupted, but the  disease is not cured by merely stopping the
paroxysms.   Treatment should  be adopted,  at once, to
restore the blood to its natural condition.  This may be
well accomplished by the use of the extract of cornus florida
with iron  and nux vom., as in the following formulae:
       5 -—Ext. hyoscyam___..........._.......jjj;
           Ext.  cornus floridae )
           Ferri citratis______).....-----------3jv.
           Ext.  nucis vomicae......._.......___pTS xx
    M. Fiant pilulae xl.  Take  one pill before each meal-time, until
the blood regains the normal proportion of its red corpuscles, and the
patient's strength is restored. 
PERIODICAL  FEVER.
53
  This patient still having slight paroxysms of an intermit-
tent character, with looseness of the bowels, will be directed
a powder of sulph. quinia, three grains, and sulph. morphia,
one-fourth  grain, to be taken  each morning and noon, in
addition to the use of the above pills.
   We have here another patient, also a native of Ireland,
aged about twenty-five years, a laborer, who has been spend-
ing some months in the South.   While there he was attacked
with periodical fever,  and found  his way into a hospital in
St. Louis.  By judicious treatment his fever was arrested,
and in due time he was discharged.   Probably from undue
exposure, he soon had a relapse, in the form  of a tertian inter-
mittent. Without any regular treatment, the patient has con-
tinued to suffer from this disease, in the meantime enduring
more or less  exposure and fatigue, until he reached  this
city,  and  was admitted into the  hospital  on  yesterday.
You  see, at  a glance, that his skin  and  the conjunctival
membrane of  the  eyes present a deep yellow  color;  his
pro-labia are pale; tongue coated with a yellowish white
fur; and  his  general  aspect that of anaemia.  His skin is
only slightly above the natural temperature ; pulse ninety
per  minute and  soft;  bowels inactive ; respiration rather
short, but not difficult; moderate cough,  with  an acute,
sore pain in the left sub-axillary  region;  urine scanty and
very high-colored.
   It is evident that  the patient has been  laboring under
the intermittent fever long enough to induce considerable
diminution of the  red corpuscles in the blood, as is shown
by the paleness of his  lips and the general muscular weak-
ness ; but this does not satisfactorily explain either the  pain
in the  left side of the chest, or  the jaundiced hue of the
skin,  with a sense of fullness and  soreness in the epigastric
and right hypochondriac regions.   To determine the origin of
these symptoms, we must resort to auscultation and percus- 
54             PERIODICAL  FEVER.
sion, or, in other words, to a physical exploration of the
chest and abdomen.
   Uncovering the patient for this purpose, you perceive
the epigastric and right hypochondriac regions  to be some-
what more  full  than natural;  but as we  percuss, you will
learn from the tympanitic resonance  that  most of the full-
ness is from gaseous  distention of the intestines, while the
hepatic dullness  is restricted  to its  natural limits.   The
patient complains, however, that  the percussion causes a
sore pain over most of the hepatic region.   From this ten-
derness and fullness of the right hypochondriac and epigas- j
trie regions, it is evident that  a low  grade of inflammation '
exists  in  the liver, and probably also in the mucous mem-
brane  of the duodenum,  which would fully  explain the
jaundiced hue of the patient.  Finding nothing unnatural
in the  left hypochondriac region, we will  pass to an exami-
nation of the  chest.   As we percuss extensively  over' its
surface, you detect no unnatural sounds  until we come  to
the sub-axillary region of the left side.   Here the resonance
is diminished, indicating that the parts within are more
dense  than natural.   Listening through the stethoscope
applied to this region, you will hear distinctly a fine, crepitant
rale, indicative of pneumonic inflammation in the  early stage
of its  progress.   We are now prepared to  explain all the
symptoms that  the  case  presents.  We have a chronic  or
protracted  intermittent, complicated  with a low grade  of
hepatic and duodenal inflammation, by which the digestive
function is impaired, the hepatic ducts obstructed, and the
coloring matter of the bile retained in the blood  to such an
extent as  to stain all the  tissues a yellow color; while a
more  acute grade  of inflammation has invaded  the lower
lobe of the left  lung.
    The  indications for treatment  are three, namely:  The
interruption of the intermittent paroxysms, the removal of 
PERIODICAL FEVER.
55
 the  local inflammations, and the  restoration of the blood
 and tissues to their normal condition.   The time has been
 when  the detection of a local  inflammation  in connection
 with a periodical fever would cause  the first of these indi-
 cations to be superseded by the second, under the idea that
 the  tonic qualities of the  quinia rendered  its exhibition
 unsafe, while local inflammation existed in any of the tex-
 tures of the body.  Experience, however, has fully demon-
 strated the fallacy  of  this idea, and shown that  the  prompt
 interruption of  the febrile exacerbations by quinia, actually
 facilitates the reduction of the local inflammation.   Hence,
 we shall  endeavor to  fulfill, in this  case, both the first and
 second indications, by the administration  of the following
 combination:
        R.—Quiniae sulph........................grs. xij.
            Hydrarg. protochlor__________________grs. xij.
            Pulv. opii______.........___________grs. vj.
    M.  Fiant pulv.  iv.   One to be  taken every  four  hours,  and  a
 teaspoonful of the following mixture between :
        R-.—Syr. scillae. comp...........__________%i.
            Tinct. sanguinariae___________________§ ss.
            Tinct. opii camph____________________§ iss.
            Tinct. verat. viridis__________________3 i-

   To-morrow, after all the powders have been taken, the
 bowels  should  be moved by  a  dose  of  castor-oil,  after
 which  a powder composed  of quinia, two  grains; potassa
 nitras, three grains;  and  pulv.  opii, one  grain, may be
 given  every four  hours,  and a  blister-plaster  applied to
 the lower part of the  left  side of  the chest.  These meas-
 ures will probably prove  sufficient  to interrupt the inter-
 mittent paroxysms, and completely  remove the pneumonic
 inflammation in two or three days, leaving only the gen-
 eraldebility, with  more or less  duodeno-hepatic derange-
ment for further   treatment.   If  so, we  shall  direct the 
5^
PERIODICAL FEVER.
following  pills, which have frequently proved effectual  in
similar cases:
       R. —Ext. cornus floridse____________________3 i-
           Ferri sulph........__________________grs- xxx'
           Pil. hydrarg.........................grs.x.
           Ext. taraxaci____....................grs- xxx-
    M.  Fiant pilulae xxx.  One to be given before each meal-time, and
at bed-time.
    This  patient, gentlemen, is a boy about sixteen years  of
age, who  was admitted to the hospital  some three weeks
since.  Those members of the hospital class who were  in
attendance at that time, will remember examining him care-
fully soon after his admission.  His  skin was  bloodless;
lips, tongue  and gums pale,  indicating  a decidedly span-
aemic or impoverished condition of the blood, especially in
reference to  the red corpuscles; pulse soft, and nearly nat-
ural in frequency; appetite impaired; and he complained  of
a harsh cough, with some  soreness in the chest;  and great
muscular debility.   He had suffered paroxysms of intermit-
tent fever, at irregular intervals, for several weeks.  You
will also remember, that a physical exploration by ausculta-
tion, percussion, and palpation, revealed  a mixture  of dry
and moist rhonchi in both sides of the chest, and extensive
dullness over the left hypochondriac region, extending from
the seventh rib to near the  anterior part  of the crest of the
ilium ; the first, indicating chronic bronchitis, and the latter,
a decided enlargement of  the spleen.   The  pathological
conditions then  presented by  the patient,  were impaired
tonicity of the organized structures, with  that impoverish-
ment of the  blood  which usually results  from chronic ague,
complicated  with a low grade of inflammation in the bron-
chial mucous membrane, and enlargement and  induration
of the spleen.  To meet the indications for treatment afford-
ed by the general impairment of tonicity, and irregular par- 
PERIODICAL  FEVER.             57
oxysms of ague, the patient was directed to take three grains
of sulphate of quinia after breakfast and  dinner, each day.
For the bronchial irritation,  and enlargement of the spleen,
he was directed to take a teaspoonful of the following mix-
ture before each meal-time,  and at bed-time :

       R. —Ammon. hydrochlor..................3 iii-
           Antim. et potass, tart_________________grs. ii.
           Morphias sulph............-----------grs. iii.
           Syr. glycyrrhiz..........—..........3  iv.

   The muriate of ammonia in the mixture acts as an alter-
ative, in promoting the absorption of the adventitious depos-
its, or  exudations  into  the  spleen, while it is free from any
of the objectionable properties possessed by the preparations
of mercury;  the small  doses of antimony and morphia will
lessen both the irritability and vascularity of the bronchial
mucous membrane.
   The patient followed this treatment for one week,  with a
constant improvement  in  all his symptoms.   The   quinia
was then limited to one dose after breakfast, each morning,
and the muriate of ammonia  mixture continued four times
a day, as before.  At the end of the second week, his cough
was entirely  removed, and  his strength, color, and appetite
so much improved, that he  ceased to present  himself for
further advice until to-day.
   You see  now  his  general aspect very much  changed.
His prolabia are red, the veins  of the surface moderately
full, and his flesh increased.   He has had no cough;  appe-
tite good ;  and bowels regular; but during the last few days
he has complained of several attacks of pain in the epigas-
trium, apparently of a neuralgic character.  We say neural-
gic, because  they were accompanied neither  by fever, loss
of appetite, or flatulency.   By re-examining the epigastric
and left  hypochondriac regions, at this time, you will find 
58
PERIODICAL FEVER.
nothing unnatural in the epigastric region proper ; but dull-
ness still  exists over too large a portion of the hypochon-
drium;  and  by placing the  patient in  the dorsal position,
with thighs flexed upon the pelvis, so as  to relax the abdom-
inal muscles, the fingers  pushed a little  deeply under the
margin of the ribs, on the left side, readily feel the rounded,
hard margin  of the spleen, thus showing that it is still larger
and harder than natural.   The enlargement is very much
less than when he  was admitted into the  hospital, three
weeks since,  but it is still  sufficient to impair the functions
of that organ, and, indirectly, that of the stomach also.  It
is quite probable that the  paroxysms of epigastric pain, of
which he  complains, have originated from taking food more
freely than the digestive organs could digest perfectly.  The
leading indications for treatment at present are, to improve
the functions of the stomach, and still further reduce the
enlargement  of the spleen.   To fulfill these indications, we
will have the patient take one of the following pills before
each meal-time, and at bed-time :

       R.—Ext. hyoscyam.
           Ext. taraxaci__
           Ferri sulph.  ^
           Pil. hydrarg. \
    M. Fiant  pilulae xl.

    The hyoscyamus and iron  are  designed to  improve the
sensibility and secretory action  of the  stomach;  while the
taraxacum and blue-mass will continue such alterative action
as will  further  reduce the  size of the spleen.   The food
of the patient should be plain, easily digested, and taken in
very moderate quantities at a time.
   We find here, in this next bed, another patient who was
attacked  by  chills and fever  five weeks ago, and in the
course of two  weeks, under  his physician's  treatment  the
3ij-
3jv
3i. 
PERIODICAL  FEVER.             59
chills disappeared and the general fever was cured.  Since
then, however, he has remained pale, coughs and  sweats
considerably  at  night.  These unpleasant  symptoms not
unfrequently follow typhoid and intermittent fevers, which
have impoverished the  blood and led to some exudation
into the tissues of the lungs. This exudation, if not absorbed,
may  degenerate, constituting  a condition which Niemeyer
calls caseous  infiltration.   The  patient  convalescing from
the intermittent, is nevertheless languid, short of breath,
coughs, especially in the evening and morning, has quick-
ness  of pulse and heat, generally with night-sweats.  Unless
prompt treatment  is resorted to, the  infiltration progresses
to suppuration, with fatal exhaustion, in two or three months,
constituting quick consumption.
   In  this case, auscultation reveals increased density in
the right lung, especially at the base, which is scarcely at all
inflated, except by forced  infiltration.   This density is due
to exudation, brought  on  by local  congestion,  with  the
impoverished condition of the patient's blood.  Tonics are
evidently indicated, and likewise anodynes, to allay irrita-
tion  in the lungs.   He  is taking, twice  a day, the muriate
of ammonia  mixture  previously described.   Besides the
anodyne  influence of the mixture, the muriate of  ammonia
as an alterative  promotes absorption.  Of the many tonics
which  might be used, the extract of malt (Liebig's)  and
compound syrup of the hypophosphites, in  the proportion
of two parts of the former to one of the  latter, taken in two
drachm doses at each meal-time,  constitute one of the best.
Many would  order cod-liver oil, which,  however,  is apt to
disagree  with the  stomach, and  so impair digestion.   For
this  patient we  shall direct the syrup  of  iodide of iron,
twenty drops  after each meal.   This gives  the  alterative
influence of iodine with the tonic properties of the iron. 
LECTURE  IV.
RHEUMATIC FEVER. —Acute Articular Rheumatism. —Mus-
   cular and Bronchial Rheumatism. — Rheumatic  Inflamma-
   tion of Spinal Nerves. — Intestinal Rheumatism. — Chronic
   Rheumatism,  etc.
   Gentlemen: — The case  before  you  is  a middle-aged
man,  a laborer, who  was admitted into the hospital, one
week  since, laboring under acute articular rheumatism.  He
had been attacked several days previous to his admission to
the hospital, but what treatment he had  received, if any, I
do not know.  You observe his expression of countenance,
especially when he attempts  any motion, is indicative of
suffering; you  find his  tongue coated with a whitish fur;
his pulse full, and 90 per minute ; skin a little above the
natural temperature, and dry; bowels rather costive; and
urine  scanty and high-colored.
   He complains of stiffness and soreness through his back,
hips, and still more in his knees, which  latter have a con-
stant knawing-pain, greatly aggravated at night.   On exam-
ination you find both knees considerably swollen and ten-
der to the touch, warmer than the rest of the body, but not
red on the surface.  While  the  swelling  is general around
the joint, with no  definite line of demarkation, you see a 
RHEUMATIC  FEVER.
61
more prominent fullness on each side of the  ligamentum
patella below, and on  each side of the  attachment of the
rectus femoris above, giving  to  the  knee a characteristic
oblong shape.  This is produced by the effusion of serum
into the cavity of the synovial membrane, which is less cov-
ered with ligaments to resist its distention at the points indi-
cated.  That  the membrane  is  distended with serum, is
readily determined by the plain fluctuation felt at the points
indicated.
    At the time the patient was admitted into the hospital,
last week, all his symptoms were more  aggravated than at
present.  The  general  fever  was more  active; the  pains
were more  severe ; and the articulations were swollen one-
third larger than at present.   The local  inflammation com-
menced  in the shoulders and  spine, and had extended
downward  to the hips and  knees, having just fully involved
the last-named joints at the time of admission to  the  hos-
pital.  This migration of the inflammation from one articu-
lation to another,  is one  of the  striking characteristics of
rheumatism.   It generally subsides in  one series of articu-
lations, at  the same time  that it attacks another, but not
always; for we sometimes meet  with  cases in which it
involves one part after another, until  almost every joint in
the body and limbs is affected, and the patient  lies utterly
helpless.   Another characteristic of the disease  is, that the
inflamed parts seldom, if ever, suppurate.  When the synovial
membranes are  involved, they become  quickly distended
with effused fluid, and the fibrous structures exterior to the
membrane  become filled  with  plastic exudation, but  in
neither locality is there  any tendency of the effused material
to degenerate into pus.
   When the  disease attacks  the sheaths of  the  tendons,
more especially in the wrists, ankles and smaller joints of the
hands and feet, it is accompanied by an exudation so highly
       6 
62             RHEUMATIC FEVER.
plastic that it forms a firm bond of union between the ten-
dons and the fibrous  sheaths  surrounding them, which, in
some individuals, remains after the inflammation and swell-
ing have subsided, causing a species of permanent  anchy-
losis.   Generally, however,  the  exudations  accompanying
acute rheumatism are absorbed soon after the active stage
of the inflammation has passed  by, leaving the parts for a
time somewhat stiff and  tender, and for a long time  predis-
posed to-new attacks.
   The fact that the general causes favoring attacks of
rheumatic fever interfere mostly with the eliminative func-
tions of the skin, in connection with the further fact that the  J
blood and secretions  appear  to contain an excess of acid,
and  all the  exudations  plastic,  afford strong evidence in  I
favor of the theory which attributes the fever and local in-
flammations of rheumatism to an  excess of some irritating'
acid material in the blood.  It is further probable that such
acid material results from  the retention  of  effete matters
which are naturally eliminated through the  cutaneous sur-
face.  Whether it is lactic acid,  as claimed by Richardson,
and  suggested by many others,  can hardly be considered
fully determined.   Conceding  this theory of the pathology
of the disease to be  correct, the indications  for treatment
become obvious.   They are, first, to neutralize the  excess
of acid in the system  by the free use of the  non-purgative
alkaline  salts;  second,  to mitigate the patient's suffering;
and, third, to lessen the  plasticity of the  exudative material
in the inflamed parts, and  hasten its  absorption.  Perhaps
the best means  for accomplishing the first of  these objects,
is to  give the patient twenty grains  of the  carbonate, or
thirty grains of  the  bi-carbonate of potassa, dissolved in  '
plenty of water, every two or three hours, and an occasional
dose of the Rochelle salts to move the bowels.  In  moder-
ate cases, the  second indication  is sufficiently met by a full 
RHEUMATIC  FEVER.             C3
dose of pulv. Doveri with a grain or two of calomel, at bed-
time, each  night.   But in the  more  acute and  severe
cases,  a teaspoonful of the following mixture,  given be-
tween  each of the doses of alkaline salts, during the  first
two or three days, will aid very much both in mitigating the
pain and lessening the fever:
       R.—^Ether. nitr_______
           Vini colchici______
           Tinct. opii camph..
   M.      Tinct. verat. viridis

   After the skin has  become  moist, the urine  more free,
and  less acid,  the pulse softer, and  less frequent, and the
inflammation has  ceased to extend  to  new  articulations,
this sedative  mixture may be omitted, and the patient left
on the use of the alkaline  salt  alone, with only a dose of
Dover's powder, without the calomel, at night.   If, at the
end  of one week, or more, the  fever has subsided, leaving
the patient  pale, the skin relaxed, and almost  constantly
bathed with perspiration, and yet the joints stiff and weak,
from two to three grain doses of quinia, given three times
a day, will generally be of much service.
   Local applications to the  inflamed articulations are gen-
erally of but little importance ; yet, in the acute stage, keep-
ing the part constantly wrapped  in  cloths wet in an infusion
of aconite leaves, holding in solution hydrochlorate of am-
monia, will aid much to mitigate the pain.  Such is the gen-
eral outline  of treatment that has  been found most effica-
cious in the treatment of acute rheumatism.  When resorted
to early, and pursued judiciously, it will, in many cases, lead
to convalescence in  from seven  to  ten days; and there will
occur a less ratio of cardiac complication than  under any
other system of treatment  that  has yet  been tried.   There
are  some  cases, however, that persist through a period of
Si-
1 ii
3i- 
64        .     RHEUMATIC  FEVER.
three,  four, or even six weeks,  despite of all treatment.
There are  many other  articles of the materia medica that
may be used instead of those already named, for fulfilling
the  same indications.  The bi-tartrate  of potassa may be
used instead of the carbonates ; or the salts of soda maybe
substituted  for those of potassa; or the oxide of calcium
—known in the shops  as the syrup of lime—may be used.
And in  cases where the colchicum  purges the bowels too
much, it may be  replaced  with  double of its quantity of
tincture  of cimicifuga racemosa.
    We would now call the  attention of the  class to some
additional cases, which serve to illustrate a few of the many
special forms and complications of rheumatism, as manifest-
ed in different parts of  the body, and the corresponding va-
riations in  treatment.
    This first  patient, a laboring  man, twenty-one years of
age, was admitted  into the  hospital about two weeks since,
complaining of pain and^ soreness in the chest; frequent,
harsh  cough,  with but little expectoration; and moderate
fever.   There were no physical  signs of pneumonia; and
the case was regarded as one of  catarrhal  irritation  of the
bronchial  tubes,  coupled with rheumatic  soreness  in the
muscles  of the chest and shoulders.
    He was directed to take one teaspoonful of the following
mixture  every four hours :
       R.—Ammon.  hydrochlor_________.......3  ijj,
           Antim. et potass, tart____________......grs. ij.
           Morphia? sulph.....____________________grs_ [[;
    M.      Syr. glycyrrhiz............____________3  iv#
   Under  the  influence of this the cough  ceased, and the
pains in the chest diminished; but in  three or four days he
began to complain  of nausea, great weakness  and soreness
in the muscles of the thighs and calves of the legs, aggrava-
ted by motion. 
RHEUMATIC FEVER.             65
   The rhythm of the heart was natural, but the first sound
was muffled or gruff, and the impulse increased.
   The former prescription was omitted, and the two follow-
ing given instead:
       R.—Ammon. hydrochlor_______........__3 iij-
           Tinct. aconiti rad____________________3 j-
           Syr. glycyrrhiz...............________§ iv.
    M.  Give one teaspoonful every six hours, in a little water.
       R,—Sodas bicarb____........------------3 ij -
           Bismuthi sub-nitr______________________3 ij-
    M.  Fiant pulveres xx.  One to be taken every six hours, alternately
with the other prescription.
    Animal broth and milk for nourishment.

    This treatment was  continued for three or four  days,
during which the cardiac sounds  and impulse became  more
natural; the pulse  slower and  more soft; and the muscular
soreness in the lower extremities less.  But the countenance
of the  patient was depressed and anxious;  the skin wet with
a cold, clammy perspiration ; the  tongue  dry and red along
the middle or upper surface ; and his bowels slightly relaxed,
as though there  was a typhoid tendency.
    He was put on the use of a powder composed of quinia^,
sulph.  two  grains, and  bismuth  sub-nit., five grains, each
morning, noon, tea-time, and bed-time.  A decided improve-
ment was observable in the condition of the skin, tongue, and
countenance, the next day.  Four days have  since elapsed,
and the improvement has continued, until, at present,  the
patient appears  to be convalescent.   In several other cases
of  well-marked rheumatic fever, which have lately  been
under my care, the rheumatic  symptoms  abated under  the
free use of  alkaline  salts; but the tongue became dry in
the middle ;  the skin cool and clammy ; pulse  quick, and
weak;  with  disgust  for food, and mental  despondency.
The combination  of bismuth  and quinia produced a rapid
                            6* 
66             RHEUMATIC  FEVER.
improvement,  however,  and  convalescence was speedily
established.
   We have here another patient, who  has been complain-
ing, for a considerable length of time, with symptoms resem-
bling those of  ordinary rheumatism, but differing from them
in some respects.  He was admitted a week ago, complain-
ing of a  troublesome cough.   Says he  takes cold  easily,
which is  followed by a hard, tight cough, that  annoys him
more in  the latter part of the night, and is very harassing.
His  chest is free from dullness or any abnormal sound ; pulse
of natural frequency and force;  temperature  of the skin
natural.
   Aside from the cough, and a vague sense of soreness in
the chest, there is a degree of lameness in the hip, manifest-
ing itself in a  manner somewhat  different from simple mus-
cular stiffness.
   In the act  of rising from the sitting posture, there is, fre-
quently,  marked and  sudden spasmodic contraction of cer-
tain muscles, more especially in the right hip, that brings him
down.   Does  not complain of any sharp pain running along
the course of  the sciatic nerve, as in rheumatism, involving
the  origin  of this nerve.  The pain appears  to be in the
gluteal and abductor muscles.  He locates  the pain in both
hips, but mostly in the  right; there is some tenderness in
the  bottom of the foot on  bearing  his weight upon it, and
some morbid  sensibility  of  the parts.
    The cramp, and an alteration in his gait, raised the ques-
tion whether this was a case of simple rheumatic inflamma-
tion, involving the muscles, or whether he was laboring  un-,
der  disease of the spinal cord,  constituting the early stage
of that form of disease styled progressive locomotor ataxia.
But in watching his movements, and noting the changeable
character of. the pain, the florid  countenance, and sanguine
temperament, we are led to conclude that there is no ten- 
RHEUMATIC FEVER.             67
 dency to atrophy of the spinal cord, but true rheumatic in-
 flammation, involving certain portions of the cord that sup-
 ply the parts in which he complains of pain.   There is prob-
 ably the  same grade of inflammation  involving the fibrous
 structure of the  bronchial  tubes, which  gives  rise to the
 cough.
    The diagnosis of these cases requires great care.  The
 early stage  of hip disease  is often mistaken for rheumatism^
 till the parts begin to fill  up with matter; and  the same is
 true of inflammation in the  psoas region.
    In hip  disease, however, if you will place  the patient
 upon the back,  with  your hands upon the  trochanters, and
 press the head  of the  femur  into the socket, he will com-
 plain at once of pain.  In addition to this, if you take hold
 of the foot,  straighten the leg, and push up, you will produce
 the same result.   Rheumatism, on the contrary, will not be
 affected by  such pressure; at least it  will produce only su-
 perficial pain, and it will hurt more to pull the hip out than
 pushing it back.   In the early stage of hip disease, also, the
 toe is turned in, and the heel drawn up.
    If the affection is in the psoas region, the thigh is more
 or less flexed, and the patient is unable to extend it.
    In this case we have absence of all of these  conditions,
 and hence regard the patient as laboring under simple chronic
 rheumatic inflammation.   On .admission to the hospital, he
 was put upon the following treatment:

       R.—Vini colchici sem.............._.....3j.
           Tinct. aconiti. rad..................-3j-
           Tinct. stramonii___________________§ ss.
           Syr. et Aquae............--------... § iiss.
    M.   Dose, one teaspoonful every four hours.

   To procure more rest at night, he took fifteen grains  of
bromide of potassium at bed-time. 
68
RHEUMATIC FEVER.
   He has been under this treatment one week, and his con-
dition is very much ameliorated;  the colchicum has not dis-
turbed the bowels;  the rheumatic trouble about the hip and
back is improved;  he has no  muscular  cramps, and goes
about tolerably free.
   In those cases of rheumatic inflammation chiefly restrict-
ed to nerve structure, we have not found ordinary alkaline
salts to produce as satisfactory results as some other reme-
dies that have a more powerfully  sedative influence upon the
nervous sensibility.
    There appears to be irritation set up in the nerve struct-
ure, which the alkaline salts alone are not able to overcome.
    The above combination, in patients of sanguine temper-
ament, acts very favorably.
    In persons less sanguineous, and with a less degree of ex-
citability  of the circulation, we would leave out the aconite,
wnich  is added to increase the sedative effect upon the nerv-
ous system.
    We would also call your attention to  this  man, who was
admitted  to the hospital this morning, and says he was taken,
three days ago, with  a violent pain or cramp in  the bowels,
The left   side  of  his abdomen  is  tender under pressure,
and at the ilio-ca^cal junction  there  is tenderness and a
little hardness.  He  was at one time sick at the stomach,
and vomited.   His symptoms plainly indicate some degree
of peritoneal  inflammation, but it is of slight extent, for his
abdomen  is not full, tense, and painful, as in severe periton-
itis.  There are two  conditions which  often give  rise to
symptoms such as we have observed :  First, a slight inflam-
mation of the peritoneal coat, with a lodgement of fcccal ma-
terial at the ilio-caecal junction, causing tenderness and hard-
ness, with obstruction and vomiting, which sometimes ex-
tends over the whole peritoneum, and ends fatally in two or
three  days.   Another condition  is observed, especially in 
RHE UMA TIC  FEVER.             69
 extreme cold weather:  The attack commences with severe
 abdominal  pains, tenderness,  but little  hardness, and no
 bloating.  The tongue is clean, but the patient feels that ten-
 sion of the abdomen which makes him think that physic
 would give  relief; yet  cathartics  invariably  aggravate the
 symptoms.   This condition generally depends on true rheu-
 matic inflammation of the  muscular coat of the intestines,
 and sometimes becomes very protracted.
    A  number of these cases occur every winter, and the
 patient before us appears to be  one of this class.   The
 inflammation chiefly affects the  colon,  and  extends to
 the  peritoneum slightly.   Considering the pain  caused by
 movements in other parts affected with rheumatism, it is easy
 to see how the peristaltic motion of the bowels should cause
 severe pain, particularly during the action of a cathartic.
    The  treatment consists  mainly in  the use  of anodynes
 and alkaline salts.   It is best to choose such medicines as
 will act freely on the skin  and kidneys.   The patient was
 ordered  the  bi-carbonate of soda and acetate of potash,
 each ten grains, to  be  taken  every four hours, alterna-
 ting with Dover's  powder  eight  grains,  nit.  potassa,  five
 grains, and calomel • two  grains — the  mild chloride  to  be
 omitted after the first twenty-four hours.   Relief may  be
 facilitated by narcotic fomentations applied to the abdomen.
 In  family practice  fomentations of hops may be used, or
 the infusion  of hops may be used to make  linseed meal
 poultices large enough to cover  the painful part  of the ab-
 domen.
   This  young woman, aged eighteen, has been afflicted
 with rheumatism for about  three years.  She  was admitted
into the hospital in the early part of last summer, and while
here has been under a variety of treatment.  The case pre-
sents some features different from  those which characterize
ordinary  rheumatism, although  there  is the characteristic 
70             RHEUMATIC FEVER.
style of inflammation  traveling from  one part to another,
and creating more or less  swelling and pain m the parts,
with a failure to suppurate.
   A  joint that is attacked becomes swollen, and the liga-
ments  seem flabby and wanting in natural tone and elasticity,
so that free movement of the part is interfered with.  There
is a progressive, persistent  atrophy of the muscular tissue,
and impoverishment of the blood.  There is  a  laxity and
want of tone in the capillaries, which disposes to effusion, so
that but little additional influence is required to make exos-
mosis  predominate.  The patient  is greatly emaciated, and
presents a bloodless appearance of the surface, which would
indicate an almost  entire loss of the power to manufacture  i
red corpuscles.  There are, however, no apparent indications  '
of tuberculous  disease.
    The patient suffers a good deal of pain at  times, which
is acute and severe.  Several weeks ago she  had an attack,'
commencing  at first in the  right hip and limb, which was
greatly swollen and almost entirely helpless, while she could
use the  other  quite freely;  the pain then  shifted to  the
left hip and knee.  Aggravations  of pain and heat in  the
part are followed by  increased swelling,  which will finally
subside to a given point.   The effusion is not organizable
like that which occurs in ordinary rheumatism, but remains
fluid.
    Almost every alkaline remedy  that  has been  tried  has
seemed rather  to aggravate the symptoms, a  result  which
might  be expected from their tendency to render fibrin  and
albumen more  soluble,  thus  increasing the  fluidity of the
blood, which  is already too thin.   The indications are, on
the contrary, to increase the  plasticity of the  blood  by in-
vigorating the digestive  and assimilative functions.  After
trying various remedies, the most  beneficial  effects seem to
have been obtained from the administration of the alkaline 
RHE UMA TIC FE VER.
71
 tincture of guaiac, one teaspoonful four times a day, fifteen
 drops of the tincture of stramonium being added  to  each
 dose to allay the irritability of the tissues ;  a powder, consist-
 ing of sub-nitrate of bismuth, six grains; sub-carbonate of
 iron, four  grains; lupuline, two grains; was directed to be
 given before each meal, in order to impart tone to the digest-
 ive system.   In about two weeks the guaiac was diminished
 to twice a day, and the iron withdrawn, as she thought it pro-
 duced  headache.  At the  same time  she  was put upon  a
 solution of bitartrate of potassa, three drachms; morphia, two
 grains; dissolve in a tumblerful of water, a tablespoonful to
 be given every three  or four hours.   At this time she could
 use  her limbs quite freely, and seemed to be progressing
 finely.  Just as our hopes  were up to par, however, the in-
 flammation moved over to the other side, and she has con-
 tinued to suffer a great deal with it  since,  although  now
 again on the mend.   The condition of  the system is such as
 presents no apparent  recuperative tendency.
   It might be an improvement in the treatment now, to
 change  the preparation  of  guaiac and try  the effect of the
 following combination :
        R.—Pulv. guaiacii gum.__________.....____3 iss.
            Ferri citratis_________________________3 i-
            Ext. cannabis indicoe............_____grs. x.
   M.  Fiant pilulas xxx. Give one pill before each meal, and at bed-
 time.
   I would continue the use of the bitartrate of potassa and
 the morphia, as long as  they produce  a good effect on the
 kidneys, and the appetite remains fair.
   Electricity might  be useful, but any more than a  very
 moderate use of this agent is apt to act as  an excitant, and
 to increase the pain.
   We find here, in this bed, a man aged about thirty years,
a laborer, who  was admitted to the hospital on yesterday. 
72
RHEUMATIC  FEVER.
He says that he  has been subject  to pains in his right side,
for a few days at a time, for  the  last two years.  Though
generally  located near  the  lower  margin  of the ribs, they
sometimes change  to the shoulder, and sometimes to the
left side.   They have not  usually  been  accompanied  by
fever or cough, and have seldom been sufficiently severe to
prevent ordinary labor.   Six or seven days  since the pain
commenced, as usual, in the right side, but  in a day or two
changed to the left, and became unusually severe.   In that
place it has continued until the present time.  -His pulse is
now eighty-five per  minute,  moderately  full;   his tongue
covered with a whitish fur;  his skin dry and  slightly warmer
than natural, and his bowels inactive; his breathing short,
with an  inclination to  dry cough, which  is suppressed  as
much as possible on account of the great  aggravation  of
pain which  it  induces;  The  pain at present is located in
the region of  the attachment of the. diaphragm to the ribs,
from the left side of the spine to near the sternum, and is
very greatly aggravated on attempting to take a full breath,
or coughing, or making considerable movement of the body
in any direction.   The pain is also increased at night.
    The severity of the  pain, its increase by  respiration and
coughing, and its location in the side, would readily lead to
the supposition that the patient had pleuritic inflammation;
while the fact that pains had long  existed  in the opposite
side, changing occasionally to  the shoulders and other parts,
and that the present  attack commenced in  the right side,
would rather indicate rheumatic inflammation  of the dia-
phragm.   Perhaps  auscultation and percussion alone can
enable us to form an exact differential diagnosis.   If pleurisy
existed in its first stage, we  should hear a friction sound on
applying the ear or the stethoscope to the affected side ; if in
the second stage, accompanied by effusion, we should have
either a continuance of the friction or < reaking, or a decided 
RHEUMATIC FEVER.             73
dullness, with absence of respiratory sound, according as the
effusion was plastic or serous.
   On making a  physical examination,  however, we  find
none of these  signs of inflammatory effusion.  The natural
respiratory murmur and the natural resonance are present
down to the diaphragm.
   We consequently diagnose the case as one of sub-acute
rheumatism, affecting the left portion of the diaphragm, and
shall prescribe for  him as follows :
       R.—Vin. colchici_________________________§ i.
          Tinct.  cimicifugse......______________§ ii.
   M.  Give a teaspoonful every four hours.

At bed-time give a powder containing pulv. opii, two grains,
potassa nitras, ten grains,  and  hydrarg.  chlor. mite.,  one
grain, to be repeated in two hours, if sleep is not induced.
The  object is to increase all the excretory functions, espe-
cially those of the  skin and kidneys, and so far destroy the
pain  as to enable the patient to sleep during the night.
7 
LECTURE  V.
SCARLATINA AND RUBEOLA. —Renal Dropsy. — Suppression
    of Urine. — Convulsions. — Measles.
    Gentlemen :—There  are but  few general practitioners
who have not found the sequelae of scarlet fever among the
most obstinate and serious ailments  that  come  under their
observation.   Among these none are more important than
the renal affections accompanied by anasarca.
    We have here before us to-day a case which well illustrates
the important series of pathological phenomena developed
in the progress  of such cases.   The patient, a girl aged
fourteen years, usually in  good health, was attacked with
scarlatina simplex, on  January nth.  The disease  ran a
very mild  course,  requiring but  little  medical treatment.
By the  22d she seemed quite well  again.   When  brought
here on the 8th of February, we found her  presenting  the
appearance of a moderate degree of general anasarca, with
a dull pain in  the  loins and head, and  scantiness of urine,
but no fever.  She was directed  to  have two  drachms of
the bitartrate  of potassa, and  three drachms of the acetate,
dissolved in half a pint of water,  and to take a tablespoon-
ful of the solution  every four hours. 
SCARLATINA  AND RUBEOLA.
    I did not see her again until the 13th.  The prescription
made on the  8th had appeared  to have very little effect.
The bloating  of  the whole  surface had  steadily increased,
with increase  of the pain  in  the head and back, frequent
nausea and some  fever.   The urinary secretion had decreas-
ed  until the 12th, when it became entirely suppressed, and
violent general convulsions  began on  the night following.
The convulsive paroxysms  followed  each other in quick
succession, allowing only an imperfect degree of conscious-
ness to be recovered between  them; the stomach promptly
rejected  all drinks by vomiting; the pulse  was small and
frequent; skin cool; pupils slightly dilated;  respirations
short, but regular, between the convulsive paroxysms.  She
had had no passage of urine or-fasces  during the preceding
twenty-four hours.  Immediately after the convulsions com-
menced,  late in the evening of the 12th, the house physician
gave the bromide  and iodide of potassa  freely, but without
any perceptible effect.   On my visit on the morning of the
13th, I ordered extensive warm fomentations, with a view
of promoting the  action of the skin, and gave  internally a
powder of hydrarg. chlor. mite., five grains,  and nitrate of
potassa, five grains, every two hours, with ten drops each of
chloroform and fluid extract of cannabis indica between.
The latter was given more to prevent vomiting than for any
supposed anti-spasmodic influence.
    The  convulsions continued to recur through the day,
but at longer  intervals; otherwise there was  no improve-
ment in  her  symptoms, and no evacuations, either of urine
or fasces.  The further use  of the  powders was suspended,
and in their place croton-oil, suspended  in the form of an
emulsion, was  given, in doses of a little less than one drop
every hour until evacuations should occur.  When she had
taken three drops, a part of which was rejected by vomiting,
it began to operate freely on the bowels. 
76        SCARLATINA  AND  RUBEOLA.
    On  the  morning of the  14th we  found  her quiet; no
convulsions since the evening previous ;  face,  and surface
generally,  still  much  bloated from dropsical  infiltration;
skin cool; pulse small, and 120 per minute ; mind dull, but
capable of being partially aroused to activity; and indications
of partial paralysis of the left side.
    The bowels had been evacuated freely several times, and
she had passed a moderate quantity  of  urine  twice.  She
was directed to" have beef-tea in small quantities for nourish-
ment, and a solution of bi-tartrate  of potassa for drink. On
the 15th  she was much improved  in all respects, except
that the left arm was completely paralyzed, and the move-
ments of  the bowels had continued frequent, with some
tenesmus,  and  mucus in  the  discharges.  The urine was
nearly natural in quantity and appearance.   She complained
of some pain in the paralyzed  arm, between  the shoulder
and elbow.
    The following prescriptions were ordered:
        R.—Ext. Scutellaria? fl________....._______1 § iii.
            Tinct. digitalis_____________....._____§ i.
            Potass, iodidi_____..................3 iii.
    M.  One teaspoonful to be taken every four hours.
Also:
        R.—01. terebinthinas_____..........______3 ii.
            Tinct. opii..........................3 ii,
            Acaciae  p.  pulv. /
            Sacch. alb.      faa.........-......3 m.
    Misce. et add.
            ^Ether nitr.................._.......% jss>
            Aquae menthae  piperit.....____________z jSSi
    A teaspoonful every four  hours,  alternating with the other prescrip-
tion, until the dysenteric irritation of the lower bowel ceases.

    The  use  of the  latter prescription was required only
three  or four times,  and the patient improved  steadily from 
SCARLATINA  AND RUBEOLA.
day to day, until the anasarca, the paralysis, and nearly all
symptoms of disease had  disappeared.  From the 18th to
the 24th the patient continued cheerful and active in mind;
appetite good;  bowels regular; strength improving, and all
the appearances of returning health.  But  there  remain-
ed some anasarcous puffiness of the face and lower  extremi-
ties, and  the urinary secretion was unsteady.  Some days
it was natural in quantity and appearance; on others it was
smaller in quantity, and turbid.  She was confined  to the
use of light food,  subjected  to no injudicious  exercise or
exposure to  atmospheric changes, and during the period last
named, took for treatment only mild diuretics  and tonics.
   On the 25th, however, she again became dull, more ana-
sarcous, and the stomach irritable, with only a slight discharge
of very high-colored urine;  and  before the  next  morning
convulsions  again  came on as violent as in the first attack.
The same means were resorted to, with the  addition of a
vapor bath, and the omission  of the croton-oil, the  powders
of calomel and nitrate of potassa operating freely.  The
convulsions  again  ceased on the  procurement of free intes-
tinal evacuations and the return of  renal secretion.   But
her subsequent  progress to recovery has been  very slow and
vacillating, and is yet imperfect.
   Another  somewhat similar case that I met with a few
years ago, was that of a girl aged twelve years, previously in
good health, who was  attacked with scarlatina simplex, at
the same time with two or three other children  in the same
family, in  one of whom it presented the anginose variety,
which was the occasion of my being called in.  At  the time
of my first visit the girl was sitting up, and complaining so
little that the mother did not think she required medical
treatment.
   The rash had been well developed  on the  surface,
the fever  moderate, and  the case free  from  any appar-
                          7* 
78       SCARLATINA  AND  RUBEOLA
ent complications.   She  convalesced, and appeared well
for some  ten days, when her  face  and  limbs began  to
swell.  I was then  called again to see her, and found the
surface generally pale, and swollen from  anasarca;  pulse
moderately accelerated;  skin  dry  and but little above the
natural temperature ; head light or giddy; dull pain  in the
back, with sense of heaviness and lameness in bending the
trunk on the pelvis; bowels  inactive ,  stomach nauseated
at times;  appetite much impaired, and  urine  scanty and
dark-colored.  On examination, the latter was found  to
contain a few blood corpuscles,  and much  albumen, with
epithelium  and fibrinous shreds.   She was directed to have
a saline laxative to open the bowels, to  be  followed by a
prescription  containing  digitalis, nitrous  ether, and iodide
potassa, to be taken every three, hours.
   Two days later, when I saw her  again, her bowels had
moved very freely, and she had taken the medicine regularly,
but there was no marked change in her symptoms.   The
urine had not increased in quantity, and  was more bloody.
   She was ordered a solution of bi-tartrate of pptassa, of
which she was to take freely.   The mixture of digitalis and
nitrous  ether was  continued, a powder  of potassa nitras,
hydrarg. chlor. mite, and pulv. Doveri, being added at  night.
Warm fomentations were also  applied, both to the loins and
abdomen.   The' anasarca continued, however, slowly  to
increase ; the pulse became smaller and more frequent; the
head more  dizzy;  the  stomach  more irritable; and the
urine more scanty, and more  largely mixed with blood.
   During two days she passed not more than three or four
ounces in the twenty-four hours, and this more than half
blood.
   In the evening of the fourth  day after my first visit, she
was  seized with several  general convulsions.   Living in a
part of the city distant from my residence, a physician from 
SCARLATINA  AND  RUBEOLA.       79
 the neighborhood was called in, who ordered a warm bath,
 followed by fomentations, and  the liberal internal use of
 bromide and iodide of potassa.   The convulsions, however,
 continued  to recur at short intervals, until I saw her on the
 next afternoon.
    The  urinary secretion had been entirely suppressed for
 the preceding twenty-four hours ; the face and whole ex-
 terior  surface of the body and  limbs  were much bloated;
 the pulse 130 per minute, small and weak; skin moist, and
 temperature nearly natural;  pupils dilated, and  mind  inca-
 pable of being roused to consciousness.  Warm applications
 to the  trunk and lower extremities were continued, and the
 following prescription ordered :
        R.—Hydrarg. chlor. mit...................grs. xx.
            Potassae  nitratis.....................grs. xxx.
    M.   Fiant pulveres iv.  One to be taken every two hours  until the
 bowels were freely moved ; the operation to be aided by warm salt water
 enemata.
   To act as a temporary anti-spasmodic, ten drops each of
 chloroform and fluid  extract of  cannabis indica were given
 between the powders.  After she had  taken three  of the
 powders and one or two enemas, the bowels began to move
 freely,  and  the  convulsions ceased.  Soon after, she  also
 passed four or five ounces  of  turbid urine.   During  that
 night and the  following morning she urinated three or four
 times, and the bowels were evacuated copiously, but with-
 out attention on her part.  She  remained quiet during the
 night, and at my visit at ten o'clock the following morning
 she could be aroused  to partial consciousness, but was very
 feeble.   She was ordered a solution of bi-tartrate of potassa
 and gum arabic for a drink; and a powder containing five
 grains  of potassa nitras, and  three grains of pulv. Doveri,
every three hours.   All other remedies were dispensed with,
except  beef-tea for nourishment. 
80       SCARLATINA  AND  RUBEOLA.
   From this time the urinary secretion  continued to im-
prove in quantity and quality; the skin  continued moist;
the pulse became  slower  and more full; and  the  mental
faculties regained their activity.  In  about one week she
had so far convalesced as  to need no further attendance.
   In  a practice  extending over  a  period of more  than
thirty years, during which I have' seen a fair proportion of
scarlet fever patients,  and have often seen some degree of
renal dropsy as a sequel, the two foregoing are the first
cases that have  occurred, in my own practice, of complete
suppression of urine, and  convulsions, following this much-
dreaded fever.   Both these cases occurred after the  mildest
grade of fever,  and in spite of some directly preventive
treatment.   And neither  seemed to  be benefitted  by any
remedies except such as  aided  in the elimination of the
retained elements of urine, by promoting the action of the
skin, kidneys, and bowels.
   Here, in an adjoining  bed, we find another girl, who was
taken sick some  five or six days ago, and was brought to the
hospital on yesterday.
   On examining her, you will see that she presents the char-
acteristic eruption of measles, easily distinguished from that
occurring in  scarlatina by the points  of eruption being ag-
gregated in clusters, with  natural skin between; and  from
that of  small-pox, in which the eruption comes in pointed,
elevated, hard nubs, not so red as in this case, presenting
only a  slight flush, and without the catarrhal premonitory
symptoms, or weeping  of  the eyes.
   The patient is now  at the stage when she  is suffering op-
pression and  tightness in  the chest,  with a harsh  cough,
which produces  intense pain through  the temples with each
paroxysm.
   In  this disease,  if uncomplicated, the  indications for
treatment are very plain and simple.  The  disease has a nat- 
SCARLATINA  AND RUBEOLA.       81
ural course to run;  cannot be  broken up;  is  self-limited;
and the  physician is not expected  to  interfere with  active
means, but simply to modify its  severity as much as possible,
so as to leave the system in the  best possible condition.
    Give  enough of some anodyne expectorant  to lessen the
severity of the bronchial irritation and cough,  and mitigate
the pain  in the head.
    One  of the best  preparations,  perhaps, for cases as se-
vere as this, consists in the following:
       R.—Syr. sciHae comp_____........_....... § iss.
           Vin. antimonii______________________§ss.
           Tinct. opii camph___.....___________§ij.
           Tinct. verat. viridis__________________3 i.
    M.  One teaspoonful every three  hours, in a tablespoonful of water

    This  will, usually, in the  course of twenty-four  hours,
lessen the fever and modify the  cough, while the pain in the
head will at the same time be greatly relieved.
    As the period is reached when the fever begins to decline,
the veratrum may be omitted from the mixture, which may
then be continued, given every  three, four, or five hours, till
the cough  has  entirely disappeared; the anodyne, with the
expectorant, produces a very pleasant  effect, and does not
tend to interfere with the progress of the eruption ; but you
will usually find, while  using this, that the bowels will be-
come constipated, tongue coated,  and urine scanty, which
condition,  if neglected, leads to a bad  state   of digestion,
disorder  of the bowels, etc.
    I am  not in the habit of giving physic until  the eruption
is fairly out, when, if the bowels have not moved for a couple
of days,  I direct a mild  laxative, as, for  instance, a  combi-
nation like the following:
       R.—Hy drarg. chlor. mit-------------.....- grs. v.
           Leptandrae......................---grs. ij.
    M.      Soda; bi-carb------------------------grs. v. 
82       SCARLATINA  AND RUBE
   This  will produce a moderately fair  operation  of the
bowels, which may subsequently be kept in a regular condition
by any simple laxative that will be most readily taken; Ro-  |
chelle salts in effervescing solution, Tarrant's aperient, com-
pound rhubarb pill, etc.
   You will occasionally meet with cases where the patient
suffers so much at night that it is best to give a tolerably full
dose of Dover's powder at bed-time.  A good combination for
this purpose is, pulv. Doveri, eight grains, with hydrarg. chlor.
mite, one  grain, followed, if necessary, by a laxative in the  '
morning.  Or you may use instead fifteen or twenty grains of  '
the bromide of  potassium at night.  This sometimes acts
very favorably, but is not reliable in cases of eruptive fever,
   One  important thing to guard against, is extension of the
irritation of the bronchial  tubes to the lobules of the lungs,
making it complicated with lobular pneumonia.   In children
under  two years  of age,  this tendency is  very  strong.
It is usually about  the second day of the eruption that
you  will first be able to detect this.  It may happen later;
seldom,  however, before the second or third day.
   You  will observe, first, that they do not breathe naturally,
nor as from simple tightness of the bronchial tubes; but
every inspiration brings out a forcible expansion of the nos-
trils ; and  at the beginning of the expiratory act there is sud-
den  falling in of the walls of the abdomen, produced by
contraction of the abdominal muscles.
   These, if the case be noticed carefully, will be among the
earliest  symptoms to warn you of trouble with the lungs.
On applying the ear to the chest, you will also find a sharp,
well-defined, subcrepitant rhoncus.
   If allowed to run along till the  time for the fever to sub-
side, you will have the little lobules of the lungs in a hepa-
tized condition; the  patient  drowsy  and dull;  breathing
short; lips blue; pulse  sharp,  short, and  quick'in  stroke, 
SCARLATINA  AND  RUBEOLA.        83
and easily  compressed;  lips and tongue dry;  patient dis-
posed to lie with the head thrown back, eyes half open; and
in a few days death will  supervene.   In adults, this is the
chief source of fatality from measles.
   When symptoms of pneumonia occur in connection with
measles, the best remedy, in children, is a combination like
the following:
      R.—Liq. ammon. acetatis.................§ iss.
          Syr. ipecacuanhas................____3 ss.
           Tinct. opii camph.........._________§ ii.
   M.       Tinct. verat. viridis..................3 i-

   The dose proportioned to the age of the child.  For a
child two years old about twenty drops are usually necessary,
though it is best to  begin with ten drops ; for an adult, one
teaspoonful.  It should be given every two, three,  or  four
hours, till the fever is controlled.  In the active  stage of the
disease, while using this mixture, cover the chest externally
with fomentations, or onions crushed.
   I have  considerable faith in the popular notion about  |
onions.  They  certainly afford more relief to the breathing  j
than any other thing we can use.  I attribute  it to the im-
pregnation  of the air which is inhaled, with the volatile oil,
more than to any absorption  from the surface of the chest,
and think this application preferable to blistering.
   It will be advisable, in these cases,  to give a powder con-
taining from half a grain  to a grain of calomel, with  Dover's
powder, according to the age and restlessness of the  patient,
about  three times a day.   The liquid  mixture may be con-
tinued, at longer  intervals, until the symptoms of pneumo-
nia have entirely disappeared. 
LECTURE  VI.
■RESPIRATORY AFFECTIONS.—Diphtheria.— Croup.— Chronic
    Bronchitis. — Rheumatic Bronchitis. — Asthma. — Pleurisy,
    etc
    Gentlemen : —You will recognize the patient  before you
as one to whom your attention was called, eight or ten days
since, on account of a sub-acute rheumatism in the ankles
and tarsus of each of the feet.   He was born in  Ireland;
is about twenty-five years of age;  slightly  anaemic;  and
thin in  flesh.  He had  nearly  recovered from  his rheu-
matic affection, and  had been  walking about, moderately,
for two  or three days.  Yesterday he began to complain
some of soreness and stiffness  in  the fauces,  with some
lameness of  the cervical muscles;  and  this morning we
find him confined  to  his  bed.   If you  now note his
symptoms carefully, you will  find  the  skin  moderately
hot; the pulse 90 per minute,  soft  and small; the eyes
watery; the tongue covered with a whitish coat; the mucous
membrane of the fauces red, tumefied, and tender; the tonsils
considerably swollen, and the whole inner face of each cov-
ered with a thick coat of diphtheritic exudation or membrane,
and the lymphatic glands in the parotid and  submaxillary
regions, on both sides, considerably swollen.   Thus we have 
RESPIRATORY AFFECTIONS.        85
all the essential  symptoms of a well-marked case of diph-
theria.
   If such  cases as this are left to pursue  their natural
course, unmodified by treatment, the pulse usually increases
moderately in frequency, but diminishes in force, for several
days; the skin continues dry and warm ; the breath be-
comes offensive;  the glands of the neck remain swollen and
hard ; the membranous exudation separates from the tonsils
and fauces, leaving more  or less irregular  ulcerations, the
discharge from which makes the saliva foetid, sanious, and
abundant.  A  similar suppurative inflammation  extends to
the Schneiderian membrane, causing a muco-purulent dis-
charge from the nostrils, and aiding the swelling of the ton-
sils, in rendering the respiration rattling, and sometimes dif-
ficult.  In the  meantime, the mental faculties become more
dull; the patient being drowsy, with periods of restlessness,
and tossing of  the extremities, and sometimes delirium.  If
it is tending toward an unfavorable termination, deglutition
becomes more difficult, and the drink  often regurgitates
through the nostrils; the pulse becomes more frequent, and
small; the  extremities cool; the sphincters relaxed, with
involuntary  discharges; very irregular  respiration;  and
death.  In  some cases, in which the general and local symp-
toms have progressed several days, without  any unfavorable
indications, the diphtheritic inflammation extends suddenly
to the larynx,  adding the dyspnoea and  cough peculiar to
croup, and determining an early fatal result.
   In a few instances, the diphtheritic inflammation attacks,
simultaneously, the fauces and the larynx, causing the peculiar
symptoms of croup to be present from-the beginning.   Such
cases  are  distinguished  from simple  pseudo-membranous
croup, or laryngitis, by the accompanying swelling  of the
glands of the  neck, and of the fauces,  and by the  lower
grade of general fever.
       8 
86        RESPIRATORY AFFECTIONS.
    In a large majority of the cases of diphtheria presenting
the symptoms exhibited by the patient before you, the gen-
eral febrile  action continues moderate for five or six days;
the patient  complains much of weakness, and of difficulty
or pain in swallowing;  the membranous exudation gradually
separates from the surface of the tonsils and  fauces, leav-
ing  superficial ulcerations, and an abundant flow of mod-
erately fcetid, saliva.   The ulcerations heal in four or five
days;  the saliva becomes natural; all febrile symptoms dis-
appear ;  and the  patient  becomes  convalescent.   In most ]
instances the convalescence  is protracted, and characterized
by much  weakness, and a susceptibility to renal affections,
anasarca, swelling and  suppuration of the lymphatic glands
of the neck, and sometimes paralysis.  It should have been '
mentioned  that  the  urine is, in many  cases,  albuminous j
during the active progress of the  diphtheritic disease; and,
also, that  diphtheritic exudations are not limited, in all cases, I
to the mucous  membrane  of the throat, but may appear on
the mucous membrane of the genital organs, or upon cut or
abraded surfaces  in any part of the body.
   From the symptoms of this case, and from the brief general
description  of the disease just given, it is  evident that dipth-
theria is not a mere local  inflammation,  but a  general dis-
ease, of a febrile character, accompanied  by local inflamma-
tory processes,  more  particularly  in  the  fauces and glands
of the neck.   To indicate  its pathology fully, we must con-
sider carefully those symptoms  which   indicate  both the
condition of the blood and the properties of the solids. The
general tendency to the promotion of membranous or diph-
theritic deposits on all inflamed or abraded surfaces, the mor-
bid condition of the secretions, and, especially, the offensive
odor of the breath and saliva, plainly  indicate a morbid con-
dition of the blood, of  a septic, or degenerative character.
The  constant tendency to ulceration, and, often, gangrene, 
RESPIRATORY AFFECTIONS.        87
 in the parts affected with local inflammation; the general
 feebleness of capillary  circulation;  the  muscular debility,
 sometimes  ending  in  paralysis; and the dullness of the
 mental faculties, all point to an impairment of the element-
 ary properties of the tissues,  more  especially that of vital
 affinity, by which all atomic and secretory changes are con-
 trolled in the living organization, and the organized struc-
 tures are enabled to maintain their integrity.   Hence, patho-
 logically, we must class diphtheria with  the typhoidal class
 of febrile diseases, in all of which there is an inherent ten-
 dency to  degeneration  or impairment of the properties of
 both solids and fluids, throughout the system.  Whether this
 impairment is  caused by the  introduction  of some subtle
 poison into the blood, in the form of a contagion, infection,
 or miasm, which, by its presence, changes the properties of
 the blood, and thereby, also, its relations, both chemical and
 vital, to the organized tissues; or, whether it is  occasioned
 by some occult atmospheric condition, by which the oxygen,
 electricity, and other ingredients of  the  atmosphere, fail to
 exert their customary sustaining influence on the vital prop-
 erties of the living organization, cannot be satisfactorily an-
 swered in the  present state of medical science.  But what-
 ever may be the immediate cause, the  existence of the patho-
 logical conditions described, can hardly be doubted by any
 one who has attentively observed the  disease at the bedside.
 With the  diminution  of vital  affinity in  the solids, and the
 progressive deterioration of the blood, there is, necessarily,
 general impairment of both secretion and innervation.
   From  these views of the  pathology  of diphtheria, we
 may deduce four  well-defined and rational  indications for
 treatment:  First—To arrest the deterioration of the blood.
 Second—To  improve  the vital affinity, and, of course, the
general tonicity of the tissues.  Third—To restore the se-
cretory organs to their natural degree of activity.   Fourth— 
88        RESPIRATORY  AFFECTIONS.
To mitigate the violence of such local inflammations as may
exist in each individual case.
   To fulfill the first of these indications, the chief reliance
has been placed on  chlorine, bromine, and  iodine, or their
salts, such as the chlorates of potassa and soda.   From ex-
periments recently made with the sulphites of soda and lime,
and which have been fully detailed to you in former clinic's,
it is rendered probable that the sulphurous acid salts will be
found  more  efficacious in the treatment of all the diseases
dependent on blood-poisoning, or a septic  deterioration of
that fluid, than those previously mentioned.   As remedies for
fulfilling the second  indication, we place our chief reliance
on quinia, iron,  and pure  air.   Many  resort  to  diffusable
stimulants or exhilarants, such as the various alcoholic bev-
erages.  These agents, however, spend most of their direct
action on the nervous centers, while, indirectly, they depress
those elementary properties  of the tissues which we deem it
most  important  to sustain.   If the two first indications are
effectually  fulfilled,  the  accomplishment   of  the  third,
namely, to restore secretion, follows  as  a necessary result.
But in the early stage of severe diphtheria, the dryness of the
skin, the scantiness of urine, and the general febrile action,
is often such that much advantage may be obtained from the
use of  such remedies as exert a more direct influence over
the more important excretory functions ; for it must not be
forgotten that retained excrementitious matter may become
as deteriorating to the blood, and as  depressing to the prop-
erties of the tissues, as the primary cause of morbid action.
Consequently, such  remedies as aid in restoring a healthy
activity to the organs of excretion are often indicated, both
to prevent the accumulation of excrementitious matter and
for facilitating the elimination of any poison that may have
been imbibed as the cause of  the disease.  Mercurial altera-
tives, aided by mild diaphoretics  and  diuretics  will  fulfill 
RESPIRATORY  AFFECTIONS.        89
this indication more promptly and efficiently than any other
means;
   The means  designed to aid, locally, in combating what-
ever local inflammations exist, must vary  according to the
extent, intensity, and stage of the inflammation in each case.
In the early stage, the external application  to  the  swollen
lymphatic glands of the neck should be anodyne and dis-
cutient, such as an infusion of aconite leaves, with  muriate
of ammonia  dissolved in it.  In the more advanced stage,
when the glands remain indurated and swollen, stimulating
liniments may  be used, such as a  combination  of olive-oil,
oil of turpentine, and chloroform;  or a mixture of camphor-
ated soap liniment and tincture of iodine.   To the inflamed
surface of the fauces and tonsils, in the first stage, the local
applications  should  be of a decidedly soothing  character.
All cauterizing  or irritating applications in this stage, I am
satisfied from close observation at the bedside, positively do
more harm than good.  In the later stages, when  unhealthy
ulcerations or gangrene actually exists, the local applications
should be antiseptic and moderately  stimulant.   For  the
first stage I generally use nothing  for the  interior of the
throat but the following :
       R.—Potass, chlor........................3 i-
           Acid, hydrochl_____..............._.20gtts.
           Tinct. belladonna;................— 3 i-
           Aquas........-----.............----1 iii-
    M.  Give from half a teaspoonful to  a dessert-spoonful  every two
hours, without further dilution.
The application is made much  more complete and easy by
swallowing it, than by any process of swabbing or sponging;
while the introduction of the medicine into the system con-
stitutes one of  the best  means for fulfilling  the first indica-
tion in the general treatment.  In the latter stages,  the best
local application is a dilute  solution of chlorate of potassa 
9°        RESPIRATORY AFFECTIONS.
and tincture of chloride of iron.  Occasionally, an ulcera-
ted surface may be presented, of  that foul character that the
direct application of a strong solution of sulphate of cop-
per, or of iodine, or of per-sulphate of iron, a  few times,
would be beneficial. But, in my own practice, I have not found
it necessary to apply anything  with a swab or sponge to  the
throat of a diphtheritic patient during the last four years.
    Having thus given, briefly, my views concerning the na-
ture of diphtheria,  and the general principles of  treatment,
it only remains to prescribe for the patient before us.  The
disease, with him,  is still in its first stage.  He is somewhat
anaemic, and, as already mentioned, has been recently under
treatment  for sub-acute rheumatism.  We shall  direct  for
him the following prescriptions :
       R.—Potass,  chlor................________3 jSSi
           Acid, hydrochl....._................ .gtts. xx.
           Tinct. belladonna;................___3 iii.
           Aquas-----..................._.....5 iv.
   M.  One teaspoonful to be taken every two hours.
       R-—Quinia; sulph.....................___grs. xvji
Pulv. Doveri.
3ij.
            Hydrarg. chlor. mit_______........- -grs. vnj.
    M.  Fiant pulv. viii.   Take one every six hours.

At the same time we will keep the  swollen lymphatic glands,
behind the angles of the jaw, covered with a cloth wet with
the following  infusion, viz.:

        R.—Aconiti fol.........._____          zj
            Ammon. hydrochlor____________     z ss
    M.  Pour on one quart of boiling water, and use only'slightly warm

   The first prescription taken  in  small and  frequently re-
peated doses,  constitutes the only local application necessary
for the throat; while,  as an  internal medicine,  it is efficient
in counteracting the  further degeneration  of the blood. 
RESPIRATORY AFFECTIONS.        91
 The second prescription will aid in improving the tonicity
 or vital affinity of the solids, gently promote the  excretions,
 and allay irritability.  In about  forty-eight hours we shall
 expect to find the white  exudation on the tonsils mostly re-
 moved, and in its place  some degree  of ulceration.   The
 saliva will then be more abundant and offensive;  the general
 febrile  symptoms less ;  the pain in swallowing  less acute ;
 but the patient complaining of much weakness.   If no evac-
 uation from the  bowels  occurs during that time, we shall
 give him  a mild  laxative, and substitute for  the  previous
 mixtures the following:
        R.—Tinct. ferri chlor....................§ ss.
           Potass, chlor........................3 ii-
           Aquas_______________________________§ iv.
    M.   Give a teaspoonful  every three hours ;  also, one dose  of suL
 phate of quinine and Dover's  powder each night and morning.

    If the glands of the neck remain swollen and hard, then
 apply, three times a day, the following liniment:
        R.—Lin.  saponis__________......________§ ii.
    M.      Tinct. iodinii.......................§ \,
   Under  this treatment we shall expect the patient to be
 fully convalescent from the diphtheritic disease in  from six
 to eight days.
   We would  call your  attention for a moment  in passing,
 gentlemen, to  this child,  a little boy three years of age, who
 is just  recovering from a severe attack  of membranous
 croup.   Some five days since he was attacked suddenly, in
 the middle of the night,  with a hoarse cough, and the chok-
 ing, suffocating symptoms characteristic of croup.  Various
 domestic remedies were tried during the night without avail,
 and the next morning I  was summoned hastily to see him.
 I found the little one on the verge of actual suffocation; the
breathing  short, hurried, and noisy; the pulse  120 permin- 
92        RESPIRATORY AFFECTIONS.
ute,  weak and thready; a dark, venous congestion  of the
surface;  lips and nails blue ; and extremities  cold.  Some
little powders, containing four grains each of hydrarg. sub-
sulphas were ordered as an emetic, and a solution of ferri
lactas, twenty grains, in two ounces of water, to be given in
half-drachm doses every three hours.
   Copious vomiting ensued in about ten  minutes after the
administration of the first powder, a large amount of thick,
ropy  mucus being ejected.  This cleared the larynx, and
gave immediate  relief to the breathing, so that  he passed off
into a quiet sleep for a  few minutes.  The relief, as is usual
in these cases, however, was but temporary, the  exudation
being rapidly re-formed, until it again blocked up the larynx,
At the end of an hour  and a half it was found necessary to
administer a second powder, which was followed by prompt
relief, as before.   Twelve  of these powders, in  all, were
given to the child during the succeeding forty-eight hours,
at intervals  of  from two to six hours, according as the
symptoms seemed to indicate. The cough and dyspnoea con-
tinued nearly the  same, improving slightly through the day,
but returning worse again at night.  He took nourishment
in the form of beef-tea, boiled milk, etc., freely and readily,
and has seemed to maintain a  surprising degree of strength
throughout.  For the past two days the obstruction and dif-
ficulty of breathing has been  gradually diminishing, so that
he has required no emetic.   The solution of ferri lactas be-
fore mentioned, has been continued every four hours, alter-
nating with half-drachm doses of the following mixture:
       R-—Liq.  ammonia; acetatis________________§ i.
           Syr.  ipecac_______................._ 3 ii.
           Tinct. opii et camph...........______z  i.
    M.     yEther nitr____________......______   zj
   The cough continues somewhat severe ;  and  you notice
that the breathing is a  little hurried and  labored, and the 
RESPIRATORY  AFFECTIONS.        93
.pulse rather small and quick.   The severe and dangerous
symptoms, however, are all past; and by simply continuing
the same treatment for a few days longer, it is probable that
the little patient will regain his usual health and strength.
    The great majority of these  cases of membranous croup
terminate fatally, from suffocation, in spite  of any course of
treatment that may be adopted. A few, however, like this
little one, if relieved from time to time, as the symptoms be-
come urgent, by a prompt emetic,  will  maintain  sufficient
strength and vitality to carry them through until the inflam-
mation in the larynx and trachea subsides.
    This next case, gentlemen, was brought to your  notice,
and fully examined, on Thursday last, which was the  next
day after his admission to the hospital.
    You will remember that  his expression of  countenance
was then anxious  and depressed;  his  breathing labored,
with a dry, wheezing rhoncus;  his pulse about 90 per  min-
ute, and firm ; tongue slightly coated with  a white fur; and
he complained of some nausea,  with pain in the cardiac  re-
gion ; a sense of constriction across the  chest, and a harsh,
severe cough, with very little  expectoration.  You will recol-
lect that, on  examining him  with the stethoscope, you
found the respiratory murmur much exaggerated, with a pro-
longed  dry  rhoncus in expiration  over both  sides of the
chest, except in the mammary  and axillary regions of the
left side, in  which there  was a strongly-marked  sub-crepi
tant rale.  The patierit then told us that he had been sick
with cough, difficulty  of breathing, and pain  in the chest,
for  two or three  months.  We  expressed  the  opinion that
the  patient  was  laboring under a chronic bronchitis,  by
which the bronchial mucous membrane  had become thick-
ened, its secretion diminished, and on which had supervened
a pneumonic congestion  of  the middle and lower lobes of
the  left lung. 
94
RESPIRATORY AFFECTIONS.
   To relieve these pathological conditions, we then directed
for  the  patient a powder composed of pulv. opii, one and
one-half grains; tart. ant. et potass., one-eighth grain; and
hydrarg. chlor. mite., one grain;  to be given every  three
hours.  He continued these for two days, during which time
his cough became less severe; expectoration more free; and
the pain and tightness in the chest much diminished.  The
powders were  then discontinued, and the following mixture
ordered in their stead :
        R.—Syr. scillae comp____..................§i.
           Tinct. opii et  camph_____.......----§ ii.
           Tinct. verat. viridis..................3 i-
    M.  One teaspoonful to be taken every four hours.
    This he has continued until  the present time.  You now
observe no difficulty of breathing while he is at rest; and on
applying the stethoscope to the chest, you find no prolonged,
dry, wheezing rhoncus on either  side; and  there is only a
slight trace of  the  sub-crepitant rale in the left mammary
and axillary regions.   The  latter regions  still  show  slight
dullness on percussion  ; and the proper inspiratory murmur
remains somewhat exaggerated  over the infra-clavicular re-
gions.  He coughs but  little,  and expectorates a  thick,
opaque mucus.   It  is thus seen that the  condition of the
pulmonary organs is greatly improved.
    On  further inquiry,  we find that the patient has frequent
pains in the abdomen; a desire to pass urine oftener than
natural, with some scalding;  and the intestinal discharges,
though not more than one or two in the twenty-four hours,
are  yet watery and unhealthy.  The  pulse remains a lit-
tle accelerated  and firm.  These  symptoms indicate a very
general irritation of the mucous  membranes  throughout
the system, and may account for the continuance of  a firm
pulse, while the general aspect  of the patient is that  of de-
bility.   The desire to urinate often, with scantiness of that 
RESPIRATORY AFFECTIONS.         95
secretion, also suggests the  possibility of albuminuria, or
Bright's disease of the kidneys.
   The latter affection sometimes comes on very insidiously,
producing mental despondency, indigestion, cardiac palpita-
tion, and  sometimes pulmonary congestions, with so little
direct  disturbance of the urinary  organs that  neither the
patient nor his physician suspect the true nature of the case.
So true is this, that in all cases of protracted  ill health, or
the frequent repetition of attacks of local symptoms with-
out a manifest cause, the practitioner should not only make
the usual general  inquiries in regard to the urinary secre-
tion, but should subject it to  such chemical and microscopic
tests as will determine, positively, its composition and qual-
ities.   Hence  we shall have some of the  patient's  urine
saved  to-morrow morning for examination,  the results of
which  I will inform you at the next clinic*  At present we
will omit the  expectorant and sedative mixture, which has
been given  during the last three days,  and give something
better  calculated to allay the general irritation of the mu-
cous membranes, and to promote a more free  and  diluted
secretion  from the  kidneys.   For  these purposes we shall
direct the  following:
       R.—Benzoini g. pulv..........___________3 ii-
           Tinct. opii___________________________3 i.
           Acacia; g. pulv. )  aa                  ...
           Sacch. alb.    I     .............
       Miscse et add
           Syr. ipecac.....................-----§ i.
           Aqua; menthse....................— § i.
       One teaspoonful to be taken every four hours.
Also :
       R.—^Ether nit...........-----......-----Iii.
           Tinct. digitalis........-........-----§ ss.
   A teaspoonful every four hours, alternately with the emulsion.
  * On examining the urine before the class, the next clinic morning, it was found to
contain both an excess of phosphatic salts, and a quantity of albumen. 
96        RESPIRATORY AFFECTIONS.
   This man, a sailor, aged about twenty-five years, was ad-
mitted into the hospital one week since.  At the time, his
face was turgid,-and some bloating over the whole body, of |
a semi-cedematous character, with a look of spaneemia.  His
breathing was short and hurried; pulse quick and irritable;
paroxysms of severe, harsh cough;  expectoration  scanty,
but sometimes mixed with streaks of blood;  respiratory
murmur harsh and exaggerated, with some dry rhonchi, but
no marked dullness on percussion.  There was also well-
marked rheumatic pains in the joints of the lower extremi- '
ties, and the urine was scanty and high-colored.  Previous I
to the attack, the patient had been exposed to cold and wet
on the lake, and the case was regarded as rheumatic inflam- j
mation  of the bronchial  tubes; especially of the  smaller
tubes, with congestion  of some  of the lobules of the left
lung.   It was remarked that  rheumatic bronchitis was not !
unfrequent in our climate, and was generally characterized
by harshness and severity of cough; scantiness of expecto-
ration;  constriction  or tightness in the  chest,  sometimes
amounting to asthmatic breathing, especially at night; and
the coincidence of rheumatic pains and swellings in other
parts.
   To correct the  rheumatic  diathesis, and mitigate the se-
verity of  the cough, this patient was given ten grains of bi-
tartrate of potassa, and ten grains of Dover's powder, every
four  hours,  and a teaspoonful  of the following  mixture
between :
       R.—Ammon. hydrochl...............______3 iii.
           Antim. et potass, tart.........._______grs. ii.
           Morphia; sulph.................______grs. iii.
           Vin. colchici........____.....:_______|ss.
    M.     Syr. glycyrrhiz................-.,.....f iiiss.

   This  treatment  has now been continued one week, and
all the symptoms are much relieved.  The soreness, cough, 
RESPIRATORY AFFECTIONS.        97
 and sense of tightness in the chest are so much relieved that
 the patient rests comfortably at night, and the urine is much
 more abundant.  He will continue the hydrochlorate of
 ammonia  mixture before each meal-time,  and the Dover's
 powder and bi-tartrate only at bed-time.
    We have here another patient, a native  of Ireland, aged
 about fifty years, who came to the hospital  about one week
 since.  He has been afflicted for many months with a severe,
 harsh cough, and severe paroxysms of dyspnoea.  For two
 weeks past his cough, and difficulty of breathing, have been
 so severe, each night, that he has been wholly unable to lie
 down and sleep.
    The expectoration is scanty and  viscid ; the skin cool;
 lips leaden  color;  and the dry, bronchial rhonchi easily
 recognizable over both sides of the chest.  The entire ab-
 sence of febrile symptoms, the wheezing quality of the res-
 piration, and the severe  exacerbations of dyspnoea at night,
 plainly designate it as a  case of asthma.
   We would remind the class, however,  of  the  fact that
 asthma, like dropsy, is merely a symptom, which is generally
 dependent on some  prior, and perhaps remote, pathological
 condition.   Thus, one class of cases depend on organic dis-
 ease of the heart; another on chronic inflammation of the
 bronchial  mucous membrane ; and another on a morbid con-
 dition of the respiratory nerves, inducing purely spasmodic ac-
 tion.  The latter  cases are distinguished by the suddenness
 and violence of the  paroxysms, and the entire relief from all
 symptoms of respiratory disturbance in the intervals.   The
 two former are to be diagnosticated  with certainty only by
 the aid of  auscultation and percussion.  In the present pa-
 tient,  there is constantly a shortness of breath, greatly in-
 creased by exercise  ; considerable cough, especially  in the
morning,  with a tenacious, opaque  expectoration ; and on
applying the stethoscope, there  is heard,  on both sides, a
       9 
98        RESPIRATORY  AFFECTIONS.
harsh and exaggerated  inspiratory murmur, somewhat pro-
longed in expiration, but neither bronchophony nor increased
dullness  on percussion.  The rhythm  and sounds of the
heart are also  normal.
   These symptoms  and physical signs, existing at a time
when the patient is entirely free from any special paroxysm
of the asthmatic affection, are sufficient to show  that the
bronchial mucous membrane is thicker and more dry than
natural, thereby lessening the capacity of  the bronchial
tubes, inducing shortness of breath,  and rendering  the
sound produced by the ingress and egress of air harsher
than natural.   This state of the mucous membrane is doubt-
less  the  product of  chronic  inflammation.  We often find
similar changes in the respiratory murmur accompanying
the early stage of tubercular deposits ; but this is easily dis-
tinguished by the  addition of more or less bronchophony
and diminished resonance, symptoms that are absent in the
present case.
   This  patient has  been  taking, for temporary relief, a
powder composed of pulv.  opii, two  grains, and tart. ant. et
potass., one-fourth grain, each morning, noon, and evening;
and they seem to have had a beneficial effect.   We shall now
put him on the following treatment:
       R.—Tinct. cimicifuga;........___.........3 iss.
           Tinct. lobelias_................______§ ss.
           Tinct. opii et camph_________.......... § ii.
       A teaspoonful before each meal, and at bed-time.
And—
       R.—Pulv. aloes......................____grs. Xx.
           Ferri sulph........................__grs. xx.
           Pil. hydrarg------------------.......grs> x.
           Ext. cannabis  indicse.......__________grs. x.
   M. Fiant pilulae xx.  One to be taken at eight o'clock each evening.

   This next patient is  a young man, admitted into  the hos- 
RESPIRATORY AFFECTIONS.        99
pital two days since.  His face was then deeply suffused with
a purplish flush;  lips pale ;  extremities cool, but surface of
trunk hot and dry; pulse 120 per minute, moderately firm;
respirations short,  and  30 per  minute, but  no  cough,
no  expectoration, and no  pain  in  the  chest;  bowels
inactive, and urine scanty.   He had been  sick about one
week.   Inspection of the chest  shows flattening of the left
infra-clavicular region, with slight dullness, and tubular res-
piration ; the right side is less flattened, antero-posteriorly,
but very dull on percussion  over the whole lower and lateral
part, with  silence on auscultation.  These  symptoms and
signs indicate latent pleurisy, with effusion on the right side,
with tuberculosis of the upper  lobe of the left lung.   His
treatment has  been  moderately sedative  and diuretic, con-
sisting of one  teaspoonful of the following  mixture every
four hours:
       R.—Syr. scilla; comp.....................§"ii.
           Tinct. opii et camph..............----§ ii.
    M.      Tinct. verat. viridis..............----3 i-

   Also, between  each of the above doses, a fluid drachm
of a mixture of equal parts  of liquor ammonia, acetatis and
nitrous ether.   This treatment  has now been followed two
days, and the veratrum  has  rendered the pulse slower and
more soft, with less  suffusion of the face, and less heat of
surface over the chest.  On account of these changes, and
a slight feeling of nausea, the veratrum will be omitted from
the expectorant and anodyne  mixture, and twenty drops of
tincture digitalis be added to  each dose of the liquor am-
monia acetatis, and nitrous ether. 
LECTURE  VII.
PULMONARY TUBERCULOSIS. — Cases Illustrative of the
    Incipient, Suppurative and Excavated  Stages. — Diagnosis.
    — Treatment.
    Gentlemen:—We  propose to occupy your attention the
present hour with a consideration of  the subject of Pul-
monary Tuberculosis, as illustrated  by three cases in  this
ward.
    This first patient,  a German, aged twenty-five  years,
was admitted into the hospital ten days since.   At the time
of his admission he had a slight fever, accompanied by sore-
ness in the chest behind the sternum,  and a pretty  severe
cough.  He  took  three or four alterative doses of  hydrarg.
chlorid. mite., with pul. Doveri, followed by a laxative, which
lessened the heat  and dryness of the  skin,  and somewhat
relieved the  soreness in the chest.   But the  cough  and
quickness of the pulse  continuing, I prescribed the follow-
ing mixture:
       R-—Syr. scillse comp............._.......% i,
           Tinct. sanguinarise...................?SS-
           Tinct. opii et camph___........._____? iss>
           Tinct. verat. viridis......_.........  _ 3 i_
    M.  To te taken in doses of a teaspoonful every four hours. 
PULMONARY TUBERCULOSIS.      101
   Under the influence of this  his cough has abated, but
not ceased;  the soreness behind the sternum  has disap-
peared, and he has no longer any febrile symptoms, except
an accelerated  pulse.   But  as you stand by his bedside,
gentlemen, you observe that his respiration is shorter and
more frequent than natural; his pulse about 90 per minute,
and quick; his face  and limbs show a moderate degree  of
emaciation;  and he  has a frequent,  short cough, more
severe  in the morning, and accompanied with a moderate
expectoration of whitish mucus.
   At  the time this patient was admitted, he was undoubt-
edly affected  with a sub-acute bronchitis.   But the symp-
toms peculiar to that disease having  subsided, while there
still remains a short cough, quick, sharp pulse, with moderate
emaciation, the question is at  once suggested whether the
patient is not affected with incipient tuberculosis.  The
probability of this is increased by the fact that  he has had
more or less cough, with some shortness of breath, on taking
muscular exercise, for three months past.  But there are no
symptoms on which we can rely as certainly diagnostic of
tubercular disease in its early stage,  except those  derived
from a physicial examination of the  chest.  Making the
chest bare, therefore,  we will  carefully auscultate the res-
piration and  the voice.  In the infra-clavicular region of
the right  side we find the inspiratory murmur enfeebled and
irregular  in its development, while in expiration the mur-
mur is  renewed  and prolonged.  There is also in the same
region  moderate bronchophony, or increased vibration of
voice.   Over the corresponding  region of the left side
the respiratory  murmur is exaggerated or  puerile, but
neither irregular nor  prolonged.   After each of you have
taken the stethoscope  and examined for yourselves, we will
ascertain  the result of percussion.   If  the room is kept per^
fectly still while we percuss over corresponding parts of the 
102      PULMONARY  TUBERCULOSIS.
two sides of the chest, you do not readily detect any alter-
ation  from the natural  resonance until we reach the infra-
clavicular region of the right side, where you at once recog-
nize a moderate diminution of the resonance.
   Hence we  may sum up the results of the  examination
as follows:  An enfeebled, irregular and prolonged respira-
tory murmur,, with increased vibration of voice, and increas-
ed dullness on percussion  over  the infra-clavicular region
of the right side ;  and simply an  exaggeration of the  res-
piratory  murmur  over  the  upper  part  of the left side.
Here, you perceive, are no rhonchi, or new sounds, but simple
alterations of  the natural ones;  requiring much care to ap-
preciate them ; and yet they are of the most serious import.
The  irregular  and prolonged murmur, the moderate bron-
chophony, and the diminished resonance, clearly demonstrate
the existence of greater density  than natural in the upper
lobe of the right lung;  while  the simple exaggerated mur-
mur of the  left side is undoubtedly produced  by the more
forcible  distension occasioned by diminished capacity of
the right lung for air.  But what  causes the greater density
of the upper lobe of the right lung?  On the  proper solu-
tion of this question depends the  correctness  of our diag-
nosis. We may have increased density of the lung from sev-
eral different pathological conditions :  from pneumonia and
its consequences;  from pleuritic  effusions; and from tuber-
cular deposits.  The first  would be preceded and accom-
panied by the well known phenomena of pneumonic inflam-
mation, which have not been present during any part of the
progress of the  case^ before us,   The second  is always ac-
companied  by  increased  fullness  of  the  side  affected;
while the dullness  is greatest  in  the most  dependent part
of the chest, instead  of the upper and anterior part, as  in
this case.  It is well known, however, that  the deposit  of
tubercular matter almost always  commences  in the upper 
PULMONARY TUBERCULOSIS.      103
lobe of the lung, and is accompanied by atrophy of the pul-
monary tissue, instead  of increased  fullness.  From  these
considerations it is very evident that the patient  before us
has incipient or primary tubercular  deposits in the upper
lobe of the right lung.   The  special pathology of tubercle,
and the successive changes which it undergoes, we cannot
take time to  consider at present.  The rational symptoms
and physical signs  accompanying these changes are strik-
ingly exhibited in the two other patients in this ward.
   Mr. C----, aged twenty-six years, native of Ireland, was
admitted to the hospital three  days since.   He has had
some cough with increasing emaciation for the last eighteen
months.  You see, by the contents of the vessel  here, that
his expectoration  is considerable;  consisting of  mucus,
with circumscribed masses of  distinctly purulent  matter.
His pulse is 100  per  minute, and soft; lips pale, cheeks
sunken, and whole body considerably emaciated ;  the pulse
is more frequent in  the  evening, with  some heat of skin,
and some sweating  toward morning.  By uncovering the
chest you see the infra-clavicular space of the left  side
decidedly depressed, and the inter-costal spaces more or less
sunken on both sides.  On applying the stethoscope to the
left infra-clavicular region, you  have no  respiratory mur-
mur proper, but a loud, sharp, sub-mucous and  crackling
rhoncus.   The bronchophony is strongly marked, and so is
the dullness  on percussion.  Here you have, then, all the
phenomena of tuberculosis in the second or  active stage of
its advancement, when the tubercular masses are  softening,
and a slow ulcerative process is  being established in the
tissue  surrounding them, inducing more rapid emaciation,
and the slighter grade of hectic  fever.  To complete the
examination of physical signs belonging to  phthisis in the
different  stages of its  progress, you may now turn to this
next bed, where we have another patient, Mr. D----, aged 
104      PULMONARY  TUBERCULOSIS.
thirty years, who has been suffering from tubercular disease
for the last three years.   You see him extremely emaciated;
his pulse no per minute, and small; respiration very short;
coarse rattling of mucus in the trachea and larger bronchial
tubes; voice hollow and husky; with copious purulent ex-
pectoration and night sweats.  Uncovering the chest, we
find  the infra-clavicular  region on  both sides  much de-
pressed, and all the inter-costal spaces sunken.  On apply-
ing the stethoscope to the upper lobe of the left lung, you
hear  a very  plain cavernous  sound  with  each respiratory
act, close under the end of the instrument, and, on causing
the patient to articulate sounds he seems, to speak almost
directly into  the end of the  instrument, producing what is
called pectoriloquy.
   Thus,  gentlemen,  you have  in the first case examined
this morning, those simple alterations in the natural sounds
produced by respiration, voice, and percussion, which  indi-
cate tubercular disease  in its first  and comparatively dor-
mant state.  In the  second case  you have  present all the
phenomena of the second stage, or that of active softening
of the tubercular masses;  while, in the third case,  you find
the cavernous respiration and  pectoriloquy indicative of the
third stage, in which  the softening has been  completed, the
matter discharged by expectoration,  and  cavities more  or
less numerous formed in the structure of the  lung.
   We  come next to consider the treatment of  phthisis,
particularly with reference to these cases.   There are but
few diseases  that have been subject to a greater variety of
treatment,  or concerning which the professional mind has
diverged into greater  or more  opposite extremes.    It is but
a few years since pulmonary phthisis was regarded as origi-
nating from inflammation, and it was deemed of the highest
importance to keep each patient closely confined in a uni-
form warm atmosphere ; to avoid all stimulants ;  to restrict 
PULMONARY  TUBERCULOSIS.      105
the diet; and to- directly combat the disease by local bleed-
ing and counter-irritation, with internal sedatives and ano-
dynes.  Subsequent investigation having developed a more
correct knowledge  of the  pathology  of tuberculosis, and
clinical observations clearly proved  the inappropriateness of
the former treatment—at least in a large proportion of cases
—the practice of the profession took so rapid a turn in  the
opposite direction, that the treatment advised by many at
the present  day might be  summed  up as consisting in free
exercise in the open air,  free use  of alcoholic drinks (es-
pecially Bourbon whisky),  cod liver  oil, and  the most nutri-
tious  diet.   Abundant  observation  has satisfied  me, how-
ever, that cases of tuberculosis differ much from each other
in their causation or mode of development, their progress,
and the co-existing condition of other important organs; and,
consequently, that no special  routine of treatment can be
marked out as applicable to all cases.   In many, the devel-
opment and progress of the disease is extremely slow, almost
entirely exempt from inflammatory or febrile symptoms, and
equally exempt from any derangements of digestion.  Such
cases will generally bear rich food,  stimulating drinks, and
abundant exercise in the open air at all seasons of the year.
In another class of cases, there is a  low grade of inflamma-
tion in the mucous membrane of the  pharynx, larynx, and
bronchia, which not only  greatly increases  the severity of
the cough, but renders the patient so  sensitive to atmospheric
changes, that out-of-door  exercise  can be taken only to a
limited degree, and  with  extreme  caution.   Still another
class, by no  means  small,  presents  a  similar inflammatory
condition of the mucous membrane  of the stomach and in-
testines, rendering it very difficult for  the patient to retain
or digest  anything but  the most  bland and unstimulating
articles of diet or drink.  A well-marked case of this kind
now occupies a bed in the ward for  females, below. 
106      PULMONARY  TUBERCULOSIS.
   It is very obvious, therefore, that we cannot prescribe a
fixed  routine of  treatment for phthisis, without doing as
much harm to some patients as we do good to others.  The
general rules which should guide us in  its treatment may be
stated, however, as follows :  First—To give  the patient as
nutritious a diet as the condition of the digestive organs will
bear without inconvenience.  Second—As much exercise in
the open air  as the strength of the patient will permit, with-
out injurious fatigue.   Third—To give  such medicines as
will allay the morbid  sensitiveness  or excitability of the
respiratory organs, and improve the functions of assimilation
and nutrition.  Fourth—To remove, with the least possible
waste of strength and vital power, such local developments
of inflammation as frequently supervene during the progress
of tuberculosis.
   To allay the morbid sensibility of the pulmonary tissue,
and to sustain the functions of digestion and nutrition, are
indications  common to all cases, and  in all stages, of pul-
monary tuberculosis.   In addition to this, in the first stage,
it is of great  importance to maintain the full capacity of the
lungs  for  air, and  to  supply the  blood  with  whatever
constituents the circumstances of the patient may .have ren-
dered  deficient.   In the  second stage, in  addition  to the
general indications, constant vigilance  is required to ward
off the frequent supervention of pneumonic, bronchial, and
pleuritic attacks  of inflammation, which  often result in the
establishment of wasting hectic.  In the third or suppurative
stage, we have  still the two leading indications mentioned,
with the addition of such  means as will lessen  the suppur-
ative  process, and prevent exhausting discharges, whether
from the skin or bowels.
   In carrying out the  first rule, many  attempt  to prescribe
a certain amount of nutritious food, and then stimulate the
digestive organs  up to the point necessary for  digesting it. 
PULMONARY  TUBERCULOSIS.       107
From such a course, I have never known good results.  On
the contrary, I fully agree with Dr. Thomas Watson, that it
is much better to adjust the quantity and quality of food to
the existing condition of the stomach than to undertake the
very difficult task of adjusting the stomach to a given quantity
of food.  One ounce of nutritious matter perfectly digested
and assimilated, is better for any patient than four ounces
imperfectly prepared, to nourish the textures of the body.
A  large  portion of phthisical patients have no difficulty in
taking a sufficient quantity of any of the ordinary articles
of diet,  such  as bread, meat, and vegetables; but  for the
class  of patients  to  which I just  alluded, as possessing a
highly irritable condition of  the stomach, or what some of
the older writers  called "dyspeptic phthisis," the selection
of diet is of paramount importance.  In the great majority
of such  patients I have succeeded better  with milk than any
other  article.   By adding lime-water in the proportion of
one ounce to four ounces of the milk, patients will generally
bear from one gill to one pint at a time,  without  inconven-
ience ; and it  contains all the elements  for nourishing the
body  more .perfectly than  any other  article of diet with
which we are  acquainted.
   For drink, I induce tuberculous patients, generally, to
use what is called "algae chocolate," as a substitute for both
tea and coffee.  Besides being more nutritious,  it contains
a small proportion of iodine, from the  sea-weed which is
mixed with the chocolate, and is, therefore, more or less val-
uable  as a medicine.   In regard to the patients here  in the
ward,  the first and second cases to which I have called your
attention, are  able to take a reasonable  quantity of all the
more nutritious articles of diet.   The third  case, however,
has become so  much exhausted  that the functions  of the
alimentary canal  are much  impaired, and he has become
subject to short attacks of diarrhcea, and has consequently 
108       PULMONARY  TUBERCULOSIS.
been obliged to rely principally on milk - porridge for nour-
ishment.
   The rule in relation to exercise, perhaps, sufficiently ex-  j
plains itself.  So long as the patient has sufficient strength,
he should take such exercise, daily, as will bring the whole
voluntary muscular system into action.   Walking, riding on
horseback, and moderate  manual  labor in the open  air, are
the most reliable methods of exercise.  The first case you
have just examined, takes active exercise by walking, every
day.   The  second has too  much shortness  of breath to
endure much walking, but might be greatly benefitted by
riding in an open carriage.  The third, however, is too feeble
to leave his bed.
    To carry out  the  third rule, requires a careful selection
of such anodynes, sedatives, and  tonics, as are best suited  I
to each  individual case.   In the early stage of the disease,  j
while the tubercular deposit is still in its crude state, I find
that many  patients derive a good  deal  of  benefit from the
following combination:
        R.—Ext. lactucae fl_______................§ i.
            Ext. cimicifugse fl......____..........§ i.
    M.  A teaspoonful before each meal, and at bed-time.

    Where there is more or less cough and morbid sensitive-
ness of  the pulmonary organs, one of the following  formula
will sometimes act more efficiently:

        R.—Syr. hypophosphis comp_________......^iv.
            Morphia; sulph......................grs. ii.
        A teaspoonful before each meal.

        R.—Bismuthi sub-nit..........._......   3 iii.
            Ferri sub-carb.......................3 ii.
            Morphia; sulph______.................(rrS- iii.
        Fiant pulveres xxx.  Take one before breakfast, dinner, and at
    M.
Or:
    M.
bed-time. 
P ULMONARY  TUBERCULOSIS.        109
   If there is much diminution in the capacity of the lungs
for air, as indicated  by shortness of the inspiratory act, a
tablespoonful of the  following solution may be taken after
each meal, with much advantage, viz.:
       R.—Potassse chloratis....................3 ii-
           Acacia; g. pulv...........------------3 ii-
   M.      Aquae...............-.............- 1 yi-
   When the second stage comes, characterized, as it usually
is, by pains in the chest, greater severity of cough, feverish-
ness, and other symptoms of an inflammatory nature, the
following expectorant and alterative solution we have found
more beneficial than  any other':
       R.—Ammon. hydrochlor..........-.......3 iii-
           Antim. et potass, tart.................grs. ii.
           Morphia; sulph......................-grs. iii.
           Syr.  glycyrrhiz________________________1 iy-
   M. Take one teaspoonful every four or six hours, according to
severity of cough, etc.
   In such cases as are accompanied by passive haemorrhage,
the fluid  extract, or  wine  of ergot, may be substituted for
the cimicifuga with advantage.   If the pulse is  quick, and
the pulmonary organs very sensitive to atmospheric changes,
much additional advantage will be derived by giving a wine-
glassful of  the  infusion of lycopus virginicus half an hour
after each meal.
   The same plan of treatment is also well adapted to some
cases in the second  stage  of advancement.  There is now
in the hospital  a patient  who was admitted three  months
since, with all the  symptoms of phthisis in its second stage.
There was much  emaciation ; copious, purulent expectora-
tion ;  night  sweats;  and all  the physical  signs of softened
tubercular  disease in the upper  lobes of both lungs.   This
patient has been kept upon substantially the same treatment
as that just described.  After the first six weeks the cough
       10 
no
PULMONARY  TUBERCULOSIS.
 and expectoration began to* diminish, and the latter has now
 ceased altogether.   The hectic symptoms have also ceased,
 and the  patient has  gradually gained sufficient flesh and
 strength to enable him to walk about the city freely. Whether
 there is any truth in the theory of Dr. Churchill respecting
 the  deficiency of phosphorous as an element  in  tubercular
 diseases,  or not, it is  certain that the hypophosphites are
 among  our best haemostatic tonics.   Still, there  are  some
 patients,  even in the  early  stage of  phthisis, who  do not
 seem to derive benefit  from them.  Such is the first case to
 which I called your attention to-day.   Previous to  his ad-
 mission here, I several times  prescribed  some one of  these
 preparations  for him;  but, under their use, his cough, and
 other symptoms of pulmonary irritation, invariably increased.
 Hence I  have kept him pretty constantly on the use of the
 following mixture, viz.:
        R.—Glyceringe________________......_____3 i'ss-
            Syr. ferri  iod..........__________.....§ ss.
            Morphia;  sulph..........______......gr. i.
    M.  Take a teaspoonful before each meal, and at bed-time.
    He  has also  taken, constantly, the infusion of lycopus
 virginicus after meals.
    In all  the advanced stages  of the disease, when the sup-
 purative process is fully established, the expectoration copi-
 ous, and the hectic rapidly wasting the patient, no medicine
 has done  more in my hands to stay the progress of the dis-
 ease, and  support the  strength of the patient,  than this last
formula.
   The powders of bismuth, iron,  and  morphia, already
given, also constitute one of the best combinations that can
be used at this stage.   There are now in the hospital wards
three cases in which the cough, night sweats, and expecto-
ration have been almost stopped by these powders, while
the appetite and strength have decidedly improved.  Occa- 
PULMONARY  TUBERCULOSIS.       ill
 sionally cases are met with in the advanced  stage, in which
 the tubercular disease is complicated by chronic bronchitis
 of such a grade  that it greatly increases  the dyspnoea, and
 the quantity of expectoration.   A strongly-marked case of
 this kind was presented to  you in Ward No. 9,  not long
 since.  In such cases' the following formula has often afforded
 great relief to the patient:
       R.—Bal. copaiba;_________________________3 iii.
          Chloroformi_________________________3 iii.
          Syr. tolu....................._______3iv.
          Acacia; g. pulv. \                    ...
          Sacch. alb.    f aa----.........--.-3 m.
       Miscas et add
          Tinct. opii camph__________________| ii.
          Aqua; menthae________________________| ii.
       A teaspoonful to be taken before each meal, and at bed-time.
    Perhaps no remedy has been more generally used in the
 treatment of consumption, during the last ten years, than
 cod liver  oil.  As the  result of much observation, I have
 come to the  following  conclusion  regarding  its  use, viz.:
 Whenever patients can take at least three tablespoonfuls of
 the oil per  day  without causing nausea, or  impairing the
 relish for food, it will pretty certainly prove beneficial.  But,
 unfortunately, a large majority of tuberculous  patients can
 take it but a short time before it begins to disturb the stom
 ach so much as to do more harm than good.   In those cases
 where it is well borne, the improvement of the patient will
 be rendered  much  more certain by giving, in conjunction
 with the oil, five grains each of hypophosphite of  lime and
 Dover's powder,  three  times a day.   Within the  last few
years, the preparation  known as Liebig's  extract, or syrup
of malt, has also grown much into favor as a tonic  and nu-
trient remedy  in  the earlier and middle stages of phthisis.
It certainly seems to exert a very markedly beneficial effect
in many cases  where the  state of the digestion renders the 
H2      PULMONARY  TUBERCULOSIS.
oil inadmissible.   It can be very advantageously  combined
with  the  comp. syrup  of the  hypophosphites, in the pro-
portion of two parts of the malt, to  one of the hypophos-
phites, from two to four drachms of the mixture being taken
after  each meal-time.  In cases where the hectic is marked,
and night-sweats excessive, hypophosphorous acid may also
be added to the mixture,  so as to give from five to ten drops
of the acid to each dose.
    In favor of the use of alcoholic drinks  in the  treatment
of phthisis, I can  say  nothing.  I have carefully watched
their  influence in connection with this disease for the last
ten years.  They have  proved worse than  useless in coun-
teracting the tuberculous diathesis, or preventing the deposit.
In the  active, suppurative stage of the disease,  their  free
use will sometimes retard the  emaciation, lessen the cough,
and give a decided appearance of improvement; but it is
in appearance only; for in most of such cases, while the dis-
ease of the lungs is apparently retarded, the retention of
carbon in the blood hastens a fatty degeneration of the liver
and kidneys,  and develops  dropsical  effusions, and albu-
minous urine.  Two cases of this character have  called on
me, from country districts, within the last three weeks.  For
more  than five years I took the trouble to keep written rec-
ords of all well-marked cases of tuberculosis coming under
my observation,  having  any  connection with the  use of
alcoholic  drinks,  either as medicines  or otherwise.   The le-
gitimate deductions from these records are, that those drinks,
whether fermented or distilled, have no  power either to pre-
vent the  development of  tubercular  phthisis, or to prolong
life, after the disease is developed.
    Perhaps I ought not to dismiss you  without  a word in
regard to the effects of climate on consumptives.   For pa-
tients predisposed to phthisis, or in the first stage after the
deposit, while it is  unsoftened, a  removal  to a moderately 
PULMONARY  TUBERCULOSIS.      113
elevated, interior region, with a dry air, mild temperature,
and good water, will be  of great  advantage; especially if
associated with  habitual  out-of-door occupation.   But the
practice of sending patients to remote  regions, away from
home  and  friends,  after the disease is advanced to its full
suppurative  stage, and  especially when it occupies  a large
part of one or both lungs, is not only useless, but unjust to
all parties.
10* 
LECTURE  VIII.
DISEASES OF THE  ALIMENTARY TRACT. — Gastritis.-
   scirrhus at the pyloric orifice of the stomach. — chronic
   Inflammation of the Stomach. — Chronic Army Diarrhcea,
   Chronic Diarrhoea, Sequel of Typhoid Fever. — Acute Dys-
   entery.
   Gentlemen :—This man I have not  seen before, and you
have heard his statement to the  effect that he came to this
country a little more than a year  ago, when he went to work
in the hay and  harvest field, laboring harder than  he was
used to.  He states that during the harvest he drank excess-
ively of milk and  water.   About last  Christmas  he felt a
burning, disagreeable pain in his stomach, and had attacks
of vomiting soon after  eating.  Though he dates this un-
comfortable feeling about Christmas, I presume, if he had
paid particular attention, he would have  noticed it in Sep-
tember.
   In the morning, when his stomach is empty, he  feels very
well, and feels as though he could eat a  good large break-
fast ; but almost as soon as he gets food down, he recognizes
the old pain, and, after  two or three  hours, it is  generally
thrown off.   Now,  mark this  particular symptom : the food
is soon thrown  off, and the pain is of a burning, heating 
DISEASES OF THE ALIMENTARY TRACT.    115
character.  When I asked him  what he vomited, he said if
he vomited soon after his food  was taken into the stomach,
he vomited only his food, which is very sour;  but when it is
retained  for some time, there is much  more thick mucus.
Gentlemen, we could easily diagnose this case as that of in-
digestion ; but this would  not benefit us  much  unless we
know the exac.t state of the stomach which causes the failure
in digestion.
   The simple  failure of the stomach  to  digest the  food,
may arise from  either deficient secretion  of gastric juice,
some grade of inflammation affecting the mucous membrane,
or from cancerous disease.
   The first class of cases  consists of a want of the peris-
taltic motion, and insufficient secretion of the gastric juice.
   Now, if this were the case with this patient, after taking
food, he would feel a heavy weight in his stomach, with fre-
quent belching of wind or gases.
   Patients of this class seldom have vomiting; the bowels
remaining torpid, the food lies like a load for  two  or three
hours, undergoing more or  less  fermentation, when it is
worked off, and  the patient again  feels quite comfortable.
This is the most frequent class you will  be likely  to meet
with.   A history of this man  shows you that it does not be-
long to this category, as there is a soreness, on pressure,
over the stomach, and a burning pain, with vomiting.
   In the second class, where there is an inflammation of
the follicles, there  is a sense of uneasiness felt before  the
meal is fairly finished, frequently obliging the patient to get
up from the table and go  out  to vomit.
   When the  inflammation affects the mucous membrane,
generally in a low, chronic form, it does not allow the gastric
juice to be secreted, but it causes the formation of an excess
of mucus, generally of an extremely acid character ; conse-
quently, food not only produces immediate distress, which 
n6   DISEASES  OF THE ALIMENTARY TRACT.
grows  worse and worse, until vomiting is induced, but the
matters vomited are sour, and often acrid.
   There is one class belonging to this category which will
give you  a different train of symptoms, and that is when the
follicles are exclusively involved.   In such cases, the patient
is apt to  vomit within thirty or forty minutes  after having
taken food; but you  will not find an atom of food in the
matters vomited, that which is thrown  up being, in some
cases, a thin, watery mucus, and, in others, as much as a tea-
cupful of thick,  ropy mucus.   Now, in such  cases,  both
mucus and gastric juice are secreted in such large quantities
that it hurries the solution and  discharge of the food  from
the stomach  into the  intestines.   In these cases the patient
does not feel much uneasiness until time enough has elapsed
for the food taken to  have become dissolved and passed out
of the stomach; but  the gastric  secretions, continuing  their
accumulation, soon  occasion sufficient  distress to induce
vomiting, when these  secretions alone are ejected, sometimes
sharply acid, at others, tasteless.
   Some of this class  of patients vomit a quantity of the
gastric secretion every morning before taking food.   Such
cases  are often called pyrosis, or water-brash.   The distress
accompanying such  cases  is more a gnawing, or craving,
than pain.
   From these general remarks, you will recognize the case
before you as that of  a diffusive inflammation, affecting both
the follicles and mucous membrane of the stomach.
   Before we decide positively,  however, on the diagnosis
of this case, we should allude briefly to the diagnostic symp-
toms of cancer of the stomach.  The fact is, cancerous dis-
ease rarely causes such smarting and burning pain as chronic
inflammation.  The favorite seat of cancer is at the pyloric
orifice of the stomach; and the food is retained for an hour
or more,  before the most severe pain is experienced. There 
DISEASES OF THE ALIMENTARY TRACT.   117
 is another difference :  the cancerous patient  seldom vomits
 more than a small portion of his food, it being usually di-
 gested and absorbed in part, leaving but little to be ejected
 with the ropy mucus that is generally vomited in from one to
 two hours after taking food.   When cancerous disease  of
 the stomach has existed for  several months, the patient will
 often go from six days to two weeks without a passage from
 the bowels, and still the abdomen will be lank and empty.
    Now,  gentlemen, when  you find a patient past middle
 life, free from fever, vomiting mostly mucus, an hour or more
 after eating ;  bowels never moving  except by medicine, yet
 the  abdomen lank and empty; with gradual emaciation;
 you  may be quite sure  you have cancer of the pylorus.
   In chronic inflammation the bowels are generally dis-
 tended  with  gases.  There is also another item which will
 help you out in your diagnosis.   In  cancer, the  disease
 comes on slower, and the patient cannot tell you positively
 when he first  began to feel unwell;  whereas, in chronic in-
 flammation, the patient will  tell you pretty promptly when
 his gastric troubles commenced.
   If it  be true  that  the patient  before  you has  a low
 grade of chronic inflammation of the  mucous membrane
 of the  stomach, the  longer  he continues to dose him-
 self  with active  physic, under the popular notion that
 he is bilious, the worse he will get.   The principle  of
 treatment should  be  to give   only the most bland and
 simple  articles  of nourishment,  and such medicines  as
 are calculated to allay  the morbid sensitiveness of the in-
 flamed surface.   One of the best items of nourishment is a
 mixture of three parts of sweet milk and one of lime-water.
 At first it should be given in doses of one or two tablespoon-
fuls, and repeated every hour.   The lime-water neutralizes
the excess of acid in the secretions of the stomach, and aids
in preventing  the coagulation of the casein of the milk until 
n8   DISEASES  OF THE ALIMENTARY TRACT.
it is absorbed.  Once  or  twice a day a  small  quantity of
thin porridge, made of milk and wheat-flour, may be given
in addition to the other.   Also, occasionally, a tablespoonful
of animal broth may be allowed.   For medicine we will give
him, for the first  three or four days, the following prescrip-
tion :
        R.—Bismuthi sub-nit........-------.....-grs. xl.
           Pulv. ipecacuanha;___________________grs. iv.
           Hydrarg. chlor.  mit_____________.....grs. iv.
           Pul. Doveri____________ ._____......grs. xx.
    M.  Fiant pulveres viii.  Take one before each meal-time and at bed-
time.

    After three or four days the powder may be superseded
by a pill containing  one  grain of extract of  hyoscyamus,
and one-third of a grain of  nitrate of silver.  In some cases,
a pill composed of one grain each of extract of hyoscyamus
and sulphate of iron, taken just before each meal, produces
a very  beneficial  effect.  But no kind of medication will
succeed in these  cases, without the most  rigid  care in rela-
tion to  the food and drinks.
   We  have here, in  this  adjoining bed, a case which pre-
sents, in a marked degree, the assemblage of symptoms just
described as belonging to scirrhus  of the pyloric orifice of
the stomach.
   The patient has been  troubled with indigestion  for sev-
eral years, and within the last month has commenced to be
annoyed with vomiting whenever food  accumulates in the
stomach.  The food  is then  ejected with a little bile' and
thick, ropy mucus.   If she  abstains  from  food and drink,
vomiting will not occur.  The same result might be obtained
by limiting the diet to sweet milk and lime-water, in equal
parts, taken every half or three-quarters of an  hour.  This
amount would  probably be absorbed without  creating dis-
tress,  but  if a large quantity  is  taken it will  produce in- 
DISEASES OF THE ALIMENTARY TRACT.    119
 creased muscular action in the walls of the  stomach.   The
 ingesta brought  in contact with the pyloric orifice excites
 reflex action, and the food is expelled.
   On examination, we find a tumor of a hard,  unyielding
 feel,  the most prominent point of which is at the umbilicus,
 and extending some distance above and below.
   There is complete  development of the cancerous cach-
 exia ; great emaciation; sallow hue of the  skin ; and some
 degree of oedema in the lower extremities, the result of an
 impoverishment of the blood.
   The most effectual method for securing  relief in these
 cases, is the restriction of the patient to a diet composed of
 bland, simple substances, capable of being absorbed by the
 coats of the  stomach; and these should be given in small
 quantities, so that what is taken at one time may be absorbed
 without leaving any accumulation to be carried through the
 pylorus.
   In cases as far advanced as  this, when the pyloric orifice
 has become sufficiently narrowed to embarrass the passage
 of food, the patients will frequently importune for something
 to move the bowels; but physic will  only increase  the  dis-
 tress.   The bowels do not move, simply because  there is
 nothing  in them  to excite peristaltic action; and  the  less
 they are interfered with the better.
   When we find a case of this kind, at any stage, there is
 no reason, in the  experience of the past, to suppose that the
 case will yield to  treatment.
   Iodine, carbolic acid, etc.,  have  all been used without
 marked success, in any  instance.
   The principal thing to be done is  to regulate the diet, as
before indicated, and put them upon such treatment as will
soothe the pain, and assist nutrition.
   I have found more  amelioration  from the use of a solu-
tion of carbolic acid,  rendered  anodyne by camph. tinct. 
120    DISEASES OF THE ALIMENTARY TRACT.
opii, than from any other combination.  The formulas directed
in this case were as follows:

       R.—Acidi carbolici cryst......----........grs. vi.
           Glycerina;_______________________■----3 ss-
           Tinct. opii et camph------------------§jss.
           Aqua;_____________..............— §ij-
    M.  One teaspoonful every three or four hours.

    This, associated with  the  use  of lime-water,  and  thin
porridge, occasionally, in small quantities.
    This patient is a young German, whose business has been
bar-keeping.  He has not drank what  is called  to excess,
but daily taking more or  less alcoholic drink.
    The combined influence of this habitual use of liquor,
and too much  confinement,  has engendered well-marked .
gastric irritation, probably genuine follicular inflammation,
but of a very low grade,  just sufficient to  give rise to an in-
creased secretion of gastric fluid, and vomiting, or what is
called pyrosis, every morning before breakfast.
    In addition,  there is  more or less distress after taking
food, which produces a heavy  sensation  in the stomach, and
is sometimes rejected.
    Besides these symptoms, there  is a difficulty in swallow-
ing, so that extra effort is required ; and it hurts, as if there
was a sore place in the oesophagus.  There is a  degree  of
actual inflammation, of a chronic  character,  in  the lining
membrane of the pharynx and oesophagus, similar to that
existing in the follicles of the  stomach.
    I have noticed, occasionally,  from the  commencement, a
peculiar noise in his breathing;  a coarse,  rough sound; and
he complains of not getting breath good'; of  a want of air.
Three-fourths of the respirations seem natural in sound; but
if he takes a quick  breath, it  will  bring a vibration in the
vocal apparatus, giving a peculiar sound with the ingress of 
DISEASES OF THE ALIMENTARY TRACT.    121
 air, and this may sometimes be detected almost to the bot-
 tom of the chest.   This led me to examine more closely, to
 see if there was any  evidence of a tumor, or enlargement
 of the aorta,  which would exert mechanical  pressure upon
 the trachge; but I was unable  to  discover  anything of the
 kind.   The chest expands easily.
    I think there is a degree of direct nervous irritation that
 is reflected to the larynx, causing tension of the vocal appa-
 ratus, and a sense of constriction that extends more or less to
 the tubes below.
    The tongue  is red  along  the edges and at the tip; the
 papillae a little prominent, but  not much coated; lips red;
 face flushed, and covered with an eruption resembling psori-
 asis, a form of tetter,  consisting in slight tumefaction of  the
 skin, with desquamation of the cuticle ; this appeared within
 the last few days.
   The membrane covering the tonsils, and lining the pha-
 rynx, is a  little reddened, and  the  parts  are  swollen and
 tumefied.
   When  admitted,  complaining of these  symptoms, and
 learning his previous history, I  directed a powder of
       R.—Bismuthi  sub-nit.......______________grs. vj.
          Lupulina;__________________....._____grs. ij.
      To be taken three times a day, before meals.

 And to hasten the disappearance of the inflammation in  the
 stomach, I prescribed, in addition, the following solution :
      R.—Acidi carbolici cryst__________________grs. vj.
          Aquae----.....----------------------§ ij.
           Tinct. opii et camph.....-------------§ iss.
          Glycerina;___________________________§ ss.
   M. One teaspoonful to be given after each meal.

   The patient improved to a certain extent, vomiting less
frequently ; but the difficulty of swallowing ; difficult brcath-
      11 
122   DISEASES OF THE ALIMENTARY  TRACT.
ing, etc., remained.  Treatment, so far, had not seemed to
make much impression on that part of the difficulty.
   Two days  ago, when this eruption on the face made its
appearance, and the membrane of the pharynx assumed a
darkish hue, I was led to believe that there might be another
element present, which had operated to produce a degree of
impurity of the blood, of a specific character.
   I accordingly directed, in place of the carbolic acid solu-
tion, the following:
        R.—Sodii iod___________________________3 iij-
           Hydrarg. bichlor_____________________gr. j.
           Ext. conii fl_________________________5j-
           Syr. glycyrrhiz____......------------3 iij.
    M.  One teaspoonful after each meal; the powders of bismuth, etc.,
to be continued as before.

    He has not been  on this long enough to  develop de-
cided effects from it; but if it does not set up  an irritation
of the stomach, it will  not be a week before this eruption,
and much  of the bad feeling in the upper part of the pha-
rynx and oesophagus will disappear.  By that time the pow-
ders should be limited  to twice a day ;  at breakfast and din-
ner,  giving the liquid mixture as before; meanwhile, the
diet should be carefully guarded.
    This patient, gentlemen, was in the army, in  active ser-
vice, and endured great hardships.  In 1863 he contracted
a chronic  diarrhcea, which  has- persisted, in spite of every
method of treatment which has been tried, up to the present
time.   He  is now much emaciated; skin- dry and harsh;
circulation languid and feeble ; tongue pale, but clean and
moist;  breathing slow and regular.  On his admission to the
hospital the passages from the bowels were copious, but thin,
white, and frothy, like  soap-suds;  occurring without pain,
and containing no mucus.  The urine was abundant, clear,
and natural. 
DISEASES OF THE ALIMENTARY TRACT.    123
    While he was living  upon an  ordinary mixed  diet the
 bowels would move five or six times a day, at certain inter-
 vals, followed by periods of quiet.
    The pathology of these cases is involved in some degree
 of obscurity.  The  cases, as they have come under my ob-
 servation, are capable of arrangement into two classes. One,
 in which the discharges are reddish-brown, with some mucus
 intermixed ; some tenderness of abdomen; quick pulse ; and
 dryness and redness of tongue, with feverishness,  especially
 in the  afternoon. The post mortem  examination in these
 generally shows hypertrophy and ulceration of  the glandular
 structures in the small intestines and colon.  The  second
 class of cases is fairly  represented  by the  case now before
 the class.
   The only alterations detected on post mortem  examina-
 tions have been attenuation and  atrophy of the mucous
 membrane of the intestines, and atrophy of the liver.   This
 condition is probably the result of the morbid  nervous sen-
 sibility, which  causes a perversion  of  the natural function
 of the mucous membrane of the  intestines, so that instead
 of imbibition, there  is constant exudation.
   The serous fluid which escapes in this way, together with
 undigested portions  of the food, constitute the  discharges.
   As regards treatment, the bowels could be held in check
 for a certain  length of time by astringents, but they would
 produce so much bloating  and discomfort that the patient
 would be clamorous for  physic  in less than  twenty-four
 hours, and at length  there would  be poured out a copious,
 profuse evacuation, equal in amount  to the se-veral discharges
 which would have occurred had astringents not been  given.
 Our object should be: First, to restrict the diet as far as possi-
ble to those articles which can be digested and absorbed by
the stomach and duodenum, without leaving any residue to
pass through  the bowels; secondly,  by the  use.of  proper 
124   DISEASES  OF THE ALIMENTARY  TRACT.
remedies, to overcome, if possible, the morbid and perverted
sensibility of the intestinal mucous  membrane.   For nour-
ishment, this patient has been furnished with milk-porridge,
in moderate  quantity, often enough to afford good support
to the  system, the quantity being increased as fast as he is
able to appropriate it.   At present he  is taking  about three
pints in the twenty-four hours.
    For medicine, he has been taking an  emulsion  of ol.
terebinth, and tinct.  opii, and the following prescription:
       R.—Bromini............___......_______gtts. xv.
           Potass, brom......__________________3 iii.
           Aqua; dist..-..........______________%iv.
    M.   Teaspoonful doses, four times a day.
    The bromine will, usually, in the course of  three or four
days, change the color of the passages to a bright yellow.
    It is useless to attempt to stimulate the liver.   There is a
suspension  of secretion, from atrophy, and alteratives ad-
ministered for the purpose of acting upon this organ would
only add to the prostration.
    We have here a patient who was admitted  into the hos-
pital six or seven weeks since, in the third week of a severe
enteric typhoid  fever.   He then presented all the phenomena
of the  gravest form  of typhoid fever  in its advanced stage,
with more than  the  usual abdominal  tympanites and intes-
tinal looseness.   The  discharges from the  bowels were not
only very frequent and thin, but were stained with  blood,
and contained some mucus.   He was sustained by regular
use of  wheat-flour and milk-porridge  for nourishment, and
the emulsion of oil of turpentine and  tincture  of opium,
every four  hours, alternated with small doses  of strychnia
and nitric  acid.  In about one week after admission the
symptoms  of general fever disappeared, and  the patient,
though   extremely   weak, appeared  convalescent  in all 
DISEASES OF THE ALIMENTARY  TRACT.    125
respects, except the continuance of diarrhcea.  His passages
numbered from six to twelve per day, and continued  thin,
reddish-brown, and offensive.   Regarding  this diarrhoea as
dependent on the ulceration of the  patches of aggregated
glands, his diet  was carefully  regulated,  and a variety of
remedies, such as sub-nitrate of bismuth, carbolic acid, ace-
tate of lead, and the mineral acids, each combined more or
less with opiates, were given, but with no other effect than tem-
porary diminution of the number of intestinal discharges.  In
the meantime, two weeks had passed since his convalescence
from the general fever, and his condition was very unprom-
ising.  There was much  emaciation ;  haggard expression;
quick, weak pulse;  much abdominal tympanites and disten-
tion ; and still from  eight to twelve intestinal evacuations
of thin, reddish-brown stools, often  distinctly mixed with
blood.  He was then put on the use of a mixture of syrup
of ipecac and  tincture of opium,  equal parts, half a  fluid
drachm every two hours.  The dose was  subsequently in-
creased to nearly a drachm.   During the  first four or five
days, this produced a decidedly favorable influence, lessen-
ing the number of discharges, and improving their quality.
After  that time it began to lose  its  beneficial effect, and
was continued at  intervals of every  four hours;  and  a
pill of nitrate of silver, one-third of a grain, with pulverized
opium, two grains, was given  between—making them two
hours  apart.  From that  time he  began very gradually to
improve,  and after about two weeks  his  discharges  were
reduced   to  one  in  the  twenty-four  hours,  but  it was
still thin.   The  interval between the  doses of  medicine
was lengthened to  six hours, at  which rate he  has  con-
tinued to the  present time.    He is now able to sit  up
a part of  the  day; is  gaining.in flesh; appetite good; but
feet become oedematous when dependent.  Though steadily
improving, the patient cannot be left, safely, without further 
126   DISEASES OF  THE ALIMENTARY TRACT.
treatment.   The ulcerated patches in the mucous membrane
are not entirely cicatrized, and if treatment is discontinued
too soon, the diarrhcea will increase again.   We shall direct
him to adhere to a bland, nutritious diet; take  one of the
pills of opium and nitrate of silver before breakfast, dinner,
and supper, and two-thirds of a teaspoonful of the mixture
of syrup of ipecac and tincture of opium at bed-time.*
    This  patient came  into  the hospital last Friday;  was
taken with acute dysentery the previous Wednesday.  The
attack commenced with slight chills and some general pains,
more especially in the abdomen, where they were griping,
sharp and severe,  with frequent desire to evacuate the bow-
els, and tenesmus.  Passages slimy and mixed with blood.
    There was moderate fever, coated  tongue, pulse slightly
accelerated, and the temperature of the skin a little elevated.
There are many remedies which have been used to arrest
acute dysentery.  Some  physicians are in the habit of put-
ting a patient in the first stage upon laxative salines till they
obtain a free fcecal evacuation, and continue them for several
days after.
    I  have  never  succeeded with the evacuant  treatment;
and, so far  as my observation goes, in most of the cases
where it has appeared  to be successful, it  has" been where
enough  of  the salines had been  given  to  evacuate the
bowels, and then combined with opium, without which they
would not have succeeded.
    Another method is by the use of ipecac in large doses,
given at  once, and the earlier the better; twenty grains, for
instance, at  intervals of four to six hours; and this is claimed
to be  infallible.   If the  first dose  vomits, the  second will
generally be tolerated, it  is said, and two to four doses are

   * One month later the patient was apparently well; bowels regular and passages
natural ; suffering only from general debility.  He had taken no medicine for a week
previous. 
DISEASES OF THE ALIMENTARY  TRACT.   127
 claimed to be sufficient to subdue the disease.   I have faith-
 fully and thoroughly tried it in but few instances.   In about
 half of the  cases it  vomited  uniformly,  no  matter how
 many  times I gave it.  In  some it produced the happiest
 effects; in others, where it could  not be retained in the
 stomach, I have  administered it successfully per  enema of
 starch associated with laudanum.
    This patient, before I saw him, had taken one dose  of
 opium.  Since then has been taking the following emulsion,
 viz. :
        R.—01. terebinth....................___3 iij.
           Tinct. opii.........._____........___3 iij.
           Acacia;   )                       , ...
           Sacch.alb. faa-----........---------3llJ'
           Aquae mentha;.....__________________§ iij.
    M.  One teaspoonful every four hours.

    And a solution of carbolic acid,  as follows :
       R.—Acid carbolici cryst___________________grs. vi.
           Tinct. opii et camph_________......... ^ jss.
           Glycerinae____..................____§ss.
           Aqua;...........................---?ij-
    M.   One teaspoonful every four hours, alternately with emulsion.
    Improvement has been steady, and  he is now almost en-
 tirely cured;  has but one passage in twenty-four hours,
 and this nearly natural.
    The method of treatment which I have  usually followed
 during the first stage, is to give, if  the  patient has not
 had free evacuations at the beginning of the attack, four or
 five grains  of  calomel, either with or without two or three
 grains of ipecac, followed in five or six hours by  a laxative
 of castor oil, sulphate of magnesia, or  Rochelle salts,  as
it is safe to assume in  such  cases that  there is more or less
foecal matter retained in the alimentary canal; then putting
them upon some combination that is sufficiently anodyne to 
128   DISEASES OF THE ALIMENTARY TRACT.
overcome the pain, and  to  reduce the  frequency of the
discharges.  Turpentine has some property that diminishes
inflammatory action of the mucous membrane, especially
after the first stage.   It is  not merely astringent or tonic, but
it possesses an alterative  influence that is valuable in the
peculiar condition of the vessels that belongs to these cases
after the acute stage.
   This patient needs  no additional  treatment, except to
lessen the amount of medicine;  and as the emulsion begins
to nauseate, and the passages occur but once in twenty-four
hours, we may safely and profitably omit it. 
LECTURE  IX.
INTESTINAL AND UTERINE IRRITATION—Bilious Colic,
  • —Tobacco Enemas. — Hydrate of Chloral and Belladonna
   Enemas. — Inflammation, and its Treatment.
   Gentlemen: — Every physician in active practice meets,
now  and then, cases of a unique character, requiring for
successful treatment either unusual remedies or new modes
of using ordinary ones.   The  special peculiarity  of  such
cases may depend on some permanent idiosyncrasy of the
patient,  or the interposition of some temporary mental or
physical condition that  modifies, for the  time  being, the
susceptibilities of the patient.   They  are  pre-eminently the
cases  that baffle  and annoy  the inexperienced and  the
routine practitioner.
   It is to a  case of this kind  that we would now call your
attention.  The patient, a middle-aged woman, and mother
of a family, was attacked severely with what is usually styled
"bilious colic."   She sent immediately for Dr.  L., who
during three  or four days exhausted his skill in vain for her
relief.  He  tried  successively  anodynes, fomentations, ca-
thartics,  enemas, etc.; but the  stomach of the patient soon
became irritable, and everything taken was  speedily reject- 
13°   INTESTINAL AND UTERINE IRRITATION.  v
ed by vomiting, while enemas returned without  any foecal
discharge.  In the meantime the abdomen had become very
largely distended and tympanitic ;  tender to the touch; the
extremities cool; pulse small,  quick, and weak ;  respiration
irregular,  and occasional sighing; frequent  retching and
vomiting; with great restlessness and prostration.  At this
stage in the progress' of the case the  patient was removed
to the hospital, and came under my charge.   It was evident
that the case had arrived at a critical stage, and must be
relieved soon, or the patient would be  lost.
    As most  of the ordinary remedies had  already been
tried without avail, we  ordered at once a drachm of chew-
ing tobacco to  be put  into one pint  of boiling water, and
when cool enough about one-half the quantity was injected
into the rectum, as an enema.  Within twenty minutes the
patient became free from all pain.  The countenance turned
pale, accompanied by a sense of faintness; and there speed-
ily followed a very copious evacuation of the bowels.  The
evacuation did not cease until the intestines were thoroughly
emptied.   She soon  rallied from  the sense of exhaustion,
and improved rapidly  for  three  or  four  days,  when  the
intestinal  obstruction again  returned, with  a  renewal  of
pain, abdominal distension, quickness.of pulse, and vom-
iting.
    The infusion of tobacco was again administered as  an
enema, which speedily induced very large fcecal evacuations,
and entire relief to  all  the bad symptoms.   This time the
relief has been  permanent, and the  patient is  now nearly
recovered.
    It is more than thirty years since we gave the infusion of
tobacco, the first time, for relieving dangerous  obstruction
of the  bowels;  produced by irregular contraction  of the
muscular  coat of the intestines.
    The disease had  been induced, apparently, by eating a 
INTESTINAL AND UTERINE IRRITATION.   131
,/arge quantity of popped corn, and walking about three
miles, carrying a baby only two weeks old.
   On the same night, after the long walk, she was attacked
with severe pain in the abdomen, which was followed by all
the symptoms attributed to "bilious colic."   A very intelli-
gent physician in the neighborhood was called and attended
the case  faithfully for  six  days, but  failed  to afford  the
patient any relief.   Being on  a visit to  my brother, who
resided in the same neighborhood, we  passed the house of
the sick woman together on our way to  the  adjoining town.
Being recognized  by a  member of the family,  we were
stopped and requested to see the patient.  We learned that
the attending physician had been in a short  time  previous,
had informed the family that further treatment was useless,
and  had  left to  visit other  patients several miles distant.
We found the  patient presenting a haggard expression  of
countenance; cool  extremities; a small, quick and weak-
pulse ; the abdomen more distended than before  her con-
finement,  very tympanitic, and tender to pressure ; prompt
rejection  of everything she took, with frequent retching;
and mind wandering.  The condition seemed fully to justify
the unfavorable prognosis which had  been  given by  her
physician.  Although far from  my own home, and without
any medicine, it occurred to me that there was still a proba-
bility that, the powerful  relaxing effect of  tobacco  might
relieve the intestinal contractions and  procure evacuations
in time  to save the life of  the patient.   Finding some chew-
ing tobacco in the house, what was  thought to be about  one
drachm was put  into a pint  of water, boiling hot.  It  was
stirred up frequently until it was no  more than milk-warm;
then one-half of the infusion was injected into the rectum
as an enema.  We stepped out to look about the farm a little
and to while away the time until the result was obtained.
In twenty or thirty minutes a messenger came running after 
132  INTESTINAL AND  UTERINE IRRITATION.
us, saying the patient was dying.  We hastened  in, when
we found the family gathered around  the  bed, the patient
as pale as a corpse, breathing slow and still; pulse a mere
thread, but slower, and the mind like one in a trance.  The
condition of the breathing soon satisfied us that she was
not dying ; and in ten minutes more an active rumbling was
heard in the abdomen, quickly followed by a copious evacu-
ation from the bowels.  Several evacuations occurred in the
next few hours,  and in the  foeces was easily recognized a
quantity of the popped corn, wholly  undigested, that she
.had eaten the week previous.   Soon after the evacuation of
the  bowels,  she rallied from  the sedative  effects of the
tobacco, her stomach ceased to be irritable, and she retained
bland nourishment.   During the next twenty-four hours the
bowels  moved so frequently as  to require small doses of
morphia to allay the  irritability of the mucous membrane,
but  she subsequently progressed steadily to complete re-
covery.  From that time to the present we have occasionally
resorted to tobacco enemas for the removal of obstinate in-
testinal obstruction,  not dependent on  invagination, and
generally with success.   It is, however, a remedy of extreme
power, and should be used with corresponding caution.
    This next  patient,  a  female, aged  about  thirty-five,
living  in the southern  part of the  city, after exercising
more than usual  for two or three days, was attacked during
the night with  severe pain in the left iliac and  hypogastric
regions, accompanied by constipation.   She had also had a
miscarriage not more than three  weeks previous.  The pain
was exacerbating and very severe; extremities cool, and pulse
small and quick, but  neither much tenderness nor distention
of the abdomen.  A  physician was called  during the night,
who endeavored to  allay the severe paroxysms of pain by
suitable doses of morphia.   This afforded partial relief for
a few  hours, but was soon followed by secondary nausea, 
INTESTINAL AND  UTERINE IRRITATION.   133
and  the  prompt  rejection of everything taken  into  the
stomach.
   In the meantime the pain in the lower part of the abdo-
men  and  back remained unabated.   Most of the succeeding
day was spent in efforts to allay the  pain  by anodynes, and
enemas were given for procuring evacuations of the bowels,
but with no relief to the patient.  I found her  here at even-
ing,  about twenty  hours  after the commencement  of  the
attack.  Her countenance was dejected; skin cool; pulse
small and quick; lower part of the abdomen rather full and
tender to  the touch ■ urine scanty, and its passage painful; no
movement of the bowels ;  and constant nausea, with rest-
lessness.   Being  satisfied that the pain was dependent
mostly on uterine  irritation,  and that no  preparation  of
opium would be tolerated, even by sub-cutaneous injection,
without perpetuating the  nausea and vomiting, she was ad-
vised to desist from all remedies by the mouth, and to have
an enema of hydrate of chloral, twenty grains, tincture of
belladonna, twenty drops,  in half  a teacupful of water,
slightly warm, and to repeat the same in one, two or three
hours, as  the pain might indicate.
   Fomentations had already  been applied over the abdo-
men, and  they were continued.  On  visiting the patient the
following  morning, we learned that the first enema of chloral
and belladonna  was retained, and in half an hour the patient
was so far relieved that she slept quietly, and continued to do
so for two  hours or more. In about three hours she had a slight
passage from the bowels, made up in part of the enema, and
some pain following it.  Another enema of the same mate-
rials was given.   This again quieted her so far as to procure
rest for the  remainder of the night.   In the  morning we
found her pupils moderately dilated;  mouth  dry, and face
suffused with redness, evidently from the effects of the bella-
donna in  the  enemas.   In all other respects she was much
       12 
134   INTESTINAL AND UTERINE IRRITATION.
better.  She was advised to rest quiet, take a teaspoonful of
nitrous ether in a little water, every three hours, to increase
the action of the kidneys;  and if the abdominal pains return-
ed, to use an enema containing  only half the  quantity of
chloral and belladonna that was used before.   She had felt
no nausea since the first enema.
    During the last twenty-four hours, she has  had three ad-
ditional enemas of  the smaller quantity; the effect of the
belladonna on the pupils and throat has gradually disappear-
ed, and the patient  seems in a fair way to recovery.
  Another Case, in which a similar course of treatment proved
successful, was that  of a young man, who was just recovering
from  a severe attack of inflammation in the right iliac region,
resulting in the formation of a large internal abscess, but
which had been entirely  healed  for ten  days.   He was at-,
tacked suddenly and severely with pain in the region of the
sigmoid flexure of the colon;  had rode out during the day,
and exercised  more than at  any time  previous since the
beginning of his  sickness.  In the middle of the night  he
began to have disturbance of  the bowels, three evacuations
occurring in quick succession, and leaving him with intense
pain in the left iliac region.  No  further  evacuations occur-
red, and though warm  fomentations were applied externally
and an anodyne taken internally, the pain continued without
abatement, and I was called early in the morning.  Knowing
from  previous trials that  any  of the preparations of opium
would be followed by secondary nausea and persistent vomit-
ing, it was very  desirable  to  avoid  their use ;  and yet the
severity  of the pain, without fever,  rendered an efficient
anodyne influence  highly important.  He was  directed to
have  an enema of slightly warm water, half a teacupful, con-
taining  twenty grains  of hydrate of chloral,  and twenty
drops of tincture of belladonna ;  and if  not relieved in one
hour, to repeat the  same with  the addition of twenty drops 
INTESTINAL AND  UTERINE IRRITATION.   135
 of the tincture  of opium.  The first enema not affording
 much immediate relief, he took the second as directed, which
 relieved the pain so fully that he slept some and rested well
 for twenty-four hours.   Fearing that the attack  might result
 in inflammation and suppuration, similar to what had occur-
 red in the opposite side of the abdomen, he was kept at rest
 for several days.   No bad symptoms followed, however, and
 he needed but little further treatment.
   We have here,  gentlemen, a  patient .who has  been admit-
 ted to the hospital since our visit yesterday.  He is a native
 of Ireland ; aged about forty years;  a laborer.   You see his
 countenance  is expressive of anxiety and severe suffering;
 and he tells us that, about three days since, he was attacked
 with severe pain in the abdomen, which still continues, and
 is coupled with extreme tenderness over the whole epigas-
 tric and umbilical regions.  His urine is scanty  ; his bowels
 quiet; considerable thirst, with  a disposition to reject drinks
 by vomiting;  pulse soft, and  not more than 90 per minute.
 All the symptoms in this case point  to the abdomen as con-
 taining the seat of disease; while the acute  pain and tender-
 ness would equally indicate its inflammatory nature.  We
 may find  severe pain in the abdomen, from colic; but this,
 instead of being accompanied by acute tenderness, is relieved
 by pressure.   We may also find  severe pain in the abdomen,
 from strangulated  hernia, either concealed or  manifest, or
 from intussusception.    But in  either  of these conditions
 the pain would be more circumscribed—that is, referred to
 some particular part of the abdomen—and be accompanied
 by complete obstruction of the bowels.   Again,  in either of
 the last conditions named, before three  days had elapsed, as
 in this case, the  vomiting would be frequent, and perhaps
 stercoraceous, with great general prostration.  In the patient
before us, however, the  pain  and tenderness are both dif-
fused ; the vomiting is not persistent; and free fcecal evacu- 
136  INTESTINAL AND  UTERINE IRRITATION.
ations have occurred since the attack commenced.   Hence,
we  regard it as hardly possible that  the present case is one
of intestinal obstruction or strangulation.  The symptoms
would  seem rather to arise from a  sub-acute inflammation
of the  peritoneal covering of the intestines.   If it involved
that part  of the peritoneum lining the abdominal parieties
there would be a much  greater degree of tenderness and
fullness of the abdomen;  and  if it extended to the mucous
membrane, there would be diarrhcea.   The  consequences
of peritoneal inflammation, when uncontrolled, are, thicken-
ing of  the membrane, plastic exudations, and serous effusion.
The second often  leads to adhesions, and  the  third to as-
cites, or abdominal dropsy.   Most  pathologists, in treating
of the  nature of inflammation, have restricted their attention
too exclusively to the condition and movements of the blood,
or fluids in the part affected.  Thus, Dr. Williams makes in-
flammation consist, essentially, of a determination of blood
to the  structure involved,  with  the circulation through it
partly  increased  and partly diminished.   We regard every
inflammation as involving three primary elements, or morbid
conditions, namely:  an accumulation of  blood in the part;
an exaltation of the elementary property of the tissue, which
we call susceptibility; and an alteration of the vital  affinity.
    If  the accumulation of blood in  the part is accompanied
by an  active determination to it, with increase of both the
susceptibility  and affinity, it  constitutes what  is  familiarly
known as active, sthenic, or phlegmonous inflammation.  If,
on  the other hand, the accumulation of blood in  the part
results not from increased  determination, but from an im-
paired action of the capillaries themselves, with diminution
of vital affinity, while  susceptibility alone is increased, it
constitutes asthenic or aplastic inflammation.
    We thus claim that the movements of the fluids, and the
properties of  the solids, are both  necessarily involved  in 
INTESTINAL AND UTERINE IRRITATION:   137
 every true inflammatory process.   Hence, we have two uni-
 form  and rational  indications for treatment,  namely:  to
 allay the morbid susceptibility, and to diminish the fullness
 of blood in the part.   Anodynes, and the local application
 of cold, constitute the principal means for accomplishing the
 first;  while the means of accomplishing the second will de-
 pend  upon the immediate cause of  accumulation.   Thus,
 where  active  determination of blood to the part inflamed
 exists, depletion  and  arterial  sedatives will be required;
 but, if the  cause  of the.accumulation is an impaired con-
 dition  of the capillaries  of the part,  then, instead of  seda-
 tives,  such  stimulants or excitants as are capable of giving
 increased tone and contractility to the capillary system, will
 be most  promptly efficient.  These observations relate  to
 inflammation in its first, or  elementary stage.    If it has ex-
 isted long enough to produce secondary effects—such as in-
 filtration of texture;  effusions, either serous or sanguine;
 softening, suppuration, etc.—these will afford other indica-
 tions for remedial agencies.  In the case before us, there is
 not that fullness of pulse, or force in the action  of the heart,
 which would call for either depletion  or sedatives;  neither
 are. there any signs of effusion.  Hence, the only  clear indi-
 cations  are, to  subdue the extreme  morbid susceptibility
 of the inflamed membrane,  and overcome the irritability of
 the stomach.
   The  most  efficient  means that we possess for this pur-
 pose are narcotic fomentations, and full doses of opium, with
 alterative doses of calomel.  To be effectual, in such cases,
 the opium must be given in doses sufficient not  only to allay
 pain, but  to induce more or less  sleep.  In inflammations
 of the serous membranes, this can be done with impunity.
 But when the respiratory organs are involved, causing in-
creased secretion into  the  air-passages, narcotism, by sus-
pending  cough, and  efforts  to  clear away the  excessive 
138   INTESTINAL AND UTERINE IRRITATION.
secretion, greatly increases the danger of suffocation.  It is
necessary to remember  this, especially  when prescribing
for children.
   For the patient now before  us we will  direct fomenta-
tions of hops, or aconite leaves, over the abdomen, and give
a powder, composed of pulv. opii, two grains, and hydrarg,
chlor. mite., two grains, every two hours, until  six doses are
taken, unless the patient sooner becomes easy, and exhibits a
disposition to sleep.   If this should occur, the interval be-
tween the doses will be lengthened to four hours.  We add
the calomel to the opium, in such cases, partly to lessen the
gastric  irritability,  and partly to  keep  up those important
secretory actions which the opium alone would retard, or en-
tirely suspend.  If we can succeed in bringing the  patient
readily under the influence of these remedies, the inflamma-
tory process will rapidly abate, and at the end of thirty-six
hours we may suspend their use, and cause a mild but effi-
cient movement of the bowels.
   But,  as the  clinic-hour has  already  expired, we must
omit further remarks until we visit the wards again. 
LECTURE  X.
SUMMER  COMPLAINTS  OF  CHILDREN. — Diarrhcea. —
   Cholera-Infantum, etc
   Gentlemen:—We bring before you to-day several little
children suffering from the different forms of summer com-
plaint, and would ask your careful attention to the general
appearance and symptoms presented  by them.
   You see, in all of them, a striking similarity of physiog-
nomy, or external  appearance of disease.   There  is the
same sober, melancholy expression  of  countenance; the
same pale, thin lips, sunken eyes, and  blanched skin; the
same small,  weak pulse,  and general emaciation in each.
You see their limbs attenuated, the muscles soft and  flabby,
and the skin hanging in dusky wrinkles  on the neck.  I am
informed  that  they  have, most of them, had diarrhcea for
from two to three weeks, the discharges being thin, like
green  or  yellowish water, and occurring as often as six or
eight times  in  the  twenty-four hours, with vomiting occa-
sionally after drinking freely.  Their skin over the 'trunk of
the  body, and  especially over the abdomen, is warmer and
dryer than natural, while the extremities are  cool.  A spell
of restlessness, or crying, or moaning, a few minutes  before
a passage from the  bowels, indicates the existence  of abdo- 
140     SUMMER COMPLAINTS OF CHILDREN.
minal pains, or gripings, though in many cases these are aU
most  entirely absent.   They have little  or no appetite for
anything but water, although the thirst is, in  some cases, so
great  that they drink almost any bland liquid greedily.
   These cases of irritation of the mucous membrane of
the alimentary canal, or the summer complaints  of children,
as met with in general practice, may be arranged into three
groups.  The first group embraces those cases in which the
patient is suddenly attacked with copious vomiting and purg-
ing of serous fluid, sometimes tinged with bile, and sometimes
hardly staining the napkin.  Under the depleting influence
of  these evacuations, the  countenance  becomes pale  and
contracted,  the eyes sunken, the pulse small and frequent,
the extremities cold and shrunken, the urine scanty  or en-
tirely suppressed, and the mind lethargic, with spells of great
restlessness.  In the more severe attacks these effects follow
so rapidly that collapse and death are reached  in from six
to twenty-four hours.
    In most cases, however, after the first eight or ten hours
the discharges become less frequent and copious, the vomit-
ing occurring only when drink is taken, and the passages
from  the bowels being less, both in quantity and frequency.
Still,  very little nourishment is retained by the stomach, and
the greater  part of that little is hurried through the intes-
tines  without change.  Consequently the little patients con-
tinue rapidly to emaciate, and unless relieved by appropri-
ate treatment, will usually reach  the stage of fatal exhaustion
in from one to three weeks.
    In the advanced stage  of some of these  cases, in addi-
tion  to  all the  ordinary-symptoms of exhaustion,  there
occurs constant vigilance or wakefulness, with rolling of the
head, tossing of the hands, and sometimes moaning.   These
symptoms induce the parents and nurses to think that the
disease has " gone to the head."   And I have known several 
SUMMER COMPLAINTS OF CHILDREN.      141
cases of  this kind  in  which the attending physician had
been applying cold applications to the head, blisters behind
the ears, and, in two cases, even leeches and a calomel purge,
under the impression that the symptoms indicated the super-
vention of inflammatory action in the brain or its membranes.
I need not remind you  that in the cases  alluded to such
opinions  and practice  are entirely erroneous, and that the
symptoms described are the  result,  not of inflammatory
action in  the brain, but of a true anaemic condition of that
organ.  It is well known  that very excessive losses of blood
will often produce the most distressing feelings in the head,
accompanied by morbid vigilance or wakefulness, and some-
times slight delirium.   This anaemic condition of the brain,
whether from haemorrhage or from  exhausting serous dis-
charges, may be distinguished from inflammation and active
congestion by close  attention to the pupil of the eye, the
carotid arteries, and the  anterior fontanelle, if this still re-
mains open.   It  is well known  that cerebral inflammation
produces  contraction of the pupils, fullness  and hardness of
the carotids,  and fullness of the  fontanelle. It is not until
the inflammation has terminated in effusion  sufficient to pro-
duce compression, that the pupils become dilated.  But the
same amount of effusion  that would dilate the  pupils would
produce also stupor or coma, and still greater fullness of the
fontanelle.  Whereas, in  anaemia of the  brain,  the dilated
pupil and  staring expression is accompanied by restless sleep-
lessness instead of coma,  by softness of the  carotids, and by
a sunken or depressed fontanelle.
   Many  of the cases included in what we  have called the
first group, after presenting the active  symptoms of cholera
morbus, for the  first few days,  undergo a different change.
The vomiting ceases, the  discharges  from the bowels remain
frequent,  but become  small  in quantity,  and  composed
chiefly of mucus,  often  streaked  with  blood.    Simul- 
142     SUMMER COMPLAINTS OF CHILDREN.
taneously with this change in the discharges, more or less
febrile reaction  comes on, causing the skin to become dry |
and warm,  especially over the abdomen  and trunk of the
body; the pulse more full and quick; and indications of
more  frequent and severe pains in the abdomen.   In a word,
the symptoms become indicative of ileo-colitis or dysentery.
   The second group of cases embraces all those (and they
constitute a majority of all the bowel affections  of  children'
during  the  hot months of summer) which commence with
simple,  thin, or serous evacuations from the bowels, without
the intermixture  of either blood or mucus, and  without
accompanying fever. The evacuations in the several cases
constituting this group vary much in their color, consistence
and frequency.  In some cases they are, from the beginning,
so thin  and colorless as to  leave no more stain or residue on
the linen  than turbid water, and so large  in quantity as to
prostrate  the patient very  rapidly,  causing  the  skin  to
become blanched  and cool, the eyes sunken, the pulse small
and weak, with  all the  indications of approaching  collapse.
In many instances the discharges of this character, after con-
tinuing long enough to induce a decided  deficiency  in the
watery and  saline constituents of the blood, and considerable
prostration, become smaller in quantity, less frequent, and mix-
ed with a little mucus.  At the same time, a moderate febrile
reaction takes place, causing the child to become more fret-
ful, and the abdomen more hot.  The color of the intestinal
discharges  varies  much,  being sometimes green,  at others
yellow, and  again  white.  They vary much also in consis-
tence and odor, being sometimes thin as water, and almpst
as  odorless, and at others only  semi-fluid, frothy, and ex-
tremely offensive.
    If the fasces are closely examined, they will generally be
found to contain more or  less of the  food or drink taken,
which has passed  through the alimentary canal, with little or 
'SUMMER  COMPLAINTS OF CHILDREN.      143
no change, and also numerous epithelial cells from the sur-
face of the mucous membrane.  The urine is generally scanty
in proportion to the copiousness of the intestinal discharges.
If the progress of  the disease is not arrested by appropriate
treatment, the patient continues steadily to lose flesh and
strength, until the  emaciation is as extreme as  in the  last
stage of pulmonary tuberculosis, and the little sufferer sinks
quietly into the arms of death,  from simple  exhaustion.  In
some cases, however, after the disease  has  continued three
or four weeks, the patients  partially  recover;  that is, the
stomach  and  upper  part  of the alimentary  canal often
recover their functions ; the child takes nourishment well,
retains it, and regains a degree of cheerfulness.  The dis-
charges from the bowels, however, continue more frequent
than natural, varying from two  to  six or eight  times in the
twenty-four hours.   They are usually semi-fluid, of a light
yellow or greyish  color, often frothy, and  always more  or
less offensive.  They often contain curds of milk and other
undigested particles of food.  The urine is generally less in
quantity  than natural, and  contains  such an excess  of
phosphates  and lithates as to give it a whitish or milky ap-
pearance, soon after being voided.   In this state, the patient
usually recovers a  good appetite; often, indeed, a morbid
craving for food;  but  so large a part of what  is taken is
either  hurried  through the bowels, or only partially  assimi-
lated, that the  emaciation continues, and sometimes slowly
increases.  The abdomen becomes gradually  more  tumid,
until after a few months it is greatly distended, presenting a
strong contrast to the emaciated extremities.  The distended
abdomen  is generally tympanitic, indicating a simple accu-
mulation  of gases,  though  sometimes  hard tumors may be
felt through  the walls of the  abdomen, consisting  of en-
larged  mesenteric  glands.  When presenting  this form, it
geneially  takes the name of tabes-mesenterica or marasmus, 
144     SUMMER COMPLAINTS  OF CHILDREN.
and may continue one or two years, before ending in death
or recovery.
    The third class, or  group of cases of bowel  affections,
occurring in young children, during the summer months, are
distinguished from the two preceding classes by the presence
of distinct febrile action at the commencement of the attack.
With the first onset of vomiting, or purging, or both, the
skin is found to be hot and dry; the lips parched; the pulse
more firm  arid frequent; and the patient more  fretful, and
exhibiting more  signs of pain.   If vomiting exists in these
cases, it is generally more a frequent retching, or straining
to vomit, with only a slight discharge of thin  mucus, some-
times colorless, but often tinged yellow or green with bile.
Of course, whatever  food or drink is  taken, is promptly re-
jected.   The intestinal evacuations are generally frequent,
accompanied by signs of pain, and almost always affording
traces of mucus.  "When the disease is limited chiefly to the
ileum and  upper part of the colon, the discharge is mostly a
thin, serous fluid, tinged green or yellow, and presenting
only  traces  of mucus.   When the lower part of the colon
and rectum  are  the  chief seat of disease, the evacuations
are almost  wholly mucus, more or less streaked with blood,
and accompanied by tenesmus  and straining.  Emaciation
progresses  rapidly, and there is more restlessness, accompa-
nied by a fretful, peevish temper, than in the  other class of
cases.
   If you credit  the statements of mothers and nurses, you
will have no difficulty in  determining the efficient cause of
all these intestinal affections of summer.   In nineteen cases
out of twenty, they will tell you, with the utmost confidence,
that it is "the  teeth," meaning  thereby that the growth
of the teeth,  causing them to press on the gums, is the direct
cause of the irritation of the mucous  membrane of the ali-
mentary canal;  and  in the twentieth case,   they  will be 
SUMMER COMPLAINTS OF  CHILDREN.      145
equally confident that worms are the cause of all the mis-
chief.   So confidently and universally are these notions en-
tertained, that hundreds  of mothers, especially among the
poorer classes, wholly neglect to seek medical aid for their
little ones, when attacked with diarrhcea, until it has run on
two, three, or even four weeks, and they are reduced to skel-
etons,  with the skin  hanging in  folds on  their emaciated
limbs and necks,  and they  are in  a  hopeless state of ex-
haustion.
   If you ask the mother why she neglected the child so
long, her ready and  uniform reply  is: " Oh! it was teeth-
ing;"  and she has been looking, everyday, for some one
or more of the teeth to come through the gums, to afford re-
lief; and  by  way of doing something, she has very  likely
given one or more doses  of castor-oil or vermifuge.  This,
however, strictly in accordance with the homoeopathic princi-
ple, similia similibus curantur, is, nevertheless, only calculated
to hurry the patient a little faster toward the grave.   If you
suggest a doubt as to  the  part the teeth play in causing the
disease, you  will be  assured that the gums are "swollen,"
and that the child  is constantly " biting the fingers, or nipple,
or whatever else is put into  its mouth ; " and this, in their
estimation, is  abundant proof that  the teeth cause all the
difficulty.   Now, gentlemen, I call your  attention  particu-
larly to this subject of teething, because  the observation of
many years has satisfied me that  the popular errors in rela-
tion to it cause the needless sacrifice of thousands of infants
annually.
   Not only the mother  and the nurse  make it an excuse
for neglecting to seek judicious medical  advice, in the first,
and most  curable stage of the diseases of infancy, but many
physicians are in the habit of directly encouraging this neg-
lect, by telling those  who bring  their children for  advice,
with the milder forms of diarrhcea,  " that they are teething,
       !3 
146     SUMMER  COMPLAINTS OF CHILDREN.
and it cannot be expected that they will be very well until
that  process is completed."   But is it true that the natural
growth of the teeth, and their exit from the gums, is a cause
of disease ?  I think not.  First, because it is  a strictly
physiological process ;  as much so as the growth of the hair
or nails.  Second, because the gum is  a  structure neither
endowed with a high degree of sensibility, nor supplied with
nerves of extensive  sympathetic  relations.  Third, because
the constant disposition of the child to put everything in its
mouth,  and bite  freely  with  its gums, proves them to  be
neither tender nor sensitive ; and without these, there can be
no irritation.
   That the growth of the teeth  is not the cause of cholera
infantum, and  the diarrhoeas of summer, will be fully evi-
dent to you, from  the following well-established facts :
   The teeth of children are growing at all- seasons of the
year : in January as much as  in July; and hence, whatever
diseases arise therefrom,  would be as liable to occur at one
season as another.  But  the  diseases under consideration
are restricted in their prevalence almost entirely to the hot-
test part of the year.   This, in our latitude, is embraced in the
months of July, August, and  September.  So true is this,
that  the  number of deaths from  this disease alone, gives to
the months named,  an average annual mortality more than
double that of any other months in the year.  And yet, not-
withstanding these  obvious  and universally admitted facts,
we daily hear mothers, nurses, and doctors, talking of" teeth-
ing "as the common, and efficient cause  of the intestinal
complaints of summer.   Again, you will often hear it alleged
that  the eating of unripe and spoiled*fruit and vegetables
is the principal cause of intestinal summer complaints.  The
fallacy of this is sufficiently shown by the fact that a major-
ity of the children attacked are so young that they have not
eaten fruit or vegetables of any kind. 
SUMMER COMPLAINTS OF CHILDREN.      147
   The real cause of the summer  complaints of children,
both predisposing and exciting, will  be easily inferred from
a careful study of  the  localities, the  season  of the year,
and  the  special circumstances  under which they  occur.
They occur much more severely in densely populated cities
than in rural districts.   They are particularly prevalent in
all those cities and populous towns of our country occupy-
ing that climatic belt or zone characterized by the greatest
contrast of the seasons;  that is, the  greatest difference  be-
tween the coldest days of winter, and the hottest  days of
summer.   This belt or zone, so far as regards  that part of
the United States east of the Rocky Mountains,  is included
between the parallels of 31 ° and 42 ° north latitude.  In a
large part of  this territory,  the difference in temperature
between the coldest days of winter and the hottest  of sum-
mer, is from 75° to 1400 of  Fahrenheit.   It can hardly be
doubted but this extreme annual variation of temperature
operates as a predisposing cause  of  intestinal fluxes,  during
the warm part of the year.   This predisposition is also in-
creased by habitual  dampness of the  atmosphere,  by  the
various impurities that exist in the air of  large  cities, and
by that morbid material  or  agent  usually called  malaria.
Age, too, exerts an  important predisposing infruence,  the
attacks being far more numerous in  infancy and early child-
hood, than at any subsequent period of life.  There are  sat-
isfactory anatomical reasons  for this.  The mucous  mem-
brane of the digestive organs, at birth, is extremely delicate,
and both the epithelial layer,  and the  numerous glandular
structures belonging  to  it, are  imperfectly  developed, so
much so as to be fitted for contact with only the  most sim-
ple fluids, such as good milk.  These structures do not com-
plete their  development and  acquire the compactness and
diminished sensitiveness of complete, or mature organiza-
tion, until the child is at  least three years old.   But the 
148     SUMMER COMPLAINTS OF  CHILDREN.
period during which the most rapid development takes place,
and during which there is consequently the greatest suscep-
tibility to morbid impressions, is the first two years of life.
   The teeth being a part of the digestive  apparatus, their
growth, and protrusion through the gums, constituting what
is familiarly called " teething," takes place during this same
two years; and  simply affords a visible index  to the rapid
development of the mucous membrane, and all other parts
of the apparatus, by which  it acquires that  diminished sen-
sibility, that increased compactness of  structure, and its
glandular appendages that secretory power, which enables it
not only to receive and digest a greater variety of  food, but
also to withstand a greater variety and intensity of morbid
impressions, without inducing disease.
    Remember then, gentlemen, that the growth of the teeth
is only a coincident of corresponding growth or development
in the whole digestive canal;  and to attribute the important
diseases of the mucous membrane of that canal, during the
first two years of life, to such growth of the teeth, is as ab-
surd as it would  be to attribute them  to  the coincident
growth of the hair on the child's head, or the  nails on its
fingers.  While we attribute to the extremes of the seasons,.
confinement in the nursery, dampness of the  atmosphere,
malaria, and other impurities, a predisposing influence, I am
fully satisfied that the immediate exciting or efficient cause
is a high atmospheric temperature.
    In this city (Chicago), the time of commencing of the
high summer heat is very variable ; but, generally,  it mani-
fests itself between  the twenty-third  day of June and the
middle of July.   In each of the five years  that I  have wit-
nessed  the prevalence of epidemic chlolera here, the first
week of high temperature commenced during the last  week
of  June.   In 1854 we had a week  of hot, sultry weather,
commencing as early as the twenty-first of June.   The pres- 
SUMMER COMPLAINTS OF CHILDREN.     149
ent season we had a succession  of three-very hot, oppress-
ive days, between the twentieth and  twenty-fourth of June,
ending in a copious rain, with  two  or. three  cooler days.
From that to the present time (July  2d), we have had con-
tinuous hot  weather, with oppressive south  and southwest
winds, inducing a great  feeling  of lassitude in persons in
good health.
    During the last of the first three days, I was called to sev-
eral cases of diarrhcea and vomiting, in children, and to two
cases of cholera morbus,  accompanied by muscular cramps,
in adults.  During the last four days the attacks of diarrhcea,
cholera infantum, and  cholera morbus, have increased so
rapidly that nearly one-half of all the patients coming under
my observation have been of that class; and the past week's
mortality will show a large increase over the previous weeks,
from the prevalence of these affections. This large increase
of mortality, chiefly from the bowel affections of children,
recurs regularly every year, beginning the  first week of hot
summer weather, and continuing  through July, August, and
a part of September; and these affections are as strictly en-
demic in the impure summer atmosphere of the cities in the
temperate zone of the earth's surface, as the intermittent
fever is on the Roman Campagna, or  on the  alluvial depos-
its in  the Mississippi Valley.  The principal determining
causes appear to be a high temperature, acting in  conjunc-
tion with an atmosphere  either deficient  in free  electricity
and ozone, or rendered impure by the products  of animal
and vegetable decomposition.
   To understand the modus  operandi of caloric,  or a high
temperature, in producing disease, we must have a clear con-
ception of the normal properties of living, organized matter,
and the manner in which  those properties  may be modified
by exterior  agents.  A careful analysis of the phenomena
connected with organization and life, shows  that  every or- 
150     SUMMER COMPLAINTS  OF CHILDREN.
ganized living structure, whether vegetable or animal, is pos-
sessed of two properties, elementary  and essential to the
existence of matter; in an organized and living  state.  The
first  is an  affinity by which the organic atoms are made to
assume a definite arrangement,  constituting  the primary
structures and types of organization.    This property, for
convenience, we call vital affinity.  The second is a suscep-
tibility to impressions from exterior influences, or a capa-
bility of being acted upon.  This susceptibility must not be
confounded with nervous sensibility, which is merely one of
the functions of nerve-structure, and  not  an elementary
property of organized matter.  The two elementary prop-
erties here alluded to, will be  most clearly  appreciated by
reference to the simpler types  of organization, such as the
germinal cells of the ovarium, the egg, or  the  acorn.  You
examine the latter, for instance, and  you find  the  organic
atoms of which it is composed arranged in a  certain definite
and  uniform manner, in strict obedience to a special affinity.
That the particles thus arranged possess a special suscepti-
bility, is easily demonstrated by the action of  certain  exte-
rior  agents upon them.
   Thus, the acorn, lying dry  upon the table, manifests no
change, any more than a piece of chalk lying by its  side;
but let a certain degree of caloric or heat, and moisture, be
brought to bear upon it, and a change immediately com-
mences, which, continued under the guidance  of the special
affinity among its particles, soon  results in the development
of a miniature oak.   But the piece of chalk, exposed to the
same influences, is only a piece of chalk still; thus demon-
strating that  the acorn possessed a  susceptibility, though
passive, or dormant, peculiar to organized matter.
   If you thus see clearly what we mean  by vital affinity
and susceptibility, as the elementary properties of all organ-
ized living matter, you are prepared to understand the effects 
SUMMER COMPLAINTS  OF CHILDREN.     151
of a high temperature, both as a predisposing and exciting
cause of disease.   Caloric  is one of those  imponderable
agents capable of pervading all matter, whether organic or
inorganic ;  and its effect is to expand all bodies, by causing
the atoms of which  they are composed to be  separated far-
ther from  each other.  Hence, it  is the great  antagonistic
power to  affinity, whether  simple, elective,  or vital.  Its
direct effects upon the living tissues of the human system,
constitute no exception to the general law of its  operation
upon other matter.   Every  successive addition of caloric,
or increase of temperature,  increases the  expansion of the
tissues, and of course lessens, in the  same proportion, the
vital affinity between the atoms  of which the tissues  are
composed.  If you wish for proof of this, you have only to im-
merse your finger a few minutes in water of as  low temper-
ature  as can be  borne without injury, fit a ring accurately
to it, and then immerse it the same length of time in water
as warm as can be borne, and you will find the size of the
finger so increased  that you will  probably be unable to get
the same ring on or  off.  But caloric not only expands liv-
ing tissues,  thereby  diminishing vital affinity, but it also in-
creases their susceptibility.   It is chiefly by its power thus to
diminish the tonicity or compactness of the tissues, while it
increases their irritability or susceptibility, that caloric, or a
high temperature, becomes  an  efficient predisposing or ex-
citing cause of disease.  Acting more directly  on the cuta-
neous surface, and, both by continuity of structure and close
physiological sympathy, on  the whole internal  mucous sur-
face, also, a high atmospheric temperature renders these struc-
tures morbidly sensitive, while their expansion renders them
more lax, and  thereby puts them  in the most  favorable con-
dition for sudden and rapid fluxes of fluids into, and through
them.   Hence it is,  that in  the midst of summer, all classes
and all ages of people are more or less disposed to intestinal 
152     SUMMER  COMPLAINTS OF CHILDREN.
affections, characterized by increased flow of fluids, such as
diarrhcea, cholera morbus, etc.  What  is thus a predisposi-
tion in all classes, becomes, in children, at that age when the
mucous membrane is yet undergoing development, as already
described, sufficient to constitute positive disease.  If to this
is added further depressing and relaxing effects of confine-
ment in  the  nursery, or in the impure air  of the narrow
streets and alleys inhabited by the poor, and  the smaller
quantity of oxygen inhaled when the atmosphere is rarified
by a high temperature, we shall have no difficulty in explain-
ing the annually destructive prevalence of bowel  affections
in young children, during  the  hot months  of  July  and
August.   If  the relaxation is excessive,  and the exudation
or effusion from the mucous surfaces  rapid,  causing active
vomiting and purging, it takes the name of cholera morbus,
or cholera infantum ; when it is slight,  causing only languor,
paleness, and several thin discharges from  the bowels, it
takes the name of diarrhcea, or " summer complaint."
   But,  gentlemen, I have  unconsciously spent so much
time  in  the present explanatory digression,  and  in the
preceding examination  of these children,  that  all  com-
ments on the  pathology of  the  diseases  under consid-
eration, and  on their treatment, must  be deferred until the
next clinic-hour. 
LECTURE  XI.
SUMMER COMPLAINTS OF CHILDREN.—Their Pathology
   and Treatment.
 ■  Gentlemen :—In a preceding clinic I directed your atten-
tion to several cases of diarrhcea in children, and described
to you the different varieties of bowel affections met with in
practice — giving  their history,  characteristic symptoms,
and the causes, both remote or predisposing, and exciting.
This morning  I shall make some brief comments on the
pathology of these affections, and then give you my views in
regard to the principles on which their treatment should be
conducted.  From a careful review of the  causes  which
are most  efficient in producing  this class  of diseases, and
their modus  operandi,  which was given at the preceding
clinic, you will readily infer the most important items con-
nected with their  pathology. It was then shown that all
the  causes concerned  in the production  of the diarrhcea,
cholera morbus,  and  dysentery of  young  children, co-
operated to produce an increased susceptibility or irritability
of the mucous membrane of the stomach and  bowels, with a
diminution of vital affinity, and consequent relaxation of
the capillary system of vessels.   This morbid  excitability,
coupled with impaired tonicity of the mucous tissue, consti- 
154     SUMMER  COMPLAINTS OF CHILDREN.
tutes the primary pathological condition in all the first and
second  groups of cases mentioned in  the former lecture.
The morbid excitability of the membrane invites a  rapid
influx of blood into  it, while  the  diminished vital affinity
and consequent relaxation of the texture, admits of equally
rapid effusion, or exudation of the serous part of the blood,
and thus furnishes the matter for the copious thin discharges.
The rapid loss of the watery element  of the blood, carry-
ing with it the salts, by this effusion into  the stomach and
bowels, speedily diminishes all the glandular secretions, such
as urine, bile, gastric and salivary juices, etc.; retards organic
or molecular  changes in all the tissues, thereby diminishing
the evolution of caloric, and causes a marked shrinking of
the whole body.
   The morbid sensibility of the nervous filaments involved
in the  mucous membrane, acted upon by the effused  fluid,
calls into action a reflex influence upon the muscular coat,
and thereby establishes the  frequent efforts to evacuate the
stomach and bowels.   Such are the pathological conditions
which constitute the active stage of these diseases.
   They cannot exist long, however, without inducing other
pathological changes of no less importance.   Thus the con-
tinuance of  the  serous discharges, more  or less  rapidly
exhausts the  blood of its  water  and  salts, leaving it too
viscid  Ao circulate freely  through  the  capillary  system of
vessels;  while the  rapidity of effusion through the mucous
membrane carries with it more or less of the  epithelial cells
of that membrane, which may be easily detected in the
evacuations by the  aid  of  a microscope.   If vomiting
exists to such an  extent as to prevent the retention of drinks
long enough to afford any replenishment of the water  in the
blood,  there will be danger of an entire suspension of capil-
lary  circulation,  and a speedily  fatal  collapse.  Or, the
increased viscidity of. the blood may so modify its relation 
SUMMER COMPLAINTS  OF CHILDREN.     15$
 to the capillaries  of the mucous  membrane as to stop the
 effusion and consequent discharges spontaneously before the
 state  of collapse  is reached.  If the discharges thus cease
 before  complete  collapse  ensues, rest,  and  a judicious
 replenishment of the blood by liquid nourishment,  soon
 restores the patient to health, in the majority of cases; but
 in some,  another pathological  state is developed, which
 should  not be overlooked.   I  have said  that,  during the
 active stage of diarrhcea or cholera morbus, the rapid efflux
 of fluid through the mucous membrane, carried with it more
 or less of the epithelial cells of  that membrane, and thereby
 produced more or less impairment of the texture.
   Hence it happens that when the discharges have ceased,
 capillary circulation and organic actions are resumed, and the
 patient is said to  have a healthy reaction fairly established ;
 the impairment of texture in some portions of the mucous
 membrane  is  such,  that the  capillaries  are incapable  of
 resuming  their circulatory function.   The  blood  accu-
 mulates in them;  a low  grade  of  inflammatory  action
 is established in  a  few  hours;  and the general reaction
 passes beyond the healthy standard to that of fever;  and,
 in common professional phraseology, the patient has passed
 from an attack of  serous diarrhcea or cholera morbus to that
 of secondary  enteric or typhoid fever.  The asthenic grade
 of inflammation thus set  up may gradually subside, and
 allow convalescence to be established in from one to three
 weeks; or it may  progress through the successive stages  of
 softening and ulceration, ending in the exhaustion and death
 of the patient.  But the mucous membrane is not the  only
 structure in  which  the  capillaries  may  fail   to  resume
 their  function, when the active discharges cease, and the
 stage of  reaction  has come.  When  the  attack has been
violent, and the amount of serous discharge so  great as  to
produce  a very marked deficiency of water in the blood, the 
156     SUMMER COMPLAINTS OF CHILDREN.
latter may become so altered in its relation to the capillaries
of the brain that the circulation becomes too feeble to sus-
tain  the function  of the cerebral hemispheres.   In  such
cases, though the intestinal discharges may cease, the circu-
lation and warmth be  restored  to the  extremities, and a
general  appearance of healthy reaction be established, yet the
patients pass into  a state of more or less complete coma,
from which they seldom recover.
   Another, and perhaps more  frequent local failure in the
resumption of capillary action,  is in the kidneys.  In the
preceding lecture, I told you that one of the early effects of
rapid and  copious  discharges from the  mucous surface  of
the alimentary canal, was a partial or complete suppression
of urine.   It sometimes happens that when the active intes-
tinal discharges cease, reaction takes place generally, but
the  secreting structure of the  kidneys fails to keep pace
with the improvement in other textures.  Consequently,  no
urine is secreted, and  symptoms of uremic poisoning are
speedily developed.
   Such are my  views of the  pathology  of  the  different
stages of the first two groups of  bowel affections, described
in the preceding clinic.  The pathology of the third group
of cases, which we described as accompanied by fever from
the  commencement  of the  attack,  differs in one primary
element from the first two.   There is the same morbid sus-
ceptibility  or irritability of the mucous membrane,  and con-
sequently the same unnatural influx of blood into it; but
the  general, relaxation  of the capillaries, which, in the first
cases, allowed  a  rapid escape  of  the fluids  constituting
serous  discharges, does not exist in this group.  Conse-
quently, although the efforts at vomiting or purging, or both,
may be frequent  and  severe,   yet  the amount  of  fluids
actually evacuated is not large, and they are found to consist 
SUMMER COMPLAINTS OF  CHILDREN.      157
 mostly of mucus, thereby indicating the existence of inflam-
 mation.
    These  pathological views afford  us clear and  definite
 indications for treatment in  each successive  stage of these
 diseases.  Thus, in the first stage of those cases character-
 ized by  simple  serous discharges,  either by vomiting or
 purging,  the  indications  are  to  allay the morbid irritability
 of the mucous membrane, and to increase  the tone or con-
 tractility of the capillaries.  To fulfill these, requires the
 judicious combination of a tonic and anodyne.
    Here  is  a case illustrating  this class,  a baby,  eight
 months   old.    You  see  it lying languidly in its mother's
 lap; the face is a little pale;  the eye slightly sunken; the
 expression sad; its  surface and extremities cool; respira-
 tion quiet, and pulse soft  and weak.  The  mother says it
 has had from four to six thin, yellow discharges every twenty-
 four hours, for the last three  days.  The passages are thin,
 copious,  and preceded by a little restlessness or peevishness,
 and followed  by languor.   There is neither  fever, pain, or
 mucus in the  discharges, or anything indicating local inflam-
 matory action. The  pathological  conditions are,  simply,
 general relaxation, with undue  excitability of the mucous
 membranes of the bowels.  The ideas entertained by some,
 that these cases depend on some  derangement of  the  liver,
 or that the discharges are  the result of an effort  of nature
 to get rid of some morbid matter, or the result of " teething,"
 are  founded on neither legitimate reasoning  nor the facts
 involved.
   This child's nursing should be regulated so as to prevent
overloading the stomach  at any  one time;  but the mother's
milk is the best nourishment that it can take, and the less of
any other fluid it takes the better.
   For medicine, we will give it the  following prescription :
       14 
158      SUMMER COMPLAINTS OF CHILDREN.
        R.—Phloridzinse_____....................Srs- xxlv-
            Spts. ammon. arom........-..........3 1.
            Tinct. opii et camph................-- Si-
            Aqua;............--.......---------§ iss<
            Syrupi simpl_____.......-----.......fss.
    M.  Shake the vial, and give half a teaspoonful each morning, noon,
tea-time, and at bed-time.
    The phloridzine, derived from the bark of the root of the
apple-tree, is a mild and pleasant tonic ;  while the camphor-
ated tincture  of opium supplies  the necessary anodyne in-
fluence.
    Another combination that we use frequently is as follows:
        R.—Acid, sulph. arom_________...........3i.
            Magnesia; sulph.....______.......____3 i-
            Tinct. opii....................._____3 i-
            Syrupi  simpl.________________.......§ i.
            Aqua;______________________________§ i.
    M.  Give, to a child of the age of this one, fifteen drops every two,
three or four hours, according to frequency of the discharges.

    Or the following may be substituted:
        R.—Quinise tannicae_______......_.......grs. iv.
            Pulv. opii________________........___gr. i.
            Sacch. alb____..............._______grs. xx.
    M.  Fiant pulveres viii.   One to be given every three, four or six
hours.

    In the  early part of mild  cases, the use of one or the
other of  these  formulae will generally speedily  restore the
patient to health.  But if  the  attack is  more  severe, charac-
terized by, not only frequent serious discharges, but  also
partial or complete suspension of important secretions, such
as urine  and bile, we must combine the  anodyne with an
astringent instead of a tonic,  and add to both a small dose
of some alterative, to aid in restoring these important gland-
ular secretions.  In such  cases, if the  vomiting is frequent, 
SUMMER COMPLAINTS OF  CHILDREN.     159
and more especially if the matters ejected are sour, I make'
a solution of soda bi-carb., one drachm, and morphia sulph.,
one grain, in two  ounces of water; and of this give from six
to fifteen drops, according to the age of the child, immediately
after each act of vomiting.   At the same time, give one of
the  following  powders every  three  hours, until the  dis-
charges cease, viz.:

       JJ.—Hydrarg.  chlor. mit----....... -......grs. iij.
          Plumbi acetatis____.....-------------grs. iii. .
          Pulv. opii_____________________________gr. i.
          Sacch.  alb_________________......-----grs. xx.
   M.  Fiant pulveres vi.

   The rule to give whatever medicine is designed to sup-
press the vomiting, in small doses, immediately after each, act
of vomiting, is one of much practical  value.   Vomiting is
an act  that  cannot be perpetuated continuously, but  must
always  occur in paroxysms,  with an  interval  of greater or
less length between them.   Hence, if a dose of medicine is
swallowed immediately after a paroxysm of vomiting, it will
remain in contact with the mucous  membrane of the stom-
ach a few minutes, at  least, before another effort at vomiting
can be  performed.  During  these few minutes, if the medi-
cine is  soluble, or already in  solution, it will gain some effect,
both on the  nervous filaments and the capillaries of the mu-
cous membrane;  and a repetition of the dose immediately
after each paroxysm  of vomiting will  soon accumulate an
effect sufficient to destroy the morbid sensibility, and conse-
quently stop the vomiting.   But if we follow the wishes of
the  patients, and the inclination of almost all nurses, by
withholding  the medicine after vomiting until the patient has
"rested a little,"  that little  period  of rest is just sufficient
for the  muscular coat  to regain its contractility, and the mu-
cous coat to  pour  out  a new supply of serous fluid, and con- 
160     SUMMER  COMPLAINTS OF CHILDREN.
sequently the patient is all ready for another  paroxysm of
vomiting.  Now, if the dose of medicine is administered, in
nine cases out of  ten it will be rejected almost as quick as
swallowed, and the effect is lost.
   The  same rule is equally important in reference to the
use of enemas for  aiding in the suppression of diarrhcea or
dysentery.   They  should always be administered as speedily
after an evacuation as possible, and while  the rectum is en-
tirely empty. The longer the enema is delayed after an evac-
uation, the more mucus,  or serous fluid will have accumulated
in the intestine, and the more readily will  the  introduction
of the enema be followed by an immediate expulsion.  You
thus  see, gentlemen, that in the more violent gastric and
intestinal affections,  success  in their  treatment depends
almost as much on the  time and manner  of administering
medicine as on the kind of medicine used.
   I have just stated, that  in those cases  characterized by
frequent vomiting of serous fluid, and  intestinal discharges
thin, and destitute of the coloring matter of bile, small and
frequent doses of  a solution of morphia and soda, with less
frequent doses of calomel and acetate of lead, usually con-
stituted the most efficient means for checking the active pro-
gress  of  the disease, and at the same time favoring the res-
toration of secretion in the more  important organs of depu-
ration, as the kidneys and  liver.  But  many cases are met
with,  in which the discharges, instead of being sour and des-
titute of coloring  matter of bile; are all  bitter and  highly
colored  with  the latter  fluid, thereby showing  a  super-
abundance instead of deficiency of the biliary secretion.  In
such cases, instead of giving alkalies or alkaline  salts and
mercurials, all of which tend  to increase  glandular secre-
tions, I  resort directly  to  the simple combination of ano-
dynes and astringents, as follows ? 
SUMMER COMPLAINTS OF CHILDREN.      IQ1
       1}.—Plumbi acetatis...........___________grs. xv.
           Morphia; sulph._____________________gr. i.
           Aquae......._______________......-- ^ii.
   M.  Give, to a child one year old, ten drops after every paroxysm of
vomiting.
   Or, if the vomiting ceases and the intestinal  discharges
continue, the same dose may be continued every three or
four  hours.  In using simple  anodynes and astringents, it
must be remembered that copious intestinal evacuations are,
almost always, accompanied by scantiness of urine ;  and that
the suppression of such evacuations by opium and  simple
astringents, whether mineral  or vegetable, often  leaves  the
kidneys still in a  very inactive state.  This difficulty can
generally be avoided by giving the  child  a teaspoonful of
the following,   between each  of  the doses  of opium and
acetate of lead :
       R.—yEther nit...........________________§ ss.
           Potassa; acetatis_____................3ii.
           Syrupi simpl.________________________^ss.
           Aqua;_________.........------------§ ii.
   M.  Shake well before using.
   This seldom offends the stomach, and renders efficient
aid in restoring a healthy action of the kidneys.
   We have here a  child,  presenting another aspect of the
same general malady.  Its  mother says  it is thirteen months
old, and was" suddenly attacked last  evening with vomiting
and purging, every  few minutes.   If  it nurses, the milk
is  ejected almost as  soon as it  lets go  the nipple;  if it
drinks  a  spoonful  of water, it provokes the same heaving;
and thus  everything  it swallows is speedily thrown  up.
Yet it is craving for water. The passages from the bowels
occur every half-hour, perhaps, and are preceded by a little
writhing and fretting, and  consist of a  turbid or yellowish
fluid, so thin as to  run readily through two or three napkins, 
162     SUMMER  COMPLAINTS OF CHILDREN.
and leave only a stain of faecal matter. The child is drowsy;
the eyes sunken; the face pale and dejected ; the skin, espe-
cially of the extremities,  cool;  pulse thready and  weak;
and  respirations slow, with  frequent sighing.  Here .you
have a more active example of the  cholera infantum, about
eighteen hours after the commencement of the attack.
   It is a  case presenting actual danger  of  fatal collapse
during the active stage.   If  it survives  this stage, and the
vomiting becomes only occasional, with a continuance of
intestinal discharges less frequently, the latter will become
green, mixed with little masses of mucus, sometimes streaked
with blood; the abdomen will become hot; the pulse quick;
the child more restless and peevish, with excessive  thirst;
and after emaciating to a skeleton, may die from inanition
at the end of three, four, or six weeks.   On the other hand,
prompt treatment, designed to allay the  extreme irritability
of the whole extent of the mucous surface  of the alimen-
tary  canal, and restore  the proper tone of  the  capillary
vessels, will, in  many  cases, arrest the disease and lead to a
rapid recovery of the patient.  We will give the little sufferer
the following prescriptions :
        R.—Acidi carbolici cryst..................grs. iij.
            Glycerina; (purse)_________.......____§ ss-
            Tinct. opii et camph........__________§ i.
           Aquas______......._________________§ iss.
   M.  Give twenty drops every half-hour until the vomiting ceases;
then extend the time to every two hours.
        R.—Hydrarg.  chlor. mit..................grs. iv.
           Pulv. opii____________________________gr. i.
            Sacch. alb---------........----------grs. xxx.
   M.  Fiant pulveres viii. Give one every eight hours.

   If the  vomiting ceases,  and the discharges  from  the
bowels are reduced in frequency to only two or three in the
twenty-four hours, the powders are to be omitted, and  ten 
SUMMER  COMPLAINTS OF CHILDREN.      163
 drops of the  nitrous ether added to  each dose of the car-
 bolic acid solution, to aid in securing proper action of the
 kidneys.  In  many  cases,  this treatment will result  in a
 rapid and entire recovery.
    In others,  the vomiting ceases, or  occurs only occasion-
 ally;  but the  intestinal discharges continue, at intervals of
 two, three, or four hours, preceded  and accompanied  by
 symptoms of  pain;  the  child becomes fretful,  craving for
 drink, and rapidly emaciates.  The intestinal discharges are
 very variable  in color and quality.   In a majority of  such
 cases the following emulsion acts very favorably:
        R— 01. terebinth........................3 ii.
           01. gaultherise........________________gtts. xx.
           Tinct. opii..........................3 ii.
           Acacia; e. pulv.,  )                  _•.
           Sacch. Alb!,     faa................3lv-
           Miscse et add aquae_______,...........\ iii.
    Shake the vial and give, to a child of this age, from fifteen to twenty
 drops every three, four or six hours, according to the frequency of the dis-
 charges.
    In all cases where the child can have a  good breast of
 milk, that alone  should be its nourishment.   But if artificial
 food must  be provided, we have  found nothing to answer
 better than a thin, well-prepared wheat-flour and milk  por-
 ridge, given in small quantities.   It is also of great impor-
 tance to give these little children access to  fresh and  pure
 air.  Their confinement  in  small, over-heated, and  badly-
 ventilated rooms, is one of the most prolific  causes of their
 sickness and mortality.
   When the  acute  stage of cholera infantum and  serous
 diarrhcea has passed by, and the disease  assumes  a chronic
form,  with  rapid emaciation,  coolness  of the  surface and
extremities, and  the intestinal discharges still thin, with  no
dysenteric straining, and little or no intermixture of mucus, 
164      SUMMER COMPLAINTS OF CHILDREN.
then  I find some one  of the following  formula? to afford
most relief:
        R.—Erigeron.  canadensis---------------— § ss.
            Quinia; tannici----------------.......grs- xx-
            Morph. sulph._____..................gr. i.
    M.  Pour on the whole a pint of boiling water, to make an infusion.
When cold, give, to a child  one year old, teaspoonful every two, four or
six hours, according to the frequency of the discharges.

    This combination has the advantage of being moderately
diuretic and tonic, while it is efficiently anodyne and astrin-
gent.   In mild chronic cases, in which the evacuations show
an excess of acid or  sourness, the following will  often answer
the purpose well:
        R.—Misturoe cretae fl.....................§ iss.
            Tinct. cinnamoni_____.......________3 ss-
            Tinct. opii et camph..........________§i.
    M.  Give ten to thirty drops, according to age of child, three or four
times a day.
    In protracted cases, accompanied by an anaemic condi-
tion of the  patient, the  liquor ferri nitratis, in suitable doses,
will be found very valuable, with one of the following  pow-
ders at bed-time, viz.:
        R.—Quinia; tannici......................grs. iii.
            Pulv. opii........_......._____.......gr. i.
            Hydrarg. cum creta..........________grs. iii.
            Sacch. alb...............______......grs. xx.
    M.  Fiant pulveres vi.
    The third group of bowel affections  of children—those
which were described as accompanied by fever, and mucus
in the discharges—involve a true inflammatory condition of
the mucous membrane, and their treatment involves the same
principles as the treatment of enteric fever and dysentery in
adults.    Hence  it   will be  more  appropriately  discussed
when we  have cases  of those diseases before you. 
LECTURE  XII.
DROPSY.—The Pathological Conditions that Give Rise to it.—
   Differences in Location and Progress.
    Gentlemen:—We have an  opportunity to-day to bring
before you a series of cases which strikingly illustrate  both
the pathological conditions giving rise to dropsical effusions
and the  differences  in  their location  and progress.  Ex-
cluding  hydatids,  or cystic  dropsy, we may arrange  all
other cases  into  three  classes, viz.:   First—Those  that
arise directly from inflammation; Second—Those depend-
ent on mechanical  obstructions in some part of the vascular
system ;  Third—Those arising from alterations in the blood.
    Of the first  class I shall not speak  at present, although
we  have in the wards two very interesting cases, the one
of pleurisy, and the other of pericarditis, both  accompanied
by copious serous effusion.
   The second  class of  cases  includes all  such  as de-
pend on  mere  mechanical obstruction,  whether from the
pressure of tumors, the  gravid  uterus, ligatures, fibrinous
coagula, diseased valves, or enlarged viscera.   But those  of
chief interest arise from either valvular disease of the heart,
or from disease  of the liver and spleen.
   This patient, Mrs. J., an American woman, aged about fifty
years, when admitted to the hospital, some weeks since, was 
166                   DROPSY.
considerably emaciated ;  countenance expressive of anxiety,
with a slight oedema of the eye-lids; pulse 85 per minute,
small, and moderately firm; tongue  clean ; bowels regular;
appetite  fair, but  digestion imperfect;  secretion of urine
very scanty, becoming turbid after standing, from an excess
of phosphatic salts, but yielded no  evidence of containing
albumen or sugar.  Her respiration  was short, and accom-
panied by a sense of oppression, which was so much increas-
ed by the recumbent position, that she maintained the sitting
posture all the time, both night and day.  The cellular tis-
sues of the lower part of the body, and the whole lower
extremities, were greatly distended with oedematous infiltra-
tion.  A  small  amount  of effusion had also  accumulated
in the cavity of the peritoneum.  The  oedema of the legs
had existed several months; and the over-distended skin on
the calves of the legs had become  broken, and the serum
was escaping in  such quantity as to keep the feet and ankles
constantly wet.
   On making a careful physical examination, no evidence
of disease was found in any of the viscera; but  over the
cardiac  region there was increased  extent of dullness, and
a loud, rough, bellows murmur, covering all the  time be-
tween  the first  and second sounds of the  heart, showing
plainly diseased valves,  with hypertrophy of the heart.  On
tracing  the history of the patient, it was evident that the
cardiac  disease, in this case, originated at  least ten years
previous, from an  attack of sub-acute rheumatism.  It will
be observed that  the dropsical effusions  in this case are
most marked in  the parts most distant from the heart, and
most dependent; and this is true of all cases dependent on
mechanical obstruction in the central  organ of the circu-
lation.
   In an adjoining  bed we find another patient,  Mrs. C,
born in  Ireland,  the mother of  several children.  When ad- 
DROPSY.
167
mitted to the hospital  she was  emaciated ;   countenance
expressive of sadness, or despondency ; face pale ; lips and,
indeed, skin generally bloodless, presenting a strongly anaemic
look; skin cool; pulse soft and about 90 per minute; respi-
ration shorter and quicker than natural;  poor appetite, and
food often  becoming  sour, and sometimes being rejected;
bowels irregular, being  sometimes  costive, and sometimes
too free; urine very scanty, and depositing a  large amount
of phosphatic and  lithic acid salts, but containing no albu-
men.  On examining the abdomen,  it was found greatly dis-
tended by an accumulation of serous fluid in the cavity of
the peritoneum, accompanied by a considerable enlargement
of the liver and spleen.   There was no tenderness or other
indication of inflammatory action.  For the  last few days
the ankles  have been also slightly  oedematous, aside from
which the dropsical appearances are confined  exclusively to
the abdomen.  There  are no  signs of  disease in the viscera
of the thorax or pelvis.
   The  history of  this  case  showed that the patient  had
been attacked with intermittent fever during  the past sum-
mer, which was somewhat protracted and accompanied by
pain in the hypochondriac  regions, and much disorder of
the digestive organs.  Although the intermittent paroxysms
ceased, and have not returned during the last  three months,
yet she does not acquire  good health.  Her bowels are more
or less costive ;  digestion imperfect and flatulent; muscular
weakness;  countenance sallow*;  and  urine  scanty  and
turbid.
   About six weeks since the abdomen began to enlarge,
and has steadily increased  until  attaining its present great
distension.   In this  case it is evident that the dropsical effu-
sion is chiefly the result  of direct mechanical obstruction to
the portal circulation, by the enlargement of the liver,  and
hence, instead of the dropsical effusion being controlled by 
168                   DROPSY.
distance from the heart and gravitation, as in Case I., it is
limited to the cavity containing the distribution of the ob-
structed blood-vessel;  and no mere  change of position of
the patient  produces any  change  in  the  location of the
effusion.
   We would next draw your attention to  this patient, Mr.
W., an American, aged forty-three years.   He  has  been
somewhat addicted to the use  of intoxicating drinks; and
eight or nine months previous to admission was exposed to
a thorough wetting and cold, which was followed by some
pain in the  right side,  and slight fever.  These  symptoms
lasted  only a few days,  but they were followed by indiges-
tion, flatulency, constipation, and  general  feelings of  ill-
health, but  not  sufficient to  confine  him  to  his house.
About six weeks since he noticed the  commencement of
some enlargement of his abdomen, which continued steadily
to increase  until his admission to  the  hospital.  At  that
time he was considerably emaciated; his lips pale and thin;
his pulse  small, tense, and about ioo per minute ; skin dry
and natural in  temperature ;  appetite variable; bowels in-
active; urine very  scanty, but destitute of  albumen;  and
his abdomen so much distended with fluid as to impede the
descent of the  diaphragm, rendering respiration  short, and
producing much uneasiness from mechanical pressure.   No
oedema of the extremities, or of any part of the cellular
tissue.   No  solid tumor can be felt in any part of the dis-
tended abdomen ; but the accumulation of fluid in the peri-
toneal cavity is  so great as to render it difficult to define the
lower boundaries of the liver and spleen.
   By  careful percussion,  however, a line of tympanitic or
intestinal  resonance is found to extend  transversely across
the right  hypochondriac and epigastric regions, quite under
the margin of  the  ribs.   This shows  that  the  transverse
colon  is  crowded upward by the  fluid in  the  peritoneal 
DROPSY.
169
 cavity, and occupies the place usually rendered dull by the
 lower margin of the liver, when of  its natural  size.   This
 renders it very probable that  the liver, instead of being en-
 larged,  is contracted, or in a state of cirrhosis.   Following
 the line of the colon to the  left side, it becomes more ob-
 scure and deflected downward, as if crowded in that direc-
 tion by some pressure from above.   This fact, together with
 uniform dullness, and general fullness of the left hypochon-
 driac region, leaves but little doubt that the spleen is moder-
 ately enlarged.  The results of a careful physical examina-
 tion, compared with the history of the case, leads us confi-
 dently to diagnosticate the case as one of well developed
 cirrhosis of the liver, coincidently with moderate enlargement
 of the spleen.
   The contracted condition of the liver, greatly interfering
 with the circulation through the hepatic branches  of the
 vena porta is, doubtless, the immediate cause  of  the dropsi-
 cal effusion.  Hence, as  in Case II., it  takes  the forms  of
 circumscribed dropsy, limited to the  abdominal  cavity, and
 is not influenced by change of position on the part  of the
 patient, or by gravitation.   Finding remedial agents to exert
 very little influence over the progress of this  case, and the
 patient suffering much  from  mechanical distention  of the
 abdomen, he was tapped by Prof.  Andrews,  the attending
 surgeon of the hospital, and about three and a half gallons
 of limpid serum drawn off.    In  about  three  weeks  the
 effused fluid had re-accumulated to such an extent that tap-
 ping was again resorted to, and between three and four gal-
 lons of fluid  again discharged.  At about the same intervals
 a third and a fourth tapping became necessary.  Of course,
 so rapid and copious a drain of serous fluid from the blood
 has produced rapid exhaustion of the patient.*
  * About one week subsequently symptoms of a low grade of peritoneal inflamma-
tion supervened, and the patient died in a few days.  Twenty-four hours after death a
       15 
170                      DROPSY.
    TO illustrate  the third  class of cases  of dropsy, which
arise from  alterations in the proportion of the constituents
of the blood, we shall now bring to your attention two cases
from the adjoining ward.   Mr. M., a native of Ireland, was
admitted  into  the  hospital  three  months since.   He is
naturally a large, muscular man, accustomed to physical labor.
He  states  that his  health  and  strength  have been  failing
several  months, accompanied by indigestion, constipation,
mental  despondency, dull pains in  the loins, and weakness
of the lower extremities.   He has been somewhat addicted
to the use  of alcoholic  drinks.  About three  weeks  before
he  came to the hospital, he began to exhibit a bloated aspect
generally;  but the swelling was most marked in the feet and
legs,  after being up  through the  day.   This swelling,  or
general oedema,  rapidly increased,  until he was  obliged to
take to his bed.   On admission to the hospital his skin was
dark, approaching  a  bronzed  hue ;  surface cool;  pulse
small,  and  95 per minute;   mental  faculties, apparently,
dull;  bowels costive ; and the whole exterior surface much
bloated from  oedematous infiltration;  but the  swelling is
much more marked in the parts most dependent.
    This is illustrated,  not only by the position  of the ex-
tremities, but the  left  side of the  trunk  of  the body,  on
post mortem examination was made.  On opening the abdomen, about two gallons
of turbid serum escaped.  The whole surface' of the peritoneum, both that lining the
abdominal walls and covering the intestines,  was minutely injected, of a dark red
color, and covered in patches with a white and partially organized membranous exuda-
tion, which possessed so little tenacity, however,  that  it is hardly proper to  say it
constituted a bond of adhesion.  The spleen was found  nearly double its natural size
and weight, color nearly natural, and texture  firm.  The liver was found firmly ad-
herent, at several points, to the ribs and parts surrounding it, as the result of  former
inflammation.  Its color was a shade lighter than natural, and its size diminished nearly
one-half.  Its  entire surface  presented a knotted  or lobulated appearance; and, on
section through the central portion of the right lobe, the contraction of the lobules, and
the " hob-nail" appearance was strongly exhibited.  The texture of the organ was
firm, and the gall-bladder moderately filled with bile.  All other important organs were
in a healthy condition. 
DROPSY.
171
 which he has been lying several hours, will pit, on the ap-
 plication of pressure, to the depth of half an inch ; while, on
 the opposite side, the pitting is comparatively slight. There
 is also a small amount of effusion into the cavity of the
 abdomen,  but none  in  the  chest.  The amount of urine
 secreted is much  less than natural, but contains so much
 albumen, that, on the application of heat, or nitric acid, the
 white  flocculent precipitate renders the whole mass thick in
 the test-tube.  The past history  of this case,  the  present
 symptoms, and the condition of the urine, render it quite
 certain that the patient has granular disease, or degeneration
 of the kidneys,  frequently called " Bright's disease."   In
 such cases as this, the large amount of albumen constantly
 being excreted through the kidneys, soon reduces the relative
 proportion of albumen  in  the whole  mass of  the blood,
 thereby rendering it much less viscid than natural.  When
 this process of lessening  the viscidity of the blood is carried
 beyond a given point, the relation between it and the capil-
 lary vessels is so changed that the physical law of exosmose
 predominates, and effusion or infiltration of the watery ele-
 ment of the blood necessarily takes place.  If, at the same
 time that the albumen is escaping through the kidneys, the
 amount of  water  eliminated  through both the kidneys and
 cutaneous  surface is greatly diminished below the  natural
 standard, the relative proportion of the  constituents of the
 blood is so rapidly altered that dropsical symptoms may be
 developed in twenty-four or thirty-six hours ; as we see fol-
 lowing sudden congestions of the secreting structure of the
 kidneys from exposure to cold and wet, and during the con-
 valescence  from  eruptive fevers.   But the viscidity  or
 density of the blood may be as much diminished by a loss
 of red corpuscles as by the escape of albumen.  Hence,
excessive haemorrhages,  suppressed menstruation, diseases
of the spleen, and the influence of malaria, are  all capable 
172                    DROPSY.
of so far diminishing the proportion of red corpuscles as
to develop general dropsical effusions.
   This next patient came into the hospital several days.
ago, presenting the appearance of general dropsy, with great
dyspnoea, and swelling of the lower extremities.
   It seemed that he had had several attacks of bronchial
irritation, and asthmatic constriction of the bronchial tubes,
with congestion of the capillaries of the tubes, and irritation of
the pneumogastric  nerve, causing great difficulty of breath-
ing,  imperfect aeration of the blood, tightness of the chest,
and  more or less harsh, suffocating cough.  With this con-
dition of the  bronchial tubes, he had  decided  pain in the
left side of the chest; lips blue ; face bloated ; "legs and feet
very much  swollen; and a general infiltration of the tis-
sues ; scrotum swollen, full, and affected with an eczematous
eruption, accompanied with a burning, smarting,  tormenting
sensation ; dullness over a larger space than normal in the
cardiac region; and abdomen distended.from the effusion.
   On application of the stethoscope, we find that the heart
sounds are distant and obscure, with hardly distinguishable
impulse;  and we are unable to make any distinction between  ,
the first and  second sounds, the motion  being tremulous  '
and  rapid.   This,  with  excessive  dullness, indicates peri-  I
cardial effusion.
   The first impression would be  that we had albuminuria
or organic disease of the kidney, giving rise to impoverish-  '
ment of  the  blood,  inducing dropsical effusion into the
cavity  of the pleura, pericardium,  etc., which  frequently  |
supervenes  during  the progress of albuminuria; but  upon  ,
examination of the urine this can not be detected.
   Not being able  to account for the effusion in this way,  j
we might expect to find some enlargement and obstruction
to the circulation in the abdominal viscera, as enlargement
of the  liver in persons who drink habitually,  or  the forma- 
DROPSY.
173
 tion of fatty deposit in the liver, or in the muscular struc-
 ture of the heart, which would give rise to dropsical effusion;
 and, in such a case, the abdomen would become greatly dis-
 tended, and it would  be  some  time before it pervades the
 extremities; the same is true of the spleen.   If the. liver
 was enlarged we  could easily bring the fingers in  contact
 with the enlarged organ, just below  the  margin of the ribs;
 and the same in regard to the spleen ;  also, by percussion.
    In this case,  instead of dullness below the margin of the
 ribs, this is the most  resonant part  of the abdomen, prob-
 ably owing to the fact  that the colon is distended with  gas,
 in which case, however, if the organ above was  distended,
 it would be  crowded  down, or  overlapped, and we  should
 get dullness on percussion;  if from  the spleen, the dull
 region would describe  a curve on the left side.
   If not albuminuria, enlargement of  these  organs, etc.,
 how shall we account for the symptoms ?
   If true that  it began with an  attack  of capillary bron-
 chitis, in conjunction with pericardial irritation, continued
 so as to retard decarbonization of the blood, with sufficient
 pericardial effusion to embarrass the  heart's action, combin-
 ing to induce impairment of the vaso-motor nervous system,
 this might give  rise  to a loss of tone and relaxation of the
 capillaries, allowing a slow circulation of the blood through
 them, and exosmosis from a want of impulse, and reaction
 under the influence of  the vaso-motor system of nerves up-
 on the muscular fibres of the  arterial system.   The blood
 does not get more than one-half the normal amount of oxy-
 gen, and this condition acts as a sedative narcotic  on the
 whole capillary system.
   As I cannot determine the existence of any disease in
the viscera of the abdomen that would account for this con-
dition — though it is not usual to get dropsy so rapidly from
obstruction  in the  air-passages, etc.— yet, from the weak
                          15* 
174                    DROPSY.
character of the  pulse, blue lip, and general  relaxation, as
manifested by the effusion, I should be led to conclude that
such was'the case in the present instance.
   There was, in the  beginning, a  stage that would  admit
of active antiphlogistic treatment, when, I have  no doubt,
a sedative and alterative treatment  would  have arrested its
progress; but the time for arterial sedatives has passed away;
we now have feeble capillary circulation,  and a weak, tu-
multuous action of the heart.
   The object in the treatment should be to give more force
to the heart's contractions, reducing the  frequency at  the
same time, and  to produce  efficient action of the kidneys,
to carry off the water and prevent further effusion.
   To accomplish this we rely upon digitalis and  Scutellaria
to control the force and  frequency of the heart's action;  ,
while the influence of  the  digitalis  on  the  kidneys makes it
very applicable in this case.
   We shall, therefore, direct the following mixture:

      . R.—Ext. -Scutellariae fl.______________......? ijss.          1
           Tinct. digitalis___________............^ J.
           Tinct. hyoscyami______________________^ ss.            j
           Potass, nitratis............._________3 iij.
    M.  One teaspoonful to be taken every three hours.
   For a further alterative influence we may direct, in addi-
tion, a powder consisting of pulv. Doveri, six grains; hydrarg.  j
chlor. mite., one  grain, to be given every night.   We  doubt,
however, if the chloride had better  be continued  more than  j
three or four nights.
   If at any time the  bowels should become so  loose as to
weaken the patient, the frequency of the liquid mixture  1
should be reduced to once in four hours, and alternate with  I
it a teaspoonful  of the ordinary turpentine and laudanum
emulsion. 
DROPSY.
175
    Will also have a blister applied over the chest, followed
 by poultice.*
    Thus far  we  have directed attention to the  essential
 pathological conditions producing dropsy, either by obstruct-
 ing the natural flow of the blood, or by changing the relative
 proportion of  its  constituents;  but in a therapeutic  aspect,
 it is almost equally important  that we appreciate correctly
 the condition of the vital properties of the textures.  Dimin-
 ution of vital  affinity—that  property by which the organic
 atoms of the various  tissues are  held in proper  proximity
 and relationship with each other—necessarily diminishes the
 tonicity and contractility of all the muscular, vascular, and
 secretory structures, and  hence not only retards  secretion,
 and capillary  action, but directly  favors  permeation of
 tissues, or dropsical effusions.   The presence of this patho-
 logical condition  of the solids,  in many cases of dropsy, led
 the older writers  to divide all dropsical affections into two
 classes, viz.: sthenic  and asthenic, or active and passive;
 and though subsequent  pathological investigations  have
 rendered the ancient classification obsolete, they have by no
 means diminished the necessity of appreciating the general
 condition of the  vital properties  as  carefully as  the  mere
 local lesions,  if  we would  direct the treatment with the
 highest degree of success.  This was well illustrated in the
 treatment of the  second  case,  already related.  The  drop-
 sical effusions being regarded as dependent on the enlarge-
ments  of the  liver and spleen, coupled  with considerable
impoverishment of  the blood,  she was  treated,  for three
   * Under the above course of treatment the dropsical effusion and difficult breathing
were rapidly relieved ; and on the third day the pulse became slower and more distinct ;
and on the fifth day it was so slow that the digitalis had to be diminished by lengthen-
ing the interval from once in three hours to every six hours ; cough easier, but dry, so
that we gave the muriate ammonia between the other. Makes water quite freely ; breath-
ing tolerably fair, but still indicative of bronchial tightness ; and the heart's action,
while slow, is irregular ; impulse still deficient and hardly distinguishable. 
176                    DROPSY.
weeks, by mercurial alteratives, iodine preparations, diuretics
and  quinia, with  very little  benefit; indeed, these reme- »
dies  entirely failed, either to  increase the  secretion of the
skin  and kidneys, or to  materially reduce the  visceral
enlargements.  Suspecting the  difficulty to arise from want
of tonicity, or, more properly, vital affinity  and contractility
in the  capillary and secretory structures, we directed her to
be  put upon the  use of strychnia  and citrate of iron, in
doses  of  one-sixteenth of a grain  of the first, with three
grains of the last, four times a day.   Very little change was
observable during the first three or  four days;  but by the
middle of the second  week  after commencing this treat-
ment, it was found that the patient was urinating freely; the
dropsical appearances were  much  diminished;  and  her
strength improved.   The same  treatment was  continued;
and  in four weeks the patient had entirely recovered, there
remaining neither dropsical effusions nor visceral enlarge-
ments.
   The important practical inferences to be drawn from the
foregoing cases and observations are : First,  that dropsy is,
in a pathological  sense,  not a disease,  but  a symptom
directly dependent on  either inflammation, mechanical ob-
struction  of blood-vessels, or  altered composition of the
blood;  second,  that these  pathological  conditions  may
arise from a great variety  of  primary pathological changes,
both local and general; third, that all rational treatment of
dropsical symptoms must  depend on  a clear appreciation of
the primary  pathological  changes from which they  have
originated, compared with the general condition of the vital
properties or forces. 
LECTURE  XIII.
CASES OF CARDIAC DISEASE. —Diabetes Mellitus. — An/emia
 and Anasarca. — Biliary Calculi.
    Gentlemen:—The patient who presents himself before
 you is a native of Ireland, aged about  thirty-five years;  a
 blacksmith by  trade; and possessed  of a well-developed
 physical frame.  You observe that his  breathing  is short
 and hurried, much like one who  has been running; his face
 and lips rather pale, and  slightly bloated; his tongue  cov-
 ered with a whitish fur; his skin above the natural tempera-
 ture, and dry; his pulse  moderately full, hard, and ioo per
 minute;  and he complains of a great sense of fullness or
 oppression in the chest, with a pretty severe, dull pain in the
 cardiac region, increased to a  sharp or acute quality on
 faking a full breath, or coughing.  He  has severe paroxysms
 of coughing, and is unable to lie down in a horizontal posi-
 tion without producing a  great sense of suffocation, and  is
 consequently obliged to  spend his nights with the body in
 an erect or semi-erect position.
  The pain in the cardiac region, accompanied by some fever,
commenced  about two weeks since, and  very soon  after an
injudicious exposure to wet and cold.  These general symp- 
178          CASES OF  CARDIAC DISEASE.
toms, and especially the pain in the  region  of  the heart,
coupled with the disturbance of circulation and respiration,
would lead us to suspect the existence  of cardiac inflamma-
tion.  To determine  this with certainty, we  must make a
physical exploration of the chest, by means of auscultation
and  percussion.  On removing the covering from the  left
side  of the chest, and  placing the hand over the cardiac
region, the impulse of the heart was found much stronger
than  natural, and  percussion showed that it occupied a
larger space.  Application of the stethoscope over the car-
tilages of the ribs covering the right side  of  the heart,
revealed a well-marked friction, or rubbing sound, with each
systole of the ventricles, and also a rough  bellows murmur.
On moving the stethoscope a little upwards, and to the left,
so as to rest over the  base of the heart, the bellows murmur
became more plain,  very rough and prolonged, so as to
completely suppress  the short, second sound.   The signs
thus elicited clearly indicate, not only the existence of cardiac
disease, but its existence in a severe and complicated form.
The  friction  sound  indicates a recent and still existing
inflammation  of-the  pericardium, with more  or less plastic
effusion  upon  the surface  of the membrane;  while  the
rough and prolonged qualities of the bellows murmur, the
dullness  over a larger space than natural, with a  strong and
sustained impulse, certainly indicate considerable hypertro-
phy  of the ventricles, with disease of the semi-lunar valves.
From the loud and harsh qualities of  the murmur, and the
hypertrophy, it is evident that the disease of the valves has
been existing a considerable  time previous to the date of the
patient's present illness.
   He now explains this by informing me  that he  had a
severe attack, of  rheumatism, accompanied by pain  in his
left breast, two years  since, and that he has been seriously
troubled with  shortness of breath, and  heavy, irregular beat- 
CASES OF CARDIAC DISEASE.          179
ing of the heart, especially on taking exercise, from  that
time to the present.
  From all these facts we infer that the patient was attacked
with rheumatic endocarditis two years since, which resulted
in thickening of the semi-lunar valves, and the consequent
gradual development of hypertrophy of the muscular struc-
ture of the ventricles;  while the injudicious exposure  to
wet and cold, two weeks since, caused the supervention of a
sub-acute pericarditis, which still exists.  Placing the patient
in an  easy  position, each -member of the class may  take
the  stethoscope and listen to  all the morbid  sounds  that
the  case presents.
   The prognosis in recent attacks  of inflammation  of the
heart, whether endocardial or  pericardial, may be regarded
as favorable.  And so far as the pericardial disease is  con-
cerned in this case, we think it can be removed in a few
days by appropriate treatment; though, as sometimes  hap-
pens,  the effusion of plastic lymph may cause adhesion of
greater or less extent between  the surfaces of the inflamed
membrane.  I have observed two cases, in which such adhe-
sions  existed  so  extensively as  to  unite the  pericardium
closely and firmly to the whole exterior surface of the heart,
thereby completely obliterating the pericardial sac.
   One of  these was a recent case, and, in addition to the
adhesions,  there was present intense  redness, and  all the
marks of acute inflammation, in all the structures  of the
heart.  The other case had been one of long standing, and
the adhesions were so firm that it was with difficulty that the
pericardium could be torn from the surface of the heart.  If
we are right in the supposition that this patient was attacked
with endocarditis two years  since, and  that the thickened
condition of the  valves which now give rise  to the  harsh
bellows murmur to which you have listened, is the result of
that inflammation, it is quite  certain that such thickening, 
180          CASES OF CARDIAC DISEASE.
and the hypertrophy consequent upon it, have become too
permanent to admit of  removal  by any  remedial  agents
known to the profession.  On the contrary, the continuance
of the valvular obstruction  will cause a gradual increase of
the hypertrophy, until at length the patient becomes  wholly
unable to exercise,  dropsical effusions supervene, and life is
cut short.
   The first object to be accomplished in the treatment of
this  patient, is to remove  the  recent inflammation  of the
pericardial membrane.   This must be done by a prompt and
judicious use of sedatives, alteratives, and counter-irritants.
Had the patient come under our  care during the  first two
or three days after the commencement of the present attack,
we might have deemed it necessary to have taken at least
one  free bleeding  from the arm.  But two weeks  having
now elapsed, and the patient feeling already debilitated, we
do not deem venesection necessary.  Consequently, we shall
endeavor to control the circulation by the following,  viz.:
        r}.—^thernit.          )              ■-..
           Tinct. opii et camph.  )             "5 "
           Tinct. verat. viridis........t.......... 3i.
   M.  Give a teaspoonful every four hours, diluted with water.
   To change  rapidly the tendency to plastic effusion, and
consequent adhesions, and destroy the inflammatory process,
we shall also direct one of the following powders to be
taken  between  each  of the  doses of the sedative mix-
ture, viz.:
        5 •—Hydrarg. chlor. mit.___.......,......grs. xv.
           Pulv. opii-------................____grs. xii.
           Potass, nitratis.....______........____grs. xl.
   M.  Fiant pulVeres vi.
   By giving  the  opium in full  doses, we shall  not  only
relieve the pain and restlessness of the patient, but we shall
overcome  that  important  element  in  all  inflammations 
CASES OF CARDIAC DISEASE.          181
 which we call irritability, or, more properly, an exaltation of
 the susceptibility of the inflamed structure, and thereby aid
 much in destroying the inflammatory process.
    We shall continue these remedies until the hydrarg. pro-
 duces a slight effect on the gums,  and then  interpose a
 cathartic.
    After the bowels  have been freely moved, the previous
 remedies may be resumed, with the calomel omitted ; and a
 blister may be placed over the cardiac region.
    It is probable that, under the influence of these remedies,
 the present pericardial inflammation will be removed in from
 four to six  days ;  but the valvular obstruction and hypertro-
 phy,  with  some  general debility, will remain.   If so,  all
 active treatment by medication may be discontinued.  The
 patient must be  instructed to wear flannel next the skin;
 avoid sudden atmospheric changes ; make his exercise, men-
 tal and physical, as quiet as possible ; avoid the use of stim-
 ulants, and highly seasoned articles of food.
    In addition to these  hygienic regulations, the increase of
 hypertrophy may  be  retarded by a judicious  use  of the
 milder sedatives, such as digitalis, gelseminum, and acetate
 of lead.
    This patient presents another phase of cardiac disease.
 Upon  auscultation, we have no difficulty in locating the
 disease in the heart;  but when we go back of that, and try
 to ascertain what particular valves are involved, it is not so
 easy.   You will observe the patient is in a sitting posture,
 which  seems to be his  most  comfortable  position.   The
 flush on the face  and hands is not  due to fever, as there
 is  no perceptible increase of heat  of  the surface;  but
 it is due to capillary congestion, and is sometimes of  a
purplish hue.  If the patient were to go down stairs and re-
turn, or take any active  exercise, the flush would become
decidedly  more  venous, as well as  the respiration  more
       16 
182          CASES OF CARDIAC  DISEASE.
labored and  oppressed.   There will lx; noticed, above the
clavicles, slight pulsation in the jugulars, which is also much
increased on  exercise.
   You could not, under any circumstances, have a patient
in a more favorable condition to distinguish the exact con-
dition of the heart's action, as he has been taking  arterial
sedatives for several days, and is now sufficiently under the
influence of the medicine to render the sounds very distinct.
A little below and to the left of the nipple, upon the applica-
tion of the stethoscope, you will get a double  murmur—one
harsh, rasping, and loud ;  the other softer  and  shorter.  The
first is synchronous with the systole, and the second with the
diastole.   The first is  heard over the whole cardiac space;
the  second only over  the left side.   This shows  that the
principal difficulty is in the  auriculo-ventricular opening of
the left side—the location of the mitral valves.
    You  hear the rasping sound all about the region of the
heart;  but, move which  way you will, when  you return a
little to the left, and below the nipple, you hear it the loud-
est.  The second sound you hear is due to slight regurgita-
tion.  Over  the rest of  the heart you get  only one sound,
occupying the entire time of both sounds  of the heart.   The
hypertrophy in this case is well marked.   When the patient
was not  under the  effects of medicine, there was regurgita-
tion on the right side, giving a strong pulsation in the  epi-
gastric region, through the ascending vena cava, and also the
descending vena cava  to the jugulars.
    When I first examined the patient, there seemed to be a
well-marked  aneurismal  tumor in  the  epigastric  region,
which was quite tender to the touch.  This tumor was pres-
ent two days ago, when I called the attention of the other
division of the class to it; but I see it is absent to-day.
  This  man's heart is, probably, in  the  same condition as
that of  the man who  died several weeks since, and whose 
CASES OF CARDIAC DISEASE.          183
heart I exhibited to you, viz.:  a dilatation of the right ven-
tricle ; contraction of the mitral opening, with thick, rough-
ened edges,  preventing  a  complete  closure during  the
systole of the ventricles;  and a general hypertrophy of the
muscular structure.
   When the patient is disturbed, the  tricuspid valve is in-
sufficient to close  the  auriculo-ventricular  opening of the
right side, because it is enlarged by the dilatation of the
right ventricle.   The apparent pulsating tumor in the  right
side of the epigastrium was, probably, caused by overfullness
of the vena porta,  from regurgitation through the auriculo-
ventricular opening of the right side into the ascending vena
cava.
   If you  notice the feet  and ankles, they will be found
quite oedematous — a condition which is present in  most
cases of cardiac disease,  in the advanced stage.   If the.
pathological conditions of the patient have been described
correctly, the prognosis is unfavorable.   To  render the
action of the  heart slower and more uniform, constitute the
principal objects of treatment.   Just  in  proportion as this
can be accomplished,  will the  patient be  rendered more
comfortable, and his life be prolonged.   By rendering the
action of the heart  slower and more uniform, more time will
be allowed,  after each systole, for the blood to pass through
the narrowed  mitral  opening  from  the  left  auricle;  and
hence the pulmonary circulation will be less obstructed, and
the equilibrium between the fullness  of the right and left
cavities of the heart be better maintained.
   To fulfill the indications just stated, the patient is taking
one fluid drachm of the following prescription, before each
meal, and at bed-time :
      r£.—Ext. Scutellariae fl..............--------3 iij.
   M.     Ext. digital, fl................------1 i. 
184          CASES OF  CARDIAC DISEASE.
   Also, five grains of bismuth sub-nit., half an hour  after
each meal.
   When  the patient commenced the use of the Scutellaria
and  digitalis, four days since, his pulse was no per minute,
and  irregular, with dyspnoea, epigastric  distress,  cool and
purplish-colored  extremities, and strong pulsation in the
jugular and subclavian veins.
   Now, his pulse is only 60 per minute, and regular, with1 a
decided improvement in all his symptoms.   His diet has
been plain  and nutritious.  The same treatment will  be
continued, with careful attention, to  prevent any  excess in
the action of the digitalis.
   This next patient, a  native of Ireland, aged forty years,
has been affected with symptoms of diabetes about one year.
Shortly previous to  the  appearance of these symptoms, he
had  two attacks of throwing-up blood to the extent of one
pint, or more, at a time.   Whether the blood came from the
lungs or stomach is not'very easily determined by the account
given by  the patient.  He also suffered  at the same time
from loss  of appetite and indigestion.  The  evacuations
from the bowels have generally been  regular once or twice
a day.
   During .the  last two or three months, his appetite has
been good, thirst excessive, and yet he has steadily declined
in flesh and strength, is morbidly sensitive to atmospheric
changes, and voids from  one to two gallons of urine per day.
At present the patient's skin  is harsh, rough, and dry, es-'
pecially on the hands and neck;  his pulse is soft,  weak, and
a little increased in frequency;  moderately emaciated; mus-
cular weakness; and mentally  despondent.  The taste of
the urine  at present is sweet, and its odor characteristic. It
readily enters into fermentation by the yeast  test.   Trom-
mer's, and other tests, might be applied, but the  foregoing, 
CASES OF CARDIAC DISEASE.          185
 in connection with the general symptoms, are sufficient to
 render the diagnosis certain in this case.
    The  early symptoms of diabetes are generally obscure,
 and the disease is often associated with  tuberculosis.  The
 digestive function is generally impaired; for, though  the
 appetite  may be  good, or  even voracious, yet digestion is
 slow, and accompanied by fullness, eructations, and mental
 depression.   The bowels are  inactive, the skin  dry, and a
 gradually increasing thirst.  As the disease progresses,  the
 dry and  harsh condition of the skin, and  the loss of flesh
 and strength, become more manifest, and  the patient often
 complains of weariness and  some  pains in the back, and,
 sometimes, sharp  neuralgic pains in different parts  of  his
 system.   The existence of these symptoms, and especially
 the steady loss of flesh and strength, while the  patient is
 eating and drinking, as well as urinating more than natural,
 should always cause us to suspect the existence of diabetes.
 And if, with these symptoms, the application of the proper
 tests shows the presence of sugar, the diagnosis is rendered
 certain.  A  mere excessive secretion  of urine, however, is
 not  sufficient to  indicate saccharine diabetes.   In certain
 paroxysms of nervous excitement, the  kidneys will secrete
 double or triple  the  natural  quantity of  urine  in a given
 time; but, in such cases, the  urine is limpid, like spring
 water, and of  low  specific gravity; while in diabetes mellitus
 the specific gravity is high.   In the case before us, the  speci-
 fic gravity of the urine, when  the  man first came  under
 treatment, was 1040.
   In albuminuria  the urine  is generally  of  high specific
gravity, but  the quantity is usually small, and the skin and
countenance  of the patient is pale and bloated, instead of
corrugated and shrunken.
   The tendency  of diabetes, when left to itself, is to stead-
ily increase until the patient becomes fatally exhausted ;  but
                          16* 
i86
CASES OF  CARDIAC DISEASE.
its progress is generally slow.   In many cases, the symptoms
are improved during the warm months of summer, and be-
come aggravated by the  cold and  damp of autumn and
winter.  An atmosphere that relaxes the skin and increases
the activity of its function, seems to lessen the activity of
the kidneys, and thereby ameliorates  the  condition of the
patient.
    The pathology of the disease is still involved  in  obscu-
rity.  It was long since ascertained that the excessive quan-
tity and saccharine quality of the urine did not depend on
any specific or  characteristic lesion  of the kidneys.  These
organs appear to be only the outlet for an excessive quan-
tity of glucose or saccharine matter, that  finds its way into
the blood  from some other source;  but from what other
source is not yet fully determined.  The experiments of
Bernard and of  Drs. A. Flint, senior and junior, seemed to
establish the fact that the liver was an active sugar-producing
organ, and hence  it became probable that derangement of
the functions of this organ constituted the true source of
the diabetes.  But still later experiments have, at least, ren-
dered it doubtful whether the sugar detected  in the  liver is
not from post mortem changes.
   It has long been known that somewhere in the processes
of digestion and assimilation, the starch  and gum taken as
food become converted into sugar; and, in health, the sugar
is further  converted into lactic acid and other products.
But in diabetes  this further change  fails to take place, and
the sugar  remains  in excess in the blood, stimulating the
kidneys to excessive action, and consequently maintaining
a constant  drain upon the whole system.
    The indications for the  treatment of diabetes are, first,
to exclude, as far as possible, all elements of food  capable
of being converted into  sugar in the process of digestion;
second, to so alter the processes of digestion and assimila- 
CASES OF CARDIAC DISEASE.          187
 tion as  to  complete the conversion of the  saccharine pro-
 ducts of digestion into lactic acid, or such other constit-
 uents as are capable  of being appropriated to  the tissues,
 or excreted without disturbing the function of the kidneys.
 To accomplish this purpose, there is probably no more effi-
 cient method than to keep the patient steadily on the use of
 skimmed milk, buttermilk, or milk-whey, bran  bread, and
 lean meat.   For fresh vegetables, onions and cabbages
 may be allowed,- as they contain  but  little starch or sugar.
 As an occasional change, a  porridge, made of roasted  or
 scorched corn-meal, may be  allowed.   In addition to the
 regulation of diet, I have found much advantage in the use
 of a teaspoonful of the liquid rennet, immediately after each
 meal.  In some instances, a pill containing  pulv. opii, one-
 half of a grain, and cupri sulph., one-sixth  of a grain, to  be
 taken before breakfast and dinner, will also help to lessen
 the quantity of urine.
   The wearing of flannel next the skin, and a warm bath
 two or three times a week, are also valuable  aids.  Dia-
 betes is a very obstinate, and often incurable disease ;  yet I
 have seen a few cases  cured by a persevering use of the fore-
 going means.
   We have here  a case of marked anaemia and anasarca,
 resembling, in  many of its features,  those described  as
 leucocythaemia.   The patient was admitted to the hospital
 three days  since, presenting the  following  conditions:  A
 bloodless hue of  the surface ;  a considerable degree  of
 oedema  in  the  extremities;  and  general weakness.  From
 the fact that this condition had remained for several weeks
 without  improvement, and  the secretion of  urine being
 diminished, albuminuria was  suggested.   The  urine  was
tested by heat and nitric acid, but no trace of albumen was
developed, which  would indicate that there was no granular
disease of the kidneys. 
188          CASES OF CARDIAC DISEASE.
   The patient  also complained of a tightness across the
chest, and some cough, but was not examined for pulmon*
ary or cardiac disease at the time.
   On auscultation, we find in  each full inspiration, coarse,
rough, bronchial sounds; over the  cardiac region we can
distinguish. no  valvular roughness or  murmur,  but the
sounds are short, quick, and distant.  The systole is shorter
than natural, yet distinct and clearly perceived;  apex im-
pulse absent.
   On percussion, no marked dullness on either side, till we
reach the cardiac space on the left side.  Here dullness be-
gins  pretty high up, and extends to the bottom of the chest;
and  over the region of the spleen there is nearly double the
normal extent of dullness.   The  intercostal spaces are well
filled out, and both  hypochondriac regions full.   There is
probably  some  pericardial effusion ; but we may  attribute
most of the enlargement on this side to the spleen.  On the
right side, also, there  is dullness over a little greater than
the normal vertical depth, showing that there is  probably
moderate enlargement of the liver.
   A combination of  causes has apparently contributed to
the  development of a degree  of fatty degeneration  in  the
liver and spleen, and there may also be, to some extent, the
same change in the structure of the heart, a slow change in
the nutrition of these organs  diminishing  their ability to
contribute their proper influence in the process of assimila-
tion, which would account for  his gradually  assuming this
anasmic condition.
   There is not that degree of  enlargement in the parts re-
ferred to which would produce  effusion from obstruction to
the portal circulation, in which case abdominal dropsy would
precede general oedema.
   The bronchial sounds are a part of an old, simple bron-
chial irritation, which many persons are subject to during the 
BILIARY CALCULI.
189
cold  season, but which involves no  structural change, and
is a minor matter.
   On admission, observing the quick, agitated movements
of the heart, oppression in the chest, and scanty urine, he
was directed to have a combination of digitalis and Scutel-
laria,  as follows:
       5.—Ext. Scutellariae fl....................1 "J-
           Tinct. digitalis-----...............-- 1 i-
   M. One teaspoonful of this to be given four times a day.

   To increase the amount of urine, and give  steadiness and
force to the heart's action, I would advise a continuation of
the same;  but for a  further influence on  the assimilative
function, he should have, in addition, some tonic and alter-
ative.  A good addition would be—
       5.—Bismuthi sub-nit---.----............ grs. vi.
           Lupulinae..................--.......grs- u-
           Ferri sub-carb.  -.....-----.....------Sfs- 1V-
    M.  To be taken half an hour after each meal.

 tie  should have a simple, easily assimilated  diet.
   Before  dispersing for to-day, gentlemen, we would call
 your attention, briefly, to this patient, a female, aged fifty-five
 years, who has been suffering from biliary calculi.
   She was attacked on the 21st of August last with violent
 pain  in the epigastrium, near the lower margin  of  the ribs,
 and  over  the region of the  gall-bladder.   There  was a
 quickening of the pulse,  but no  fever.  The extremities
 soon became cool; the pulse quick, but small  and weak; and
 acute tenderness was manifested over the course  of  the
 hepatic ducts.  I feared a supervention of peritoneal inflam-
 mation • but  expected that  the severity of  the pain would
 abate after a few hours.   Chloral hydrate  was ordered
 to be given, in  large doses,  together with  some morphia; 
190             BILIARY  CALCULI.
also  active  narcotic fomentations were  applied over the
abdomen.
   None of these measures, however, were  successful in
overcoming the pain.  Two  or  three evacuations occurred,
which were thin, and intermixed with mucus, but not of the
clay-color, which would indicate a  retention of the bile.
The acute pain was overcome by keeping the patient stupefied
with chloral hydrate; but for a week she remained in a critical
condition.   She then began to improve.  The  tenderness
over the abdomen remained, however, with a slight tendency
to diarrhcea, but hardly any evidence of jaundice.
   On the 19th of September the patient was again attacked
with the same symptoms, more violently than before.  The
warm  fomentations  were renewed, and chloral promptly
given.   She was also placed in  a warm  bath, and remained
there until symptoms of faintness began to be manifested.
On the second day a moderate  laxative was given;  and on
examining the evacuations, the  calculi  h'ere  exhibited were
obtained.    There  are  thirteen of  them,  varying from
two-tenths to four-tenths of an  inch in  diameter.  They are
of rather irregular outline, and  many of them, having been
apparently worn off at the corners, display very nicely the
concentric layers of which they are composed.
   Since the passage of these, the patient has begun rapidly
to recover;  but now, at  the  end of a  week, there still  re-
mains  some slight feeling of discomfort, nausea, etc., and
the bowels continue irritable, but there  are no signs of active
inflammation.  With a view of preventing the further forma-
tion of calculi, she has been taking six  drops of nitric acid,
well diluted  with water, three times  a  day.  This, however
seems to irritate the bowels,  and we shall  therefore  substi-
tute  liquor potassa, in doses of ten drops, at first, and grad-
ually increasing to fifteen drops.  To improve the condition of 
BILIARY  CALCULI.              191
the bowels, she  may also have some powders consisting of
bismuth sub-nit., six grains, and lupuline, one grain.*
    Another somewhat similar case occurred in my practice
some six or seven years ago.  A Jewish lady had been sub-
ject to repeated attacks of severe pain, etc.  Being called
in the midst  of one of the paroxysms, I was satisfied, from
the  character  and  situation of  the pains,  and from  the
marked jaundice, that it was a case of biliary calculi.  The
nitric acid was ordered for her, six drops to be taken at each
meal-time,  and continued  for several weeks.  She  had one
subsequent attack, a short time after commencing treatment,
but has had none since.
    I can recollect three other cases, where the re-formation
of calculi has been entirely prevented.   In two of the cases
an opposite course of treatment was tried, an alkali, liquor
potassa, being given instead of the acid.
    Our aim in the treatment of these cases should  be, first,
to relieve  temporarily the pain, by narcotics, warm fomenta-
tions, etc.;  and, secondly, to  so change the constitution of
the bile as to prevent  the  future  formation  of new calculi.
Their formation is probably caused by- an excess of choles-
terine in the bile, which  becomes crystalized.  The calculi
formed are sometimes  so large as never to pass through  the
ducts ; but being retained, and blocking up  the  ducts, they
produce permanent derangement, congestion, atrophy, jaun-
dice, etc.
   The  treatment  by either  acids  or alkalies seems  to
accomplish the desired change in the constitution of the bile.
  * The patient soon afterwards went East on a visit, but had three repetitions of the
attacks during her absence ;  a number of calculi being passed on each occasion, amount-
ing to about sixty in all. Siftce her return home, however, during the past few weeks, she
has remained perfectly well. 
LECTURE  XIV.
Neuralgia.—an obscure case.—sciatica.—neuralgia of
   the Rectum.
   The patient before you, gentlemen, is a fair  representa-
tive of a class of cases, which, from their persistence, often
tax the resources of the practitioner to the fullest  extent.
He states that, three years since, he was attacked with pain
in the left hip, principally in the course of the sciatic nerve,
though extending, at times, through to the groin, and a par-
tial loss of motion in the limb.  After a few weeks, the pain
ceased, and he recovered nearly the perfect use of the limb.
During the subsequent two years, he suffered occasional at-
tacks of  pain in the same parts, and the muscles of  the left
leg became weaker than those of the right.  During  the last
year, he has been afflicted with neuralgic pains and  morbid
sensations almost every day, but  extremely variable, both in
their location and severity.   The pains are more  severe in
the hips, and lumbar portion of  the spine, than elsewhere;
but they frequently change from one to the other, and to the
shoulders, arms, legs, especially  the heels, the  neck, head,
and face.  In the head, face, and gums, the sensation is de-
scribed as more of a burning and dryness than' acute pain.
These morbid sensations, whether of heat, dryness, or acute 
NE URALGIA.
*93
 pain, are  extremely changeable, both in their location and
 severity.   They  appear to be influenced some by  atmos-
 pheric conditions, but not in a marked or uniform manner.
 There is no positive paralysis of either sensation or motion*
 although  the muscles of the left leg are  weaker, and  a little
 more attenuated, than those of the right.  His appetite and
 digestion are good, his bowels regular, and his urine  appa-
 rently natural in  quantity and  color.   His countenance
 does not  exhibit the physiognomy, or expression, of severe
 organic suffering, and  his blood and tissues appear  to be
 fairly nourished.   I find no  marks of disease in his fauces,
 or on his  skin; but the Schneiderian membrane throughout
 his nostrils is  thickened, redder than natural, and his nos-
 trils constantly becoming filled with dry, hard, and  black
 crusts.   This condition of the nostrils, he says, has existed
 since his early boyhood, he being now over twenty years of
 age.   He denies all knowledge of  having had any form
 of syphilitic disease ;  but of  his parents  or ancestors I have
 learned nothing.    Such is, briefly, the  history of  the case
 before you.
    If the suffering  of the patient is such as he  describes, it
 is evident that the  case must be classed among the neural-
 gias.  To class it thus, however, does not explain its nature,
 or the essential pathological  conditions  on which the  pains
 and morbid sensations depend.  To aid in arriving at some
 definite conclusions in reference to this, we  may state that
 all cases of neuralgia may be arranged,  pathologically, into
 three groups:
   First — Such as arise from disease, or injury, directly in-
 volving the trunk of one or more nerves.
   Second — Such  as arise from disease  of some portion of
 the nervous centers.
   Third — Such as are caused by morbid  conditions of the
blood.
       17 
194
NE URALGIA.
     In  those cases belonging to the first variety, the pain is
 necessarily limited to  the  single  nerve involved, and its
 branches, as we see in sciatica, tic-douloureux, etc.
     In the second class of cases, where the seat of disease is
 in some part of the cerebral or cerebro-spinal centers, caus-
 ing neuralgic pains in distant parts, such pains seldom follow
 the track of any one nerve ;  but they affect a particular lo-
 cality or section, such as the  forearm, the leg, the foot, the
 side, etc.
     In  the  third class of cases, the pains are limited to no
 one nerve or  part, but  affect many  nerves, and usually
 change  with rapidity from  one nerve, or  set of nerves, to
 another, as illustrated in the history of the case now before
 you.
     The morbid conditions of the blood, capable of causing
 neuralgia, may be either toxemic  or spanemic.   That is,
 poisoned by the presence of some virus, imbibed from with-
 out, or some effete or excrementitious matter, such as urea,
 the materies morbi of gout, etc.;  or  such an impoverishment
 of the blood, in relation to its corpuscles and nutritive con-
 stituents, as renders it incapable of affording the  elements
 for  healthy nutrition  of  the  nervous  structures.   Those
 blood-poisons which, by their  immediate or  remote effects,
 are most apt to so  modify the sensibility of the nerve-struc-
 tures as to cause  persistent and distressing neuralgia, are
 the syphilitic, the gouty, the uremic, and the koino-malarial.
    The effects  of  these  poisons  on the properties of the
 several  tissues, are not limited to the  individuals  primarily
 affected, but may be transmitted, more or less distinctly, to
 their offspring.   This is particularly true in reference to gout
 and syphilis.   Some of the most distressing and  obstinate
 neuralgic  affections of the heart, stomach,  and extremities,
 accompany  the  hereditary diatheses transmitted  by gouty
parents.   I  knew a lady,  in  this city, who was subject to 
NE URALGIA.
195
 sudden attacks of the most excruciating neuralgic pain, in
 the great toe of one foot.  It was accompanied by no swell-
 ing, or redness, or other traces of inflammation.  Her father
 had suffered many years from gout.   It is, doubtless, true
 that a large proportion  of  the  cases  of neuralgia,  arising
 from the syphilitic poison, are caused by a low grade of spe-
 cific inflammation, either in the neuralema  or in the peri-
 osteum lining the bony canals, or orifices, through which the
 affected nerves pass;  but there  are some cases that  cannot
 be attributed to either of these pathological conditions, but,
 from their changeable character, are evidently dependent on
 some morbid condition of the blood, and nerve-sensibility
 generally.   Although the patient before you  admits of no
 known syphilitic influence upon  his own  person, yet the ex-
 ceedingly erratic character of his neuralgic pains—the burn-
 ing dryness of which he  complains—in his  head, face,  and
 neck, in connection with the condition of the Schneiderian
 membrane of his nostrils, renders it quite probable  that his
 condition is  the  result  of  hereditary syphilitic  influence.
 The bridge of the nose is broad, and looks a little swollen;
 and, in examining the nostrils, the Schneiderian membrane
 throughout appears rough, thickened, and constantly secret-
 ing a morbid product, that dries  into hard, black crusts.
   That  a certain degree of syphilitic influence is capable
 of being  propagated to a very remote degree, we have
 abundant clinical evidence.   Hence, we meet  with it some-
 times under circumstances where it would be least expected.
 It is not many months since I saw a lady — the mother of a
 family  of children grown to maturity — who  was laboring
 under such symptoms as had led  her physician to confidently
 believe she  had  serous effusion into the ventricles of the
brain.  On placing my hand on her head, I discovered the
 existence  of no  less than  three  well-marked  pericranial
nodes; and all  her  symptoms of cerebral oppression  dis- 
196
NE URALGIA.
appeared under the subsequent use of iodide of potassa and
conium.
    During the last year, a gentleman, over seventy years of
age, was brought here from a neighboring city, where he had
led an active business life, and enjoyed a high  social po-
sition.  Several months previously, he had been attacked
with what was regarded as apoplexy, or, at least,  dangerous
congestion of the brain.   He was treated  actively by men
of  high  standing  in the profession, and   the first severe
symptoms of oppression and stupor were relieved.   But he
remained with partial paralysis of  one arm and leg;  severe
pains in his head and extremities;  impaired memory; fre-
quent mental hallucinations; and almost entire sleeplessness
at night.   I was told that his case  was regarded by his med-
ical attendants as softening of the  brain, and mostly beyond
the reach  of remedial  agents.   His head being partially
bald,  I thought one parietal region was more prominent than
the other;  and, on careful examination,  a periosteal thicken-
ing, with some tenderness, was found to extend  nearly the
whole length  of one parietal bone.   The patient had noticed
this prominence from the commencement of his attack, and
it  afforded strong evidence that all his  cerebral  symptoms
had been the result of a corresponding  disease, and tume-
faction of the dura mater, pressing upon one hemisphere of
the brain.  All the cerebral and paralytic  symptoms disap-
peared in a few months, under the influence  of country air,
the steady use of six-grain doses of iodide  soda, combined
with  the thirty-second  of a grain of bi-chloride  of  mer-
cury ; and bromide of potassa, at night, to procure sleep.  If
this old gentleman ever had syphilis (which I did not ascer-
tain with certainty), it was, doubtless, more than forty years
previously.  Such cases, with many others that I might men-
tion, are  sufficient to show the necessity of  inquiring care-
fully  into the family history  of  patients  laboring  under 
NE URALGIA.
197
chronic affections of  the nervous system, and of observing
carefully all local developments that  might afford  any in-
formation concerning the constitutional condition of  the
patient.  In the patient before you, the fact that the morbid
condition of the membrane lining the  nostrils, already  de-
scribed, has existed from childhood; the peculiarly change-
able character of his neuralgic pains and morbid sensations;
while the general functions of nutrition, secretion, etc., seem
to be well performed, have led me to think that the consti-
tutional vice, from which  all his distressing symptoms have
arisen, is a remote  effect of the subtle poison about which we
have been speaking.
    If this view is correct, we need  not expect any perma-
nent advantage  from the  ordinary  remedies for  relieving
neuralgic pains.   His only hope of recovery must be found-
ed  on an effort to change his  diathesis, or constitutional
condition.   The  means best calculated to effect  such a
change are as follows :
    First — Regular and judicious exercise  in the open air,
by moderate walking  and  riding, and, if possible, a change
of climate.
    Second—A plain,  nutritious diet, chiefly of milk, farina-
ceous articles, and fruits;  but from  which must be rigidly
excluded all fermented and distilled  drinks, tobacco,  and
strong tea and coffee.
   Third—The use  of  such alteratives  as will be likely
to effect  a  change in  the  elementary properties of the  or-
ganized structures of the body, without materially impair-
ing either the plasticity of the blood, or the general tone of
the tissues.
   The first two of these  propositions need no comment.
The advantages  of moderate exercise,  a  mild  and  dry
climate, plain food, and the exclusion of all nervous stimu-
lants, are obvious to all of  you.   But what system of medi-
                           17* 
198                 NEURALGIA.
cation will effect  the third indication ?   I  shall, at present,
direct a prescription  consisting of—

       rj.—Sodii iod____...................---3 iij.
           Hydrarg. bichlor----------.......----gr. i.
           Ext. conii  fl________________________ §j-
           Syrupi simpl.,
            .            c aa._________________x iss.
           Aqua; mentnae, )                   °
    M.—Take a teaspoonful before each meal, and at bed-time.

    I will have this  continued until it produces a change in
the secretion from  the Schneiderian membrane,  or slight
traces of the  mercurial  influence  on  the gums.   When
either of these effects are produced, the prescription should
be discontinued, and the following given in its place:

        Ij.—Potass, iod______...................3 iij.
           Potass, bromid......._________.......3vj-
           Ext.  conii fl______....._.........___§ j.
           Aquae menthae^____,..............__3 iij.
    M.  Give a teaspoonful from three to four times a day.

    This may be  continued for  six  or  eight  weeks, unless
some unpleasant effects are  sooner induced.   In  the mean-
time, if the patient  becomes in  any degree debilitated, as
indicated by a feeling of lassitude, diminished appetite, and
paleness of the lips,  some  direct tonic should be given, con-
jointly with the treatment just mentioned.   The best tonics
I have  used, in such cases,  have been either a teaspoonful
of the syrup of  pyrophosphate of iron,  given half an hour
after each meal; or a pill, composed of citrate of iron, two
grains, and strychnia,  one-thirtieth of a grain, given  at the
same times.
   A neglect to insist  on good air, and a proper use of
tonics, in conjunction with the usual alteratives, is one cause
of failure in the treatment of such cases as the one under
consideration. 
NEURALGIA.                 199
   Besides the  hygienic  and  internal medical  treatment
which has just been mentioned, I shall direct, with a view
of affording temporary relief, or mitigating the morbid sen-
sations of the patient, anodyne frictions to the whole length
of the spine, each night and morning.   For this purpose, a
liniment, composed of the camphorated soap liniment, four
ounces, and veratria, four grains, is  as  effectual as anything
I have used.   Sometimes,  the judicious application of elec-
tricity  to  such cases will  produce beneficial results.   It
should  be applied in such a manner, however, as  to obtain
its tonic effects, rather than irregular shocks.
   In this adjoining ward  we have present a case of sciatica,
which  it will  be of interest for  us to study in this con-
nection.
   The patient, Mr. M., a native of  Ireland, aged  about
thirty years, was admitted into the hospital between three
and four weeks since. He was thin in flesh, with a depressed
and anxious expression of  countenance; pulse frequent, but
not full;  skin hot;  tongue coated with a thick, white fur;
considerable  thirst; bowels  slightly relaxed ;  and a con-
stant dorsal position.  He kept the left thigh flexed upon
the pelvis;  complained of  a very severe paroxysmal pain in
the outer part  of the left groin, extending at times down the
anterior part of the  thigh, which  was  greatly increased  by
every attempt to move the limb.  The  groin was tender to
pressure, but not visibly swollen.  Alteratives and anodynes
were given internally,  and cloths  wet in the infusion of
aconite  leaves  applied to  the groin and upper part  of the
thigh.  In three or four days the general febrile disturbance
ceased, and the pain changed from  the groin to the hip, or,
gluteal region, extending from  the  left side  of the sacrum
to the  level of trochanter major, and  sometimes  following
the whole length  of the  sciatic nerve and its branches, to
the toes.  There  was a constant dull pain, with  frequent 
200                 NEURALGIA.
paroxysms of great  severity.   The paroxysms were often
accompanied by spasmodic action in  the  flexor muscles of
the limb.  The whole  gluteal region,  and  especially the
trunk of the sciatic  nerve and its origins from the spine,
was  tender  to  the touch.  The  thigh  was partially flexed
upon the pelvis, and  the knee  turned  in, resting against the
knee of  the  opposite side, and  every  attempt to move it
from that position caused the most excruciating pain.  The
skin was relaxed, and  almost constantly bathed in per-
spiration.
   The attention of  the class  is called  to the symptoms of
this  case minutely,  as  it  involves the diagnosis  between
psoas inflammation  and  abscess, hip-joint  disease, and
sciatica.   It  will be  noticed that the pain, commencing in
the groin, and the flexed position of the limb, with the knee
turned inwards, corresponds with the phenomena  of psoas
abscess,  or, at least,  irritation along  the  upper part of the
psoas muscle.  But the  sudden change  of the pain  from the
groin to  the upper part of the hip, leaving, in the iliac and
psoas regions, neither pain, swelling, or tenderness,  together
with the  absence of the rigors  and hectic which usually
mark the commencement of internal abscesses, renders it
almost certain that no inflammation or suppuration  exists in
the iliac  or psoas regions.  Reviewing the symptoms of hip-
disease, in comparison with this case, we  shall find the fol-
lowing marked  differences:   In  the ordinary coxalgia, or
hip-disease,  it commences very slowly, by a simple awkward-
ness in walking, and,  generally, neuralgic pain, referred to the
knee;  and  many months will elapse before  the patient
becomes  wholly  disabled, thus differing  entirely from the
progress  in  the case before  us.   However,  we  sometimes
meet with cases of a more acute inflammation of the syno-
vial  membrane  of the  hip-joint, which may develop  itself
rapidly,  characterized  by  great  pain,  increased  by every 
NEURALGIA.
201
 movement of the limb, and more or  less general febrile
 symptoms.  But in all such cases there  is early and marked
 swelling, with acute tenderness directly  in the region of the
 joint; while here  there is no swelling, although the patient
 has been.confined to the bed for several weeks, and no ten-
 derness,  except in the track of  the sciatic nerve.   Again, in
 hip-disease, whether acute  or chronic, pressure on  the
 trochanter major, in such  direction as to press the head of
 the  femur into  the acetabulum,  pretty  uniformly causes
 pain; while here  no  pain is occasioned  by such  pressure.
 We thus  find, by a close comparison, that some of the essen-
 tial  phenomena of both psoas abscess and  coxalgia  are
 absent, while the  prominent symptoms  actually present are
 such as might result from  irritation of the sciatic  nerve, or
 of that part of the spinal cord from which  it originates.
 Hence, it would be called a case of sciatica.   To  get  a
 rational basis  of treatment, however, we  must pursue  the
 subject of diagnosis still further.  For, at the  bed-side, we
 have found  three varieties of disease involving the sciatic
 nerve, not only differing in their pathology, but also in  the
 therapeutic means required for their treatment.   The first
 consists  in  an inflammation of the neuralema or fibrous
 sheath investing the nerve, and is, generally, of rheumatic
 origin.   It is characterized by a dull, aching pain, extending
 from the  lumbar vertebrae to the upper and outward part of
 the thigh, with irregular  exacerbations  of great acuteness,
 and extending through the whole length of the limb to  the
 toes.  There is acute tenderness over the  origin and  trunk
 of the nerve, but  without  swelling; and  the pain is more
 severe at  night, and greatly aggravated by any movement of
 the limb.  In the early stage  it is  often accompanied by
 slight genera] fever, and sometimes by rheumatic inflamma-
 tion  in other  parts  of the body.   The  second variety is
characterized  by severe  paroxysms of  pain  in the nerve, 
202                 NEURALGIA.
generally commencing behind and above the trochanter, and
extending more or less down the limb, but strictly periodical
in their occurrence; that is, the paroxysms commence about
the same  time every day, or every second day, continue a
given number of hours, and then cease, with as much regu-
larity as the paroxysms of an intermittent. There is, usually,
no fever, and if slight  tenderness exists during  the parox-
ysms,  it  entirely  disappears in  the  intermissions.  This
variety is undoubtedly of malarious origin, being chiefly met
with in districts  where intermittents  appear endemically,
and may be properly styled periodical sciatica.
   The third variety is characterized  by irregularly recur-
ring paroxysms of very acute pain in the  course of  the
nerve, commencing as  suddenly as a current of electricity,
and ceasing equally sudden, and unaccompanied by either
fever or tenderness to  pressure.  When it has continued for
several months, the muscles of  the limb are  generally found
to be more or less  atrophied, and their contractility so much
impaired as to produce a clumsy or awkward gait in walking.
   Both  the causes and the pathology of the third variety
named are involved in obscurity and doubt; and the major-
ity of  cases seem  to be but little  influenced by  remedial
agents.  The second  class of cases  more  generally yield
readily to a judicious use of anti-periodics and tonics.  The
first class of cases, to which the patient before  us evidently
belongs, are generally amenable to such remedies as relieve
sub-acute  rheumatism in other parts of the body.  If we
have  correctly interpreted  the symptoms  of this case, it
consists of a sub-acute rheumatic inflammation of the neura-
lema, or sheath of the  sciatic nerve, from its origin in the
spinal cord to a point a little below the level of the trochanter
major.
   We have before explained, that all inflammations, when
closely analyzed,  are  found to  contain three  elementary 
NEURALGIA.                 203
 conditions, namely : an exalted  susceptibility in  the  struc-
 ture, an altered affinity, and an accumulation of blood in
 the capillaries; and that  these  several conditions exist, in
 very variable degrees of intensity, in different cases, thereby
 causing the different varieties of inflammation.  In all rheu-
 matic inflammations, the first element, which we call exalted
 susceptibility, predominates, causing great pain and  sensi-
 bility of parts, with comparatively little change either in the
 accumulation of blood or  the nutrition of the  part.   This
 is  pre-eminently  true  when, as  in  the present  case, the
 inflammation is in parts immediately investing nerve-matter.
 Hence, in  examining this  man's hip, you do not find  suffi-
 cient  accumulation of blood  in any of  the structures to
 cause a perceptible degree of swelling, or even increased
 local temperature;  and  yet  the  sensibility is  so  much
 exalted that every motion  or touch  causes the most severe
 pain, while the spasmodic  action of  the muscles  shows the
 same exaggerated influence of the motor filaments of the
 nerves.
    These  conditions have an important bearing  on  our
 therapeutic measures.   If  the inflammation was located in
 a highly vascular structure, like the lungs, for example, the
 accumulation of blood  might be  so great, that,  with the
 altered  vital affinity, a dangerous degree of engorgement
 and infiltration  of texture would result.  Hence, measures
 calculated  to counteract or relieve  such  accumulation of
 blood, would constitute a  primary indication in the treat-
 ment.   But in the case before us, the  small extent of the
 texture  involved, and  the little  comparative vascularity,
 renders this indication  of minor importance; while  the
 extreme exaltation of susceptibility in the  enclosed nerve-
 structure calls for the use of such agents as tend to subdue
 this, as  a primary step  in  the treatment.  You are already
aware, from previous instruction in these wards, that rheu- 
204
NEURALGIA.
matic  inflammation is very generally regarded  as  arising
from the retention of  some effete and disturbing element in
the blood;  and, consequently, that  the  first object of the
physician should be, either to expel by elimination, or neu-
tralize by chemical agents, this supposed  irritant.
    Without denying the correctness of this doctrine in rela-
tion to the essential  cause  of rheumatic inflammation, we
must caution  you  against a prevalent tendency  to restrict
our attention  entirely to this, and the remedial measures it
suggests.   You must  remember that an inflammation, or
any other morbid  process, does not always cease with the
cessation of the efficient cause which excited it to action.
    Hence,  though a  removal  of the cause may be a pri-
mary indication, it does not  necessarily supersede all other
indications  for treatment.  On  the  contrary, a morbid pro-
cess, like inflammation, once established  in any given struc-
ture, may persist,  accompanied by great pain, until it results
in serious  change of structure  by effusion, infiltration, and
induration; or, in destruction by suppuration and gangrene.
    For reasons already given, we have  little to fear  from
any of these changes of texture in the case before us;  con-
sequently,  it  presents but  two  prominent  objects  to be
accomplished by treatment:  First, to remove the exciting
cause; and, second, to overcome the extreme susceptibility
and consequent pain which has been engendered  in the
affected nerve, and the parts  on which it is distributed.  On
the first admission of the patient, we endeavored  to accom-
plish these two objects, by using such remedies as promote
excretion, in  conjunction with such as directly diminish
morbid susceptibility.   We gave the  following:
       5 •—Vin. colchici_______________.......___5i.
           Tinct. cimicifugae__________________„. _ ? ii,
           Tinct. verat. viridis__________........3 i,
    M.  One teaspoonful every four hours, with the following powder at
bed-time : 
NEURALGIA.
205
       3.—Pulv. opii___________......-........-grs. ii.
           Potass, nitratis_____................- grs. x.
           Hydrarg. chlor. mit___...............grs. ii.
   M.
   At  the same  time, we  kept the groin and hip covered
with cloths wet in a warm  infusion of aconite leaves.  In
less than forty-eight hours the general febrile symptoms had
disappeared;  the skin and kidneys acted freely ; the tender-
ness of the nerve-tracks had diminished; but the paroxysms
of pain and spasmodic action of the muscles of the thigh
continued.   The tincture  of veratrum viride was now
omitted from the  first prescription, and, otherwise, the same
treatment continued.   The  next day, the pain and tender-
ness had left the groin entirely, but remained severe in the
origins and trunk of the sciatic nerve.  The patient had
sweat copiously,  and the kidneys had acted freely during
the whole of  the past three days; and now, the colchicum
began to  move  the  bowels too freely.  We continued the
same applications externally, and gave, internally, the fol-
lowing :
       3.—Pulv. opii!___________________.......-grs. x.
           Potass, nitratis.......--.............grs. xxx.
           Pulv. Doveri.......__________________grs. xxx.
   M.  Fiant pulveres vi.  Give one every four hours.
   The questions now arise, why does the pain continue ?
and what further  remedial agents are called for ?   You have
already been cautioned against relying too exclusively upon
such means as are calculated merely to remove the exciting
cause of a disease.   The case directly before us proves the
necessity for that caution.  For three weeks, all the important
excretory  organs  have been kept active;  and for more than
one week the fluids of the body have been freely saturated
with alkaline salts.  Hence, if the disease  depended upon
the presence of any acid irritant in the system, as the prevail-
       iS 
206                 NEURALGIA.
ing doctrines of the profession claim, it certainly should have
been either  eliminated or neutralized.   It is true that, under
the past  treatment,  all  general  fever has  disappeared,
and the local tenderness has much diminished; but the pain
and  spasms,  depending, as  we suppose they do, on the
irritation or morbid susceptibility of the nerve-structure, still
continue.    May not  this continuance of  nerve-irritation
depend, in part at least, on too  great a relaxation of struc-
tures,  or,  in other words, debility, favored by the excessive
elimination of the past two or three weeks ?
   Whatever may be the theory we may adopt  for explain-
ing the condition of the patient, it is certain that he is now
much debilitated,  and all his structures relaxed;  and yet, a
fixed position of the limb, with frequent and excessive par-
oxysms of pain.   Hence, the indication for further treat-
ment  plainly consists  in the  use  of  such agents  as will
strongly diminish  nerve - irritability and pain, while they
increase the  vital  affinity and consequent tonicity  of the
tissues.  For this  purpose, no  more efficient  combination
can  be found than that of  opium, with  quinia, given in
moderately large doses.   Sometimes, however, opium, when
thus administered for several days in succession, checks too
much the action of the kidneys.  This can be prevented by
adding nitrate of potassa to  the  other ingredients.  We shall
therefore  direct, for this patient, the following :
        3 •—Quiniae sulph........_...............grs. xxiv.
            Pulv. opii............___....._______grs. xvi.
            Potass, nitratis _....._...............grs. xl.
    M.  Fiant pulveres viii.   Give one every four hours.
   At the same  time  we shall cause  a small  blister to be
made just above the left  sacro-iliac junction, the cuticle to
be removed, and half a grain of morphia applied to  it each
night  and  morning,  with a dressing  of  mild  mercurial
ointment during the interval.  If the pain becomes subdued, 
NEURALGIA.
207
and  the  patient  sleeps, we  shall gradually diminish  the
quantity  of both  quinia  and  opium, aiming to so adjust
the doses as to keep the pain under control, without stupe-
fying the patient.   If necessary, a fresh blister will be made
over the track of the  sciatic nerve, every two  or three
days.*
   Another case that occurred in my practice, a short time
since, was that of Mr. M., a laborer, who was attacked rather
suddenly with severe pain in the rectum, while at his work.
I saw him on the  following day, when I found him in bed,
with no fever, only slight quickening of the pulse; no coat-
ing on the tongue, and temperature natural; but suffering
excruciating pain  in the  rectum.   It was  accompanied by
no tenesmus or straining  at stool, and no outward swelling.
The interior  of the rectum was very sensitive to the touch,
but there were no haemorrhoidal tumors within reach of the
finger, and no point of hardness and swelling, such as would
indicate cellular inflammation tending to  the formation of
an abscess.  Such acts as coughing, straining, or passing of
wind from the rectum, rendered the pain more  severe.
   The patient was directed to  remain at  rest, and take
eight grains of Dover's powder every three  hours  until the
pain was  relieved.  The next day, I found him still suffering
from the  pain, unchanged, with the addition of nausea and
moderate dysuria.   I now directed warm narcotic fomenta-
tions to  the  perineum  and  hypogastrium, and, instead of'
the Dover's powder, gave sulphate of  morphia, one-third of
a grain, with bi-carbonate of soda, five grains, every four
hours.    The following  day  I  found him  still suffering
paroxysms of extreme  pain in the  same locality as before,
with extreme  nausea and efforts at vomiting, cool extremi-
   * Two weeks later, the patient was slowly recovering, without any material altera-
tion in the plan of treatment just set forth. 
208
NEURALGIA .
ties,  and great sense of prostration.  Being  satisfied that
most of the nausea and prostration  was occasioned by the
opiates, I omitted their further use, and directed the follow-
ing treatment:

       3.—/Ether nit___......-----.....-.....1 ij-
           Tinct. belladonnae--------------------3 ij-
   M.  Give a teaspoonful in sweetened water every four hours.

   Also twenty drops of tincture of belladonna in half a
teacupful of milk-warm water, to be used as an enema, and
repeated every three or four hours, until the pain was relieved,
or the pupils became dilated from the effects of the bella-
donna. This treatment has been followed by very prompt
relief to both the nausea and the pain, and no further treat-
ment is required.
   Mr. H., a young man of good  habits, but  nervous tem-
perament, the night after having sat on the  damp ground,
was attacked with extreme paroxysmal pains in the  rectum,
with tenderness to pressure  at the lower end of the coccyx,
but no swelling or redness.
   The intestinal evacuations had been previously regular,
and  there was present no decided febrile disturbance of the
system.  Any motion of the body by which the rectum was
disturbed,  greatly aggravated the pain.  The local tender-
ness near the lower end of the coccyx, led me to regard the
case, at first, as one of cellular inflammation, such as usually
results in  the formation of an abscess, afterwards  followed
by a fistula.   I consequently enjoined  rest, narcotic fomen-
tations to the anus, and gave pulv. Doveri internally, to pro-
cure sleep.   After pursuing this treatment  for two days,
without any decided  change in the  symptoms, I caused the
bowels to be moved  by a saline  cathartic, the operation of
which was accompanied by severe rectal pains, and followed
by no relief to the patient.   Enemas, containing tincture 
NEURALGIA.                 209
 of opium, were used after the bowels had been  evacuated,
 but afforded partial relief only so long as their effects were
 sufficient to stupefy the patient.  After the patient had been
 under treatment three full days, finding the pain and mor-
 bid sensitiveness of the  rectum nearly the  same as at first,
 and yet  no  point of swelling and hardness in the vicinity
 of the anus, such  as always indicates the  approach of an
 abscess,  I became satisfied that the case was one of neural-
 gia, and  directed the following treatment:
       5 •—Chloroformi____....._________________3 iij.
           Tinct. belladonnas____________________3 iij.
           Syr. aurantii corticis___________________| iij.
    M. Take a teaspoonful every two hours, until  the pupils become
 slightly dilated, when the interval between the doses should be increased
 to four hours.
   He was  also  directed to have twenty drops of the tinc-
 ture of belladonna, in half a teacupful of warm water, inject-
 ed into the rectum  each morning and evening.  Under this
 treatment, the pain almost entirely subsided  during the first
 twenty-four  hours, and in three days the patient was able to
 leave the house, quite well.   In two other cases,  of similar
 character, relief was speedily obtained by the  internal use
 of an  equal mixture of  tincture  belladonna  and  tincture
gelsemium, taken in doses  of twenty drops every two or
three hours.
18* 
LECTURE  XV.
NERVOUS AFFECTIONS. —Spinal Irritation. —Hemiplegia.—
    Partial Hemiplegia. — Paraplegia. — Progressive Locomotor
    Ataxia.
   Gentlemen :—This man tells us that, some six months
ago,  while engaged  in  sinking a  shaft in the vicinity of
Morris, in this State, he was attacked with pain in the an-
terior portion of the thigh, stopping  short  above the knee.
The  pain, however,  soon extended to the iliac and lumbar
regions, and subsequently across to the epigastrium, which has
continued since the last of July, with but  little relief.  He
has been under treatment for rheumatism.   I first saw him
at my office one or two weeks since.   I find, on examining
the spine at the lower, or next to the lower, lumbar vertebrae,
there is a little prominence.  There is but  little tenderness
over the  spinous processes, but directly along the right side
of the vertebrae, for several inches, it is extremely sensitive,
and  seems to be  almost exclusively limited to  the right
side.   There  seems  to  be a little swelling,  which may be
due to dry cups, that were applied two days since.  He will
allow any degree of flexion of his  thigh; but if you extend
the leg and carry it back of  its fellow,  the pain is reflected
along the margin  of the  crest  of  the ilium  and abdomen 
NERVOUS AFFECTIONS.
21 I
If he sits down, or stoops to pick up  anything, instead of
bending forward  as a well person would, he  squats  down,
endeavoring to keep his spine as straight as possible.
   This symptom is of great value  in  forming a diagnosis,
and raises the question as to what the disease is, and what
has produced it ?  To the experienced observer, his  symp-
toms immediately suggest one  of the  three  following dis-
eases :  First, inflammation of  the  psoas  muscle, or ad-
jacent areolar tissue, tending to the formation of an  abscess;
second,  disease  of  the vertebrae;  third, inflammation of
the right half of  the spinal  cord.   Any one of these three
diseases would  be brought  to  mind  in  the  investigation.
First, we will take up affections  involving the psoas muscle.
Pain in the front part of the thigh and abdomen would first
lead us to  suspect that this muscle was involved.   The first
effect of inflammation in contact with a muscle, is to render
it rigid.   The tendency, if the  psoas muscle  is inflamed, is
to relax the abdomen by flexing the thigh on the pelvis.  If
he puts his leg down straight, or stands square on  his feet,
he will lean his body forward, so as to  still relax the muscle
on the anterior part  of  the spine; and, if  in bed, he will be
found to have the thigh drawn up. The pain accompanying
psoas abscess is dull  and deep-seated, extending from the
abdomen to the junction of the lumbar vertebrae, and across
by the  crest of the  ilium.  The most  diagnostic  signs are
pain down the thigh, and in one side of the abdomen, and the
flexion of the thigh.   If asked to flex the thigh strongly, he
cannot, the pain being much increased.  If you examine the
patient while on  his back, you  will  generally find, on pres-
sure, a degree of tumefaction along the inside of the anterior
part of the  crest of the  ilium, or  a sense of fullness and
tenderness, which does not correspond to the opposite side.
In the present case none of these  symptoms are present,
except the  pain in the anterior part of the thigh,  and pain 
212          NERVOUS AFFECTIONS.
in extending the leg backward.   Is the disease in the verte-
brae ?  One symptom  exactly  corresponds with the early
stage of  spinal disease, viz.: the mode of stooping  down,
which may be  noticed  in  children who have spinal disease
coming on, even before they complain much.  Instead of
stooping  over, they will squat  down;  and  if they  can
reach anything to support  them in rising, they will do so.
This symptom, however, is not restricted to  disease  of the
bones of the spine, but may be present in any affection that
renders the spine sore.
   Six months have elapsed, and  there  is no  perceptible
alteration,  except in the one  spinous process previously
mentioned ; hence, we  are not justified in  saying that he has
disease of  the vertebrae from the manner  of stooping alone.
   The tenderness along the sides of the vertebras is acute;
while in disease of the  bone there is rarely any muscular
soreness  or neuralgic pains,  until the disease has progressed
to such an extent as to make some degree of deformity per-
ceptible ; then you have  severe paroxysms of pain  in the
epigastric region, in the  intercostal spaces, or horizontally
around the abdomen.  There is seldom any evidence, in the
early stage, of interference with muscular action.   But in
this  case, pain in the muscles was one of the first symptoms ;
and, taking this together with the facts that  it is  of six
months'  duration, and  no deformity; while the pain follows
certain nerves, with  acute and  severe  tenderness  along the
right side  of  the spine;  increased by exercise, and occa-
sional cramps in the abdominal muscles;  all of which point
to the  right half of the spinal  cord, corresponding with the
lower half  of the dorsal vertebrae, as the seat  of disease.
   Both sets of nerves are involved—namely, those of sen-
sation  and motion.  From a close investigation of his case,
my opinion is  that he has chronic inflammation of the mem-
branes of the spinal cord,  along the lower third of the dorsal 
NERVOUS  AFFECTIONS.          213
vertebrae.   If that is the case, has  it produced any disor-
ganization  of structure ?  We  answer no, or it would have
left him with paralysis;  and, if there was effusion, this would
certainly have produced paralysis in some degree.   If it be
simple chronic inflammation, involving the  roots of nerves,
what is the appropriate treatment ?   We  answer, dry cup^
ping, followed by belladonna plasters, or hypodermic injec-
tions of atropine ; and, internally, we will first  put him on
the following treatment:

       R.—Tinct. cimicifugae_____________________§ij-
           Tinct. stramonii______________________Sss-
           Potass, iod___________________-......3 iiss.
           Syr. simpl___________________________§ iss-

   M. Give a teaspoonful  every four  hours, and,  three times a day, a
powder, consisting of—

       E .-Potass nitratis, )...............    viii
           Pulv.  Doveri,   C                   s
           Hydrarg. chlor. mit----..............gr. i.

   The calomel to be discontinued as soon as  its  alterative
effects are perceptible in the breath  or gums.
   These means, with  rest  in the  horizontal position, will
be likely to remove the  disease in from four  to  six weeks.
   Common tumblers form  good cups for broad surfaces
like the back, as was shown by their application in this case
before the  class.
   This  next patient  had  been in  good  health, and  was
attacked suddenly with  violent and well-defined pain in one
side of the head,  followed by fever and continued pain, which
caused it to be styled brain fever, and lasted  for a week or
more, at the end of which time she was  found to have com-
plete hemiplegia, and was brought to the hospital.
   On admission, the pain had not entirely  gone ; pulse was 
214
NERVOUS  AFFECTIONS.
slightly accelerated, not full, but strong; heat of the surface
slightly elevated, with somewhat increased sensibility in the
paralyzed parts.
   Paralysis was observed over one entire side of the body;
one-half of the tongue being  slightly affected; the arm and
leg, on that side, utterly destitute of motion, but control of
the sphincters was still perfect.  It is the left side which
is paralyzed,  the  pain in  the head having been  in the
right side, at  the  junction  of the frontal and right parietal
bones.
    The  suddenness of the  attack, the fever, and continued
pain  in  the  head, with hyperaesthesia and loss of motion,
led me to  attribute it to capillary congestion of the interior
portion of the right anterior lobe of the brain, coming sud-
denly, developing severe  pain, and leaving some  degree of
exudation; but probably not sufficient actual extravasation
of blood to form a clot.
    Either one prompt bleeding, or leeching, at the outset,
before sufficient exudation had taken place to cause paraly-
sis, would have exerted a good influence, especially if fol-
lowed by  sedatives  to  take off the  increased force of the
circulation, keeping the bowels open, cold to  the head, etc.;
but the time for these remedies  had passed by, and the
patient was already paralyzed. She was accordingly put upon
the following  course of treatment:
        R.—Potass, bromid.......................3 iv.
           Potass, iod.....------.........----3 ij-
           Aquae________------........-----§iv.
    M.  One teaspoonful every four hours.

    Directed her to be kept at rest; the bowels to  be moved
with laxatives, if necessary.  In the first few days there was
no change, except a gradual decline of the pain in the head.
    The  next  improvement  observed was diminished  hyper- 
NERVOUS AFFECTIONS.          215
sesthesia, but without  much indication of  change in the
motor power.  In about ten days, however, she was able to
stand, and from  that began to walk, but in a very awkward
manner, characteristic of this form of paralysis, carrying the
foot forward by means of the muscles in the upper part of
the thigh ; the outer muscles seem to be more paralyzed than
those  of the inner side of the limb, so  that in walking the
toes turn outward.
   After she began to walk, from  some cause unknown,
probably over-excitement  of the mind, the pain  came back
in the head, which was subdued  in two or three  days by
giving in  addition to the  other medicine, twenty grains of
bromide potassa with a little chloral, and directing her to
be kept perfectly still.  Yesterday, for the first time, she
was able to raise  the arm.
   The patient  is a little  too anxious, and will be apt to
overdo ; but if we can keep the nervous system composed,
and induce regular and systematic exercise, she will doubt-
less gradually regain the  use of- the parts.   Our success
 in the management of  these cases depends upon the proper
 adaptation of treatment to the successive stages of the dis-
ease.   In the use of the bromide and iodide we bring in an
alterative, combined with  a moderate sedative and quieting
influence, allaying morbid  sensibility, and promoting absorp-
tion ;  when this  has been  accomplished,  we  shall begin,
very cautiously, little by little, with another class  of reme-
dies,  viz., nerve-tonics, of which  strychnia stands at the
 head.
    The "great thing is to know when to leave off the altera-
tive and begin with the tonic treatment; if we commence
 the latter too quick, it will bring on a return of the pain in
 the head, prostration, fever, and  loss of power; if deferred
■ too long, the patient will  cease  to  improve and become ex-
 hausted, grow pale and feeble. 
216          NERVOUS  AFFECTIONS.
   Treatment should be so conducted as to remove the in-
flammatory action, and get rid of the exudation ; then, and
not before,  commence giving the  other class of remedies.
I have usually withheld tonics as  long  as hyperaesthesia or
muscular rigidity remained.
   You will notice in the  early stage  of paralysis, from in-
flammatory action especially,  that hyperaesthesia will be the
rule, with more or less actual stiffening or  rigidity in  the
paralyzed part.  As long as these  conditions exist, you are
safe in acting upon the rule, that no benefit will be derived
from the use of strychnia, or the different varieties of electric-
ity, galvanism, and other stimulating agents.
   When hyperaesthesia ceases, and there is flaccidity of the
muscles, you will find it advisable to gradually diminish the
sedatives and  alteratives, and commence the use of nerve-
tonics ;  feeling your  way carefully by introducing the bat-
tery very lightly at first; giving moderate  doses of strych-
nia, one-sixtieth of a grain, morning  and  noon, while you
continue  the bromide and  iodide after breakfast and at
bed-time.  If this is  well borne, the potassium mixture may
be limited to supper and bed-time, giving the strychnia three
times a day, afterwards increasing the dose to one-fortieth of a
grain, and giving the solution of the bromide at bed-time only,
which will contribute to sleep, and keep the secretions free.
In this way a full restoration  to  power and normal sensi-
bility may be  brought  about, usually in  from one to three
months.
   We shall continue to pursue the present  order of treat-
ment in  the  manner  alluded  to.   The  question  as to
the probability of a full and perfect  recovery,  depends
on  whether  positive  sanguinous  extravasation  has taken
place; if not, the  mere  inflammatory exudation  can be
made to  be  re-absorbed,  and function restored.   If  san-
guinous, we  shall be unable  to bring about re-absorption 
NERVOUS AFFECTIONS.
217
of the fibrinous  material, the brain in the vicinity will re-
main hardened, and  its functions permanently suspended,
ultimately proving  fatal from altered nutrition and disin-
tegration of brain substance.
   The next case to which I propose to  call your attention
to-day is one of partial hemiplegia.   The patient  is a car-
penter, and says that, two or three months before the attack,
he was  at times light-headed  and dizzy,  and was  afraid
to venture upon the  scaffolding, and  consequently went to
work in  the shop.
   It seems that, the night of the attack, the patient was
out later than usual with some friends, and during the evening
had indulged in a glass or two of stimulants, but not enough
to feel the effects to such an extent that he did not  know all
that  occurred.  After parting with his  friends, he started
for home.  Before he proceeded far, however, he  says that
he was  gradually taken blind  and dizzy, and  finally  fell
on the sidewalk, and became partially unconscious.  When
he recovered  himself, he found he had no power in his
right arm nor leg, but succeeded in dragging himself to  a
doorway.
   Until within the past week, he has been under treatment
at Madison,  Wis., where he was living  at  the time of the
attack.   At present, you would  hardly know that his leg was
affected in walking ;  but, on  closer observation, you would
notice that  he raised it with difficulty when attempting to
step over anything.   His face has improved equally with his
leg, but  his  arm is still nearly useless.   Can  shut his hand
quite tight,  and has a good  degree of power in  the flexor
muscles ; but  the action of the extensors is much  impaired,
and  supination is also  rendered imperfect.  This shows us
that the whole set of extensors, from  the shoulder  down, are
more feeble than the flexors.
   The first item which we wish to investigate is the seat of
        19 
218          NERVOUS AFFECTIONS.
the disease.   The  paralysis of the arm and  leg are but
symptoms,  and  may arise  from three  sources:  first, the
muscles themselves, as  in  lead palsy;  second, the spinal
cord; third,  the brain itself.   The symptoms  of giddiness
and  the paralysis, extending to the face, must necessarily
involve the nerves within the cranium; hence we refer it to
the brain.  If there had been no paralysis of the  face and
tongue, we might have presumed it was in the  spinal canal.
The patient's mind being clear, while there is giddiness and
dimness of vision at times, we  refer the  seat of disease to
the base and central portions of the brain.
   In determining the nature of a disease  like this, it is
essential to  get as accurate a history of the  case as pos-
sible.
   First, we may  have paralysis  come  on  suddenly, with
severe pain, as in the case of the patient up-stairs, to which
your attention was a few days since directed, indicating a
pathological  change of an apoplectic character.   In this
case it has come on gradually, and became fully developed
when under the effects of stimulants.  Rest  improves his
muscular power, while exercise uniformly exhausts it.  This
would indicate  the existence  of some  gradual change at
the base  of the brain, like syphilitic thickening of the dura
mater, the  growth  of a  tumor,  or gradual  softening  of
brain substance.  We will endeavor  to draw the  line  of
distinction  between  these pathological conditions.  The
symptoms  of white  atrophy  or  softening  do not corre-
spond to  those  of  the case before us.   That disease comes
on insidiously,  by  simple impairment  of the  muscular
power, the legs or arms  requiring an  extra  exertion on  the
part of the patient  to use them.  It is a gradual weakening,
which, when once  begun, continues on worse and worse,
and involves loss of co-ordinating power and strength, with-
out complete paralysis, until the last stage of disease. 
NERVOUS AFFECTIONS.
219
    Now this man was not progressively losing the strength
 and co-ordinating power of his muscles, but merely giddiness
 and headache, and instead of steady increase of his disease
 under treatment he has been decidedly improving, and now
 only complains of paralysis  of the right arm, with pain  in
 the shoulder of the affected  side, and  occasional darting  of
 pain up the back part of the head.
    It seems  that, several years ago, this patient contracted
 syphilis ; and he now has maculae on the skin, and what  he
 calls  catarrhal disease in the nostrils.  And it  is  highly
 probable that his giddiness and paralysis arise from thicken-
 ing of the dura mater over the sphenoid bone.
    It is of the utmost importance to ascertain the cause,  in
 such cases as this, in order to know how to treat the disease
 intelligibly.  He  has  been taking iodide of potassium and
 strychnia; and I  think, had the iodide been  combined with
 minute  doses of the bi-chloride of mercury, it would have
 benefited  him still  more.   The  question is,  has the disease
 involved the bones — either the  ethmoid and palate, or any
 portion  of the  sphenoid ?   If it  has, the prognosis will  be
 unfavorable, although it may not  terminate  fatally for three
 or four years.  If it is confined  to the  soft  parts,  we would
 expect a recovery.
    Viewing the case in this light, we will put him on the
 following  treatment, with  an occasional intermission  of a
 week :
       R.—Sodi iod______....................3 "j-
           Hydrarg. bichlor.........----------.. grs. j.
           Syr. et aquae_____________.........-- § iv.
    M.  One teaspoonful  four times a day.
   We will  also use a weak  solution of carbolic  acid as  an
 injection,   which  may be  applied  by means of  a curved
syringe  through the posterior nares.   We may derive some
benefit from muscular tonics when the  muscles are flaccid ; 
220          NERVOUS AFFECTIONS.
but strychnia  and electricity should never be used to any
extent, if there is rigidity of  the muscular fibres.
   Under  the  foregoing treatment, we  may expect  the
patient to recover a good degree of health, and the use of
his arm, in from  four to six weeks.  It will  depend, how-
ever, upon whether the bones at the base of the brain are
affected or not.
   This next  patient  is a man  about forty  years of age,
native of Ireland, and has been in the hospital two or three
months.   He is thin in flesh; pale or anaemic ; his eyelids
affected with chronic  inflammation ; tongue clean ; respira-
tion  and  pulse natural; skin  rather cool;  appetite and
digestion moderate;  bowels nearly regular once a day; and
urine also nearly natural in quantity.   But the patient has
only partial control over the passage of either urine or faeces,
and can exert  only a very limited  motor influence over the
lower extremities, merely being able to draw up  the  feet a
little and  extend them again when lying down.   The lower
extremities are also extremely emaciated and nearly desti-
tute  of sensibility, yet subject to frequent spasmodic twitch-
ings.
   At the time the patient was first admitted to the hospital,
all the parts below the crest of the ilium  and the junction
of the lumbar  vertebras with the sacrum, were completely
paralyzed, both in regard to the sensation and  motion.  The
faeces and urine passed without the knowledge or control of
the patient, and the lower extremeties were entirely motion-
less and anaesthetic.
   He is a man who has long been addicted to the use of
intoxicating drinks, and had been under treatment by some
physician  for a chronic  affection  of his eyelids  some time
before he was  attacked  with the  paraplegia.   This case is
undoubtedly one arising primarily from  morbid  nutrition
of the lower  third  of  the  spinal cord.    This  class  of 
NERVOUS AFFECTIONS.          221
 patients, by using  such drinks as interfere with the  natural
 metamorphosis of  tissue and  excretion, especially of the
 waste  carbonaceous  matter,  thereby  encourage  fatty de-
 generations of structure in various parts of the  body.  In
 most cases these structural alterations  take place most pro-
 minently in the liver and kidneys; but in others the  change
 appears to affect the coats of the vessels in the  brain and
 spinal cord, weakening them by the deposit of fat granules,
 until, in the brain, they yield to the pressure of the contained
 blood, permitting extravasation and apoplexy, or hemiplegia.
 The same process in the spinal cord would result in the pro-
 duction of various  morbid sensations  and weakness of the
 lower extremities, and when the extravasation takes place,
 more or less complete paraplegia.  The  prognosis in  such
 cases is decidedly unfavorable.  Under the influence  of
 proper  nourishment,  good air,  and the judicious  use  of
 tonics (not exhilarants), they will often slowly improve, un-
 til, as in this  case, they regain some  sensibility and a very
 limited  power of motion in the  paralyzed  parts.  At that
 point the  improvement usually  ceases,  and the patients
 remain apparently almost stationary for weeks and months;
 but in truth the  nervous centers involved are undergoing
 atrophy, or softening from defective nutrition, and  eventu-
 ally the patients die from asthenia.
   This  patient has  been taking a combination of citrate
 of iron, quinine, and extract of nux vomica  during most of
 the time that he has been in the hospital.  When the  spas-
 modic  twitchings have been troublesome,  and his  nights
 restless, he has had from fifteen to twenty  grains of either
bromide  of potassa, or of hydrate of  chloral, at bed-time.
 His diet has been plain and nutritious; and constant atten-
 tion  given to cleanliness  and proper ventilation.   Close
attention to the hygienic management of  such patients is of
the highest importance ; otherwise  their  imperfect  control 
222          NERVOUS AFFECTIONS.
over their evacuations will keep the bed foul, the air of the
room impure, and  speedily induce large  and. tormenting
sloughs or bed-sores on the hips and sacrum, and  materially
hasten the final exhaustion of the patient.
   This  patient that  we now bring before you  presented
himself a few days ago at the dispensary, for treatment, and
the physician in attendance, finding it a case of unusual in-
terest, has brought him in for your inspection to-day.
   Rather more than a year ago, the patient was attacked
with a sensation of  weight or bearing-down in the left groin,
and  extending around to  the  lumbar  region,  especially
troublesome  when he walked or attempted to go up-stairs.
A short  time after  the commencement of these  symptoms,
he had a sudden attack of blindness.
   The  blindness  was  partially relieved  in a short time,
although the  sight  has never been fully restored; and the
bearing-down sensation, with some twitching, jerking in the
muscles,  has continued, more  or  less up to the present
time.  The course of the lower two-thirds of the spine, the
region of the left groin, and the entire surface of the lower
extremities, you notice, is very sensitive to the touch.  The
slightest  touch  at any of these points causes quite as much
or more  pain than is produced by more  decided pressure,
showing  plainly that  there  is a mere morbid  sensibility of
the parts, and not an inflammation in them. As the patient
entered the hall you noticed that he was somewhat uncertain
in his movements, and inclined to steady himself by the
table, chairs, or whatever was within his reach.   When we
requested him, however, to walk a short distance before you,
by directing his course to a  certain  point  and  fixing his at-
tention upon his movements, he controlled them  sufficiently
so that there was no apparent unsteadiness in his gait; but,
had  his attention been suddenly withdrawn, he would prob-
ably  have reeled,  and been  inclined  to fall.   There  is, 
NER VO US A FEE C TIONS.
223
  evidently, no paralysis present here, but the difficulty  is
  owing entirely to an impairment of the power of co-ordina-
  tion.
    The impairment in this  case  is so slight that  the un-
  steadiness of the movements would not ordinarily be noticed
  without the  attention was directed  specially  to them.  In
  cases  further  advanced,  the  gait becomes  unsteady and
  reeling,  as that  of an  intoxicated person.   Special  diffi-
  culty is  experienced in mounting stairs, on  account of an
  inability to raise the  feet from  step to step.   The patients
  frequently complain of acute pains, of a variable character,
  like those  of rheumatism, moving from one  organ  or por-
  tion of  the  body  to  another.   Perverted sensations, not
 actual pains, are  also  experienced, such  as thrills  and
  jerkings in  the  muscular  structures,  like shocks  from a
 galvanic battery.   These alterations  of sensibility are de-
 rived from the  nerves  of sensation,  and  are associated
 particularly with  this condition  of  failing co-ordination.
    Should pain in the head and dizziness be complained
 of among  the prominent symptoms, some disease  in the
 cerebrum  or  cerebellum  should at  once be suspected.
 When, however, the first and most prominent symptoms are
 a morbid sensibility of the extremities and impairment of
 co-ordination, we may be pretty sure that we have a case of
 progressive locomotor ataxia.
   The progress of the disease is slow at different stages of
 its course;  it may even remain  stationary for considerable
 periods.  Its  progress  is  always resumed,  however,  and
 generally continues to  the  end, in spite of any course of
 treatment which has, as yet, been discovered.
   Sudden  attacks of  blindness, either partial  or total, al-
 most always occur  in  connection with the disease.   Fre-
quently, dark spots  are perceived, apparently floating before
the eyes, and  the pupils are largely dilated.  Where  oppor- 
224          NERVOUS AFFECTIONS.
tunity has been offered for examination after death in these
cases, the optic nerve  has been found to be  more  or less
atrophied.   The principal lesion, however, consists of an
alteration in the deposit of nerve structure  in the lower
spinal cord.  This alteration  may be  limited to a space of
not more than two or three inches in length, and consists in
a deficiency of nerve substance, and a substitution for it of
amylaceous or fatty matter.   The fibrous or connective tis-
sue of the cord is  not atrophied, but rather increased or
thickened.  This atrophy extends  also to the roots of the
spinal nerves.
    The direct cause of the disease is involved in obscurity.
All the cases that I have met with have occurred in persons
addicted  to  the  immoderate use of tobacco, and I am in-
clined to consider  this a predisposing  cause,  although it
cannot, of course, be considered a direct exciting cause.   I
think the excessive use of tobacco retards  nervous growth
and nutrition.  Other  influences have  also been assigned as
predisposing causes, such as excessive  sexual  excitement,
either  solitary or social.  It would be  logical to suppose
that everything which  exhausts and impairs nervous nutri-
tion, would act  as a predisposing cause—a damp, change-
able climate, and  occupation in damp, unhealthy rooms,
would be classed among these causes.  It is probable,  how-
ever,  that there  is  something in the  system  of the patient
which acts as the direct exciting cause.
    As regards the possibility of checking the progress of the
disease  by any course  of treatment, we must confess that
experience has not given us the best encouragement to hope
for favorable results.   It  used  to be the custom to blister,
cauterize, introduce setons, etc.  These  measures  were
found, however, to only hasten the development of the dis-
ease.   Alcoholic stimulants, recommended by some  authori-
ties, are also contra-indicated, on account of their action in 
NERVOUS  AFFECTIONS.         225
retarding healthy nutrition, and promoting the tendency to
fatty degeneration.  What we wish to accomplish is, to bring
back a healthy nutrition of the nerve-structures.   Phos-
phorus is well  known to be an abundant element in nerve-
structures ;  and we may expect, therefore, to derive some
benefit from the administration of phosphoric acid and the
phosphites.   We generally prescribe  phosphoric acid, com-
bined with  compound syrup of the hypophosphites; a tea-
spoonful  before each  meal.  To lessen the morbid sensa-
tions,  we think that fluid  extract  cannabis  indica,  ten to
fifteen drops, three times a day, is  the  most appropriate in
these  cases.   The opiates produce too much general  de-
rangement.   Belladonna, hyosciamus, and ergot, all  tend to
produce the quieting  effect desired.   The ergot is liable,
however, to produce  too much capillary contraction.  If
digestion is not good,  should  prescribe  liquid  rennet; a
teaspoonful after each meal.
   The patient should be allowed a good, plain, substantial
diet, plenty of milk, milk-whey, buttermilk, etc.  No tea or
coffee should  be allowed, or at least only a single cup, very
weak.  Alcoholic stimulants, and tobacco, should be rigidly
excluded.   The patient's chances of recovery will be greatly
increased, if he will leave  off the use  of tobacco  entirely.
He should  be encouraged to take a moderate amount of
exercise in the  open air,  every day,  but not  enough to
produce excessive weariness; must be careful not to over-
tax the strength.   Such a course,  if followed out,  offers a
better prospect of benefit than any other.
   Another case was treated in  the hospital, about one  year
since, in which all the characteristic symptoms of progressive
locomotor ataxy were strongly developed.  The  power of
co-ordination of muscular movements was so  impaired  that,
for several  weeks, the patient could not walk, or maintain
the upright position, without assistance.   He was treated 
226         NERVOUS AFFECTIONS.
with quinia, iron, and strychnia, for many  weeks, aided by
good  food, frictions,  and some use of  electro-magnetism;
but with very little  improvement.  He was then put on  the
use of Liebig's extract of malt, and the comp. syrup of  the
hypophosphites, plain, nutritious food, and allowed to rest.
After some time, he began to gain gradually; and in  about
four months, had so far recovered that he walked well, and
left the hospital in fair health. 
LECTURE  XVI.
AFFECTIONS  OF THE  BRAIN. — Epilepsy. — Probable Soft-
   ening of the Brain. — Chronic Hydrocephalus.
    Gentlemen: — The patient before you is a woman  aged
 forty-five years, the mother of several children.  The coun-
 tenance has a slight expression of sadness, coupled with suf-
 ficient paleness to indicate some deficiency of red corpuscles
 in the blood, though no marked emaciation.   She represents
 her appetite as fair;  her circulation and respiration are un-
 disturbed ;  and her secretions and excretions are represented
 as natural.  But she has been subject to paroxysms of epi-
 lepsy—or falling sickness, as it is sometimes called—during
 the last three years.   With her, the paroxysm comes  sud-
 denly, without any premonitory symptom, or peculiar warn-
 ing.   The head begins to swim, with dimness of vision, and,
 in a very  few seconds, she  falls unconscious, in  whatever
 place she may be standing or sitting at the  time.   The fall
 is accompanied by general muscular spasms, contorting the
 features, suppressing respiration, and stiffening the muscles
 of the trunk and extremities, until the face becomes very
 turgid and purple, from the unoxygenated blood.  In  a few
 moments, the  spasmodic action ceases; the  respirations are
resumed—at first very irregularly, with the forcible ejection 
228       AFFECTIONS OF THE BRAIN.
of saliva, often mixed with blood, from  the  biting of the
tongue or lips—and afterwards more regular and quiet, like
one in sleep.  This period of  quiet, or apparent sleep, con-
tinues from  fifteen to thirty minutes, when she awakes with
an expression of surprise, coupled with a feeling of weari-
ness, but is soon able to go about as usual.  She usually has
one or two paroxysms each day, for two days  in succession,
and then is exempt from their return  for twelve or fourteen
days.  The marks of recent injury, which you  see on her
forehead and nose, were produced by falling, in one of her
paroxysms, just before her admission into  the hospital, some
four days since;  and these extensive  cicatrices on her fore-
arms, were occasioned -by her falling upon the hot stove, in
her family, several months ago.  The frequent repetition of
her paroxysms, for three years, has perceptibly impaired her
mental faculties, including the memory.   The failure of the
last-named faculty is the first to be noticed by the friends of
the patient.  She says her family often "scold her " for for-
getting everything.  This case illustrates one of the most
common forms of epilepsy originating in adult life.
   Here is a case from  another ward in the hospital.   It is
a man near forty years of age, who has had  epileptic par-
oxysms ever since  he was fourteen years old.   You  see in
his expressionless face  and undeveloped forehead,  unmis-
takable evidences of imbecility, and  impaired cerebral nu-
trition.   Now, when he should be in  the vigor of manhood,
he is a mere indolent child, caring for nothing but food and
tobacco.
   The nature or pathology of epilepsy is involved in much
obscurity.   It  occurs in  both sexes,  and at  all periods
of life, though  it  more  frequently  commences  in  child-
hood and youth.   Its paroxysms exhibit every degree of
severity, from  mere  momentary  giddiness, and  arrest of
mental  action, to the most violent and general convulsions. 
AFFECTIONS OF  THE  BRAIN.       229
 They may vary from once in one or two years to five or six
 times per day.  The disease affects persons of widely diverse
 temperaments or physical conditions, and may be  excited
 by a great variety of causes.  The  latter, however,  may be
 divided into  two  classes, viz.:  those that  establish the pri-
 mary seat of irritation in some part of the periphery or sen-
 tient extremities of the nervous system, and those that act
 more directly on  the brain, or  cerebro-spinal nervous cen-
 ters.  Hence, many modern writers have divided all cases
 of epilepsy into two classes — the  one called centrifugal, or
 peripheral, and the other centripetal, or  concentric.  To
 the first class belong such cases as arise from primary irrita-
 tion in the alimentary canal;  in the uterus; in the sexual
 organs of both sexes, more especially from masturbation and
 excessive sexual  intercourse; and in the wounded  or  me-
 chanically injured nerves of the extremities,  or any  part of
 the body.   To the second class belong  those cases that
 arise from causes acting directly on the brain, or nervous
 centers, such as mechanical injuries of the brain, depressing
 mental emotions and passions, alcoholic and  other cerebral
 exhilarants, etc.   None of the causes belonging to either of
 the classes  mentioned  are sufficient  to induce  epilepsy,
 without the  pre-existence of a peculiar morbid  excitability
 of the cerebro-spinal centers, favorable to the development
 of spasmodic paroxysms.   This morbid excitability is, in-
 deed, the only pathological condition that  appears common
 to all cases of epilepsy.
   This, with the special  physical condition of the patient,
 and the nature of the exciting cause, must determine the in-
 dications for treatment in each  case.   To ferret out and re-
 move  the exciting  cause,  more  especially in those cases
 classed as peripheral, is a step of primary importance.  To
 expect a  cure of the disease by  any of the supposed specific
or empirical  remedies, while the reflex influence of a dys-
       20 
230       AFFECTIONS OF  THE  BRAIN.
menorrhcea, a gastric  or intestinal  irritation, over-excited
genital organs, or an injured  nerve, is constantly radiating
a morbid impression upon the nervous  centers, would be
unreasonable.  After  due attention  to  all matters of this
class, the next step is to regulate  the  diet, exercise, and
mental habits of  the patient.   In all cases, except such as
exhibit evidences of positive  impoverishment of the blood
and  tissues, I think it. important to exclude meat altogether,
as an article of food.  Milk, farinaceous articles,  tuberous
roots, and fruits, may be taken freely.   In all cases, all
kinds of fermented or distilled spirits, together with strong
tea and coffee, should be rigidly avoided.   It is more safe to
wholly exclude tobacco also.   Moderate daily exercise in
the open air, and, if possible, some congenial regular mental
occupation, is important.
   Without careful and persistent attention to these hygienic
regulations, the most  appropriate administration  of medi-
cines will fail to produce any permanent effect in  the  cure
of epilepsy.  To aid in overcoming the  morbidly  excitable
condition of the nervous centers, we probably have no rem-
edies more reliable than the bromides of  potassium and am-
monium, aided, in some cases, by gelsemium, and, in others,
by belladonna.
   For the immediate relief of a  convulsive paroxysm, the
bromide  of potassium should be given, in doses of twenty
grains, or thirty grains combined with  ten or twelve  drops
of tinct. belladonna, and repeated every two hours, until the
paroxysms cease.  But, for more permanent effect, it should
be continued steadily, for a long period of time, in doses of
ten grains, morning and noon, and fifteen grains at  bed-
time.  The  sedative influence, in cerebral excitability, will
be increased by adding to each dose eight drops of tincture
gelsemium ;  or, if there appears to be much tendency to vas-
cular fullness of the cerebro-spinal centers, the same  quan- 
AFFECTIONS OF THE BRAIN.      231
 tity of tincture of belladonna  may be  substituted for  the
 gelsemium.  The female patient to which we have just di-
 rected your attention, affords nothing in her history calcu-
 lated  to  explain the cause of her disease, except the fact
 that, for a little time before the occurrence of the first par-
 oxysm, she had been separated from some of her relations,
 and yielded to an inordinate  degree of grief and despond-
 ency.   Since her admission into the hospital she has taken
 ten grains of bromide of potassium before each meal, and at
 bed-time, and has had no recurrence of the paroxysms since
 the first  twelve hours after her admission.   We shall con-
 tinue  the same  treatment, and, as she is somewhat anaemic
 we shall  give her, in addition, one teaspoonful of the syrup
 of pyrophosphate of iron after breakfast and dinner, each
 day.   Before leaving this case, I cannot impress upon you
 too strongly the necessity of long-continued perseverance in
 the treatment of epileptic cases.   The patient  and friends
 should be  informed at  once that no treatment  will have
 any prospect of permanent success that is  not continued
 faithfully, in all its details, for from six to eighteen months.
   This next case,  to which we would ask your attention, is
 one of interest, more  especially in regard to its pathology
 and diagnosis.   The  patient is a native of Ireland; about
 forty-five years of age;  naturally muscular and strong;  by
 occupation a laborer.
   As you look at him in bed, you readily  recognize a  va-
 cant, staring expression of  countenance; a  dorsal position,
 with limbs extended;  not a tremulous, but an unsteady and
 awkward movement of  the hands;  and, in  answer to  my
 questions, you notice his speech is slow, hesitating, and he fre-
 quently stops in the middle of a sentence, apparently losing
 the connection of thought.   His mind  often wanders, and
his sleep  is disturbed.   He complains of no pain, and  ex-
hibits  no  sign of fever—not even increased heat in  his head. 
232       AFFECTIONS OF  THE  BRAIN.
The pupils are slightly dilated, and the vessels of the con-
junctiva  free  from congestion.   He protrudes his tongue
readily, giving it  a narrow  and  pointed shape;  and  you
see on its  surface a thick, moist coat, particularly along its
middle line.   You find his  skin  soft, temperature natural,
and sensibility good.  While lying in bed, he can move all
his limbs,  and in any desired  direction; and yet he  can
neither get up, nor  stand  erect, nor walk.  He has only a
partial control over the sphincters,  both urine and faeces
being passed  in bed.   His pulse is soft,  and  rather slow,
but not intermitting; and, when awake, his respirations are
nearly natural.
    He was admitted, into  the hospital only two days since,
and his  history, so far as I can  obtain.it, is as follows:
About six  months since, his friends began to  notice slight
indications of failure in his mental  faculties, and some un-
steadiness  in  his  walk.   These indications gradually in-
creased, without the supervention of any sudden  or severe
sickness,  until he  has arrived at the entirely helpless con-
dition, mentally and physically, that you see before you.
For several years previous  to the supervention of his present
sickness,  he had been addicted to the  intemperate  use of
alcoholic drinks;  and the same Were continued for two or
three months after his health began to fail.
    With  this review of the history and present symptoms,
where is  the seat of disease, and what the nature of the
pathological  changes which have  taken place?   The ina-
bility to  maintain  an upright position,  or to control the
sphincters  of the bladder  and rectum, taken in connection
with the  impaired  state of  the mental faculties, show plainly
that the seat of the disease is within the cranium.
    We may have inability  to walk, with  loss of control over
the sphincters, from the disease of the spinal cord, or  its
membranes ;  but, in such cases, the mental operations would 
AFFECTIONS OF  THE  BRAIN.       233
not be impaired.  But, conceding the seat of disease to be
the brain, or its covering, what is the nature of such disease?
Is it a chronic inflammation of the cerebral substance ?  Or
is  it a slow atrophy, from  defective nutrition?   Or, again,
can it be a mere functional  derangement, consisting  of  im-
paired cerebral sensibility ?  To answer these questions re-
liably, requires close  examination  of  the patient,  and an
accurate knowledge of the symptoms that distinguish one
pathological condition of the brain from another.  Inflam-
mation, either acute or chronic, involving the membranes
or convolutions of  the brain, causes  increased  heat, pain,
restlessness,  acuteness  of  sensibility,  with positive  mental
derangement, in the first stage;  followed by effusion, par-
alysis, and coma, or continued insanity, in the second.  If
the inflammation involves the interior of the brain, there may
be less evidence of mental derangement;  but there will still
be pain, indisposition to move the head, increased tempera-
ture, altered pupils, and more or less  rigidity of the volun-
tary muscles, either  of the neck or extremities.
   At no period in  the  history of the case before us, were
any of those symptoms, characteristic of cerebral inflamma-
tion, present.  On the contrary, the  head has been free from
heat or pain, and the muscular system more and more flac-
cid and feeble in contractility, from the  commencement of
ill health to the present time.
   Mere  functional disturbances of the brain  are  usually
variable in the symptoms, and rarely cause a steadily pro-
gressive loss of flesh, or of muscular strength.   But when
the nutrition of the brain  has been impaired, by the long
continuance of slowly-acting causes, and the  texture begins
to soften, or  atrophy, from deficiency of atoms, the symptoms
are those of  simple impairment of function.
   The patient is not, at first, either delirious or paralyzed.
He becomes forgetful; is unable  to maintain  continuous
                          20* 
234
1FFECTI0NS OF  THE  BRAIN.
thought and  expression, often losing the thought  in the
middle of a sentence ; while his gait becomes unsteady, and
all his muscular movements enfeebled.  The symptoms thus
begun generally increase steadily, until the mental manifesta-
tions become simple, imperfect, and  sometimes incoherent,
and the muscular action so impaired as to render the patient
incapable of  walking, or even of maintaining the erect po-
sition.   Only a few weeks  since, a young man  occupied a
bed in this ward, who had been  employed  as  a clerk in a
grocery store, and had been regarded as a reliable and cor-
rect  young man.  He was first noticed to be  despondent,
without any known cause.  Soon  he became forgetful; then
slow in his movements ;  and, after some weeks, wholly in-
capable of doing business.   When admitted into the hospi-
tal, his face  was pale; expression downcast, and vacant;
skin cool; pulse slow and soft; bowels inactive; and entire
loss of all disposition to either mental or physical exertion.
It was  difficult  to induce  him to answer a question, and
when he did, his  voice was weak, and  his expression slow
and interrupted.   He neither asked  for food or drink, but
would  sit in a chair, or lie  in a  bed, from  morning until
night, almost motionless.   It was  necessary to feed him, in
the same manner as a young child, and, at suitable intervals,
call his attention to the necessity of evacuating the bladder
and rectum.   He complained of little or no pain ; exhibited
no spasmodic action of muscles, or rigidity ; but sometimes,
especially in  the night, under some mental hallucination, he
would  attempt to wander about the house.
   After observing  him for some  time, and trying, without
benefit, several items of treatment, I  became satisfied that
the condition of the brain was that of anaemia and deficient
nutrition, but not yet advanced to the degree of actual soft-
ening,  or disintegration. He was, consequently, put upon
the use of syrup of pyrophosphate of iron, in doses of a tea- 
AFFECTIONS  OF THE BRAIN.       235
 spoonful, three or four times a day;  a diet of plain, nutri-
 tious food, such as milk, bread, rice, tender meats, etc.; and
 the use of an electro-magnetic battery, once  or twice every
 day.   He was also encouraged to make efforts at walking,
 and, as soon as possible, to get out in the open air daily.
    This course of  treatment was carried out faithfully sev-
 eral weeks, and  resulted in a slow recovery of the patient,
 who is now at his previous occupation.  All the symptoms
 of the case before yo'u  have been, and  now are, of such a
 character as  to indicate a similar arrest  of- nutrition  of the
 brain, more  especially of the internal parts.  But in this
 case,, the morbid process  has, probably, been continued un-
 til the texture has become so far changed as to be unable
 to perform  its functions.   In other words, some parts of
 the brain are in  a  state  of ramollissement, or softening.   If
 so, the prognosis  is exceedingly unfavorable;  and there
 would be little benefit from any kind of  medical treatment.
 So long, however, as we  cannot know positively that  cere-
 bral disorganization exists, it is our  duty to prescribe such
 treatment as would be most likely to  restore the patient, if
 the structural changes had not reached a stage incapable of
 repair.  The indications are, to increase  the sensibility and
■activity of  the  nervous centers, thereby  restoring more
 steady and efficient muscular action, especially  in the invol-
 untary muscles, and to improve the  nutrition of the  brain.
 Probably, small doses of strychnia would fill the first indi-
 cation, and some one of the phosphatic salts of iron the
 second, as  well  as any remedies  that we could select.
 Hence, we will direct the following prescription :
       R.—Strychniae..........................gr.  i.
           Acid, nitr____....................... 3 j.
           Syr. simpl__________________.........|j.
           Aquas________________________________5'ij-
    M.  Give a teaspoonful every six hours, diluted with sweetened water. 
236      AFFECTIONS OF THE BRAIN.
   Also, one teaspoonful of the syrup of pyrophospate of
iron, every six hours; making the medicines come alternately,
three hours apart.  We will have him fed regularly with milk,
bread, rice, etc.
   This little child has been brought in for your inspection,
to-day, as presenting a very good example of chronic hydro-
cephalus, or dropsy of the brain.  The entire head, you per-
ceive, is enlarged to nearly twice the normal size, the bones
being widely separated at the  sutures.  The occipital bone
forms a firm, fixed base, while the upper part of the cranium
yielding easily at the ununited sutures, gradually enlarges
as the effusion  increases.   There is a peculiar bulging ap-
pearance of the  eyes, caused by the pushing  forward and
downward of the frontal bone, decreasing the orbital space,
thus crowding the eye-ball outward, and turning the axis of
the  eyes somewhat downward.  The scalp is quite tense
over the separated sutures, and the fluctuation very distinct
upon pressure.    The general nutrition  of the body and
limbs is better than is usual in these cases.
   This child  is now about a year old.  Its head was first
noticed to be enlarging after an attack of fever, accompanied
by derangement of the stomach and bowels, which occurred
when it was three months old.  The  enlargement had been
progressing about a month, when the case was first brought
to my office.  From the rapid  rate  at which the disease was
progressing, I judged that the child would live but a short
time.   It was, however, placed under treatment, and seen
several times, at short intervals.  I  then lost all track of the
case, and supposed the  child had died.   A  few days ago,
however, it  was again brought to  me, in the  condition  in
which you now see it. During the  interval  since I had seen
it last, the mother stated that it had been  kept constantly
upon the treatment that I had directed.   The size of the 
AFFECTIONS OF THE  BRAIN.       237
head has increased some, but the enlargement has not been
so rapid as previously.
   The cases of chronic hydrocephalus may be distinguished
into  three classes.   The first class includes the  cases  in
which the  disease is congenital.  The child, in  these cases,
usually lives but a few days, although life may occasionally
be prolonged for several months.
   In  the second class  of cases, the child is  apparently
healthy at birth, and continues so until between the second
and third months.   It is then attacked with acute symptoms
of restlessness, and crying out in  sleep.  The discharges
from  the bowels are  variable in  character, frequently of a
greenish color.   Vomiting is frequent, if the child is raised
up.  These  symptoms continue for two or three days, when
there supervenes an  attack  of convulsions, and the child
will now be  found to be laboring under all the symptoms of
effusion on  the brain.   Previous  to the  occurrence of the
convulsions, the pupils are  usually contracted; after  their
occurrence,  however, the pupils will be found to be widely
dilated, and a want of co-ordination will be noticed in the
eyes, the axis being  turned in  different  directions.  There
may be but a single attack of  convulsions, or  they may be
repeated several times.   Some cases terminate fatally in
 a very short  time —the fever increasing, the pupils be-
coming more widely dilated, the face pale, and coma and
 death supervening.
    In young children, where the sutures are still ununited,
 the head  easily expands, as the exudation  increases.   The
 inflammatory  stage,  and active  symptoms, then pass off;
 some  restlessness, and  starting  in sleep,  continue.   The
 child cannot hold up or steady the head well.   The muscles
 of the extremities are also  weak,  so that it cannot stand.
 The parents may, very likely, suppose for four or five weeks,
 that the child is improving and getting well, considering the 
238       AFFECTIONS OF THE BRAIN.
debility and muscular weakness  as merely the effects of the
previous disease;  but, as time  passes on, the head is ob
served to be enlarging;  the urine is scanty, and the bowels
deranged;  passages variable in character.   In two or three
months, the head will sometimes have attained the size of
this one.
   The third class, of which the case before you is a very
good example, are of more  obscure origin.  There are no
active  symptoms to commence with.  Slight fever and rest-
lessness, the  stomach  and  bowels  deranged, and  urine
scanty, as in  the other cases.  The child acts as if in pain,
every time it  is moved.   No convulsions, however, super-
vene.   In six to  ten days, the fever disappears, and only
slight derangement of stomach and bowels remains, the food
frequently passing through undigested.   Occasionally, the
bowels are constipated.    In this way they will continue for
perhaps  a month, when  it is noticed that  the head is en-
larging, and the child is growing weaker.  It cannot hold up
its head, and is averse to the upright position.  The surface
generally  is pale ;  the veins passing over the head are en-
larged, and blue.  When the head is examined, the sutures
are found to be  wide open.   The intelligence is, apparently,
unimpaired ;  there is generally considerable weakness of the
extremities, so that it cannot stand, or attempt much use of
its legs.
   The pathology of this disease, except in the congenital
cases, seems to consist of a low grade of inflammation in the
pia mater, and arachnoid membranes.  Hereditary tubercle
frequently  forms the starting-point  of the  disease.  When
not  traceable to this tuberculous  origin, it usually origi-
nates from simple  sub-acute inflammation.   The inflamma-
tory stage  lasts  but a  short time.   The effusion, however,
continues.
   The large majority  of  these  cases  terminate fatally, 
AFFECTIONS OF THE  BRAIN.       239
 although  some of the children live for a considerable time.
 In a case to which I directed the attention of the class, some
 years ago, the child had lived to be four years old.  The
 head had expanded, until it had become heavier than all the
 rest of the body;  and the  child could not be ^supported in
 an upright position, for even an instant, without fainting.
 Another case, about the same age as this one, was brought
 before the class last winter, and was placed under treatment,
 although without any expectation of a favorable result.  It
 soon began, however, to improve, and continued to progress
 favorably for three months, when I lost sight  of the child,
 and do not know whether it finally recovered or not.
    The books give no  encouragement for the  treatment of
 these cases.  There are two methods, however, that have
 been proposed, the one surgical, the other medical.   The
 late Prof. Brainard was one of the first, I believe, to attempt
 the cure of these cases by the  insertion of a small trochar,
 allowing a little of the fluid to  escape, and then injecting a
 weak solution of iodine and iodide of potassa into the cavity.
 The theory was, that the contact of the iodide with the sur-
 face of the membranes would stop further effusion.   Some
 considerable disturbance, nervous twitching, etc., were  pro-
 duced at the time of the injection.   These symptoms passed
 away in a short time, and no further effects were manifest
 from it.   In one case, I think, he repeated the  injection as
 many as six or seven times.  No case of successful result
 from this operation has, however, been recorded.
   The  objects  that I  have attempted  to accomplish by
 treatment, in these cases, has been, first, to allay the morbid
 excitement of the cerebral structures; and, second, to exert
 a gentle,  persistent, and  long-continued  alterative  and
 diuretic influence, avoiding carefully any impairment of the
 digestive organs.  I have succeeded  in accomplishing these
purposes by the following prescription : 
240       AFFECTIONS OF  THE BRAIN.
        R .—Ext. Scutellaria fl--------------------1 »•
           Tinct. digital_________________________3 ss-
           Potass, iod.___............-----------3 ij-
           Ext. hyoscyami fl---------------......3 ss.
    M.  Dose, twenty drops, four times a day, in sweetened water.
    If the digitalis is found to be exerting too much influ-
ence, the dose must be diminished.
    Mercurials are of no advantage in the chronic stage.
During the early inflammatory stage, mercurials, combined
with mild  laxatives, might  check the progress of the dis-
ease;  and, if  promptly followed by efficient doses of the
iodide of potassa, any considerable  effusion would  be pre-
vented, except in such cases as are complicated with tuber-
cular deposits.   If  effusion does take  place,  and the case
becomes chronic, it will be better to unite  the iodide with
the digitalis, Scutellaria, etc., as in the formula  already given
to you. 
LECTURE  XVII.
CEREBRO-SPINAL DISEASE. — Symptoms, Progress and Treat-
   ment.— Some  Remarks Regarding its Epidemic Prevalence
   in Chicago, during the Months  of February, March, and
   April, 1872.
   Gentlemen :—This patient is just recovering from a severe
attack of cerebro-spinal meningitis.  About six days ago,
on returning from his work at evening,  he was suddenly
attacked with chilliness and violent pain in the forehead,
temples, and occiput.  This was soon followed by febrile
reaction and vomiting.   I  did  not see him  until the after-
noon of the following day, when he was brought to the hos-
pital.   I  then  found  him  in  bed, with the  head drawn
firmly  backward;   face  flushed;  head  hot;  expression
anxious ;  pupils nearly natural; pulse 100 per minute, soft;
respiration hurried and irregular ; mouth moist, but tongue
covered with a white fur ;  urine scanty ;  bowels quiet, but
promptly rejecting by vomiting whatever drink was  given
him, and  making  efforts to vomit whenever he was  raised
up; his mind wandering, and almost constantly crying out
with the distracting  pain in  his head.  Cloths, wet iri cold
water, had been kept to his head; and I directed the same
       21 
242
CEREBRO-SPINAL  DISEASE.
to be continued, and immediately ordered the two following
prescriptions:
       R .—Tinct. physostigmae-------------------% iss.
           Ext. ergotae fl-------------------------I »ss.
    M.  One teaspoonful to be given every two hours, in half a table-
spoonful of water.
       R.—Acidi carbolici cryst..................grs. vi.
           Glycerinae___________________________Iss.
           Tinct. gelsemii____....._____......._ § ss.
           Aquae____.......----------------------§ iii.
    M.  One teaspoonful to be given every two hours, alternately with
the other, making the medicines come only one hour apart.
    Directions were given to have the medicines and drinks
given without raising the patient's head from the pillow, to
avoid the  danger of vomiting.  The directions were faith-
fully executed, and the following day all the symptoms were
moderately improved.   The treatment  was continued, with
no change, except to extend the time between the doses to
three hours instead of two.
    The same treatment has been continued for  the past four
days, the  interval between the  doses of medicine being
lengthened one hour each day.   We  now find the pain in
the head, the muscular  rigidity, and the febrile symptoms,
entirely relieved.  The  carbolic acid mixture will be omit-
ted, and  the calabar bean and ergot continued  three times
a day.   If the patient continues to improve, he will proba-
bly be entirely convalescent in a few days more.
    Both personal observation and the statistics  of mortality
furnished by the board of health, show an unusual preva-
lence of cerebro-spinal  disease of a serious nature, in this
city, during the  past two months.  For instance, the certifi-
cates of death returned to the health  office, show thirteen
deaths from cerebro-spinal  meningitis in February, forty-
four in  March,  and  twenty-two  during the first  week in 
CEREBRO-SPINAL DISEASE.        243
 April.  This not only indicates an unusual prevalence of
 cerebro-spinal disease in  the  city but also that it is rapidly
 increasing.  The first case that  attracted my attention was
 that of a  young man employed as a clerk in a store, who
 sent for me on the first day of February.   He was boarding
 at 810 Michigan avenue.
    He had been attacked  two days previous with chilliness,
 and a severe pain in the head,  for which he went to a
 physician, who gave him some  cathartic medicine.  It oper-
 ated freely on the bowels,  but afforded no relief to his head.
 I found him in a reclining position;  some  flush of redness
 in his face, and  an  expression of  suffering; averse to free
 motion, especially of  the  head;  some general increase  of
 sensibility or hyperaesthesia;  temperature  moderately  in-
 creased ; pulse  90 per minute, firm,  and  moderately full;
 respirations 20, and  a  little unsteady;  tongue covered with
 a white coat, but moist; urine free ; abdomen natural; mind
 despondent;  and complaining of an intense pain, mostly in
 the lower part  of the anterior  region  of  the head, and
 extending, at times, to the occiput.   The temperature of
 those regions of  the head,  and  the  pulsation in the arteries,
 were  greater than in the other parts of the body.  The
 pupils were small, with slight photophobia.  The assemblage
 of symptoms was such as caused me to think there was
 positive inflammatory  hyperaemia in the base of the brain.
   The following day the pain was less intense, but in all other
 respects the symptoms  were unchanged, except the addition of
 slight stiffness of the muscles of the neck, and complete apha-
 sia.  The patient understood whatever was said to him, but,
 in  reply, repeated a number of meaningless words, mostly
 monosyllables, and often appeared vexed that those around
him could not understand  him.   He was now moved to the
house of a friend on Cottage Grove avenue.  There,  for
three days, he claimed to be each day better.  He recovered 
244
CEREBRO-SPINAL DISEASE.
the power of expressing his thoughts, and had less pain in his
head.  But  his neck remained  stiff;  his pulse variable;
mind more dull and wandering, especially during the night.
There was less febrile heat; the tongue more  clean ;  the
urine more abundant; and he insisted on sitting  in his chair
and taking some food every day.  On the night of the 6th,
his symptoms became more aggravated ;  his head was more
retracted;  mind  more dull; pupils considerably dilated;
pulse slow and intermitting ;  respirations very variable; and
urine more scanty. On the 8th there was evident  hemiplegia,
with  divergence  of  one eye ; and entire  coma followed,
ending in death on the morning of the i ith.   No postmortem
examination was  allowed.
   Since the ist  of February, a period of seventy-two days,
there have occurred  in  my own practice forty  cases, suffi-
ciently well characterized to render the diagnosis reasonably
certain.
   I  have  seen  several other  cases, in consultation with
other practitioners, during  the same period of time.  Of
the  forty cases here  alluded to, twenty-one were  in  the
south division, fifteen in the west, and four in the north
division   of  the city.   Six  were  adults,  between  the
ages of twenty and thirty years;  ten were between five and
fifteen years; and twenty-four were  between  six months
and five years of age.  Of  the  whole number, seven have
died, twenty-seven recovered, and  six remain under treat-
ment.  Of  the latter, one  will  probably  soon terminate
fatally, and the other five have a  fair prospect of recovery.
Of seven deaths, three were of adults over  twenty years of
age;  one  was five years,  one  was three  years,  and the
remaining two six and seven months, respectively.
   The duration of the disease  has varied  much.  Of the
seven fatal cases, one continued twelve days,  one seven days,
one five days, one six days, one four days, one twenty-eight 
CEREBRO-SPINAL DISEASE.
245
days,  and one only twenty hours.  Three  of these cases
were brought under treatment at the commencement of the
attack;  the other four were seen so late as to admit of only
from one to three visits each.  The cases that recoverd have
required treatment from one to four weeks each.
   Four-fifths  of the cases coming under my  observation
have occurred  among the poor and laboring classes of peo-
ple, and in a territory or part of  the city bounded by east
and west Harrison street on the north, south by Twenty-sixth
street, east by  State street, and west by Center avenue.  Yet,
one of the most rapidly fatal cases in the list  was a little
German boy, five years of age, living  on Wabash avenue,
near Fourteenth street,  who died  within twenty hours from
the attack.
   In many instances only one  child or member of a family
has suffered from the disease; while in a few cases, three or four
in the same family have been  prostrated within  twenty-four
or thirty-six hours.  In one small house, on the rear end of a
lot on  State street, north of Sixteenth, three  children were
attacked within the same twenty-four hours;  another was
attacked  in the house on the  front end  of the same lot;
another in the adjoining house south ; and two others, in the
care of another physician, in the adjoining house north.   I
 have been unable to gather any evidences of the contagious-
 ness or communicability of  the  disease.  The cases have
 varied much,  both in the severity and variety of symptoms,
 and  yet  have preserved enough  of uniformity to identify
 them as  belonging to  one group, and dependent on some
 common pathological  conditions.  For instance, in all the
 cases the access of the  disease is sudden or abrupt.  They
 all give evidence, at  first, of unusually severe pain  in the
 head, with very variable  neuralgic pains in distant parts,
 especially in  the  abdomen,  thighs, and legs ;  and in from
 one to  three days, rigidity of the neck, with some retraction 
246        CEREBRO-SPINAL  DISEASE.
of the head, and  general hyperaesthesia  sufficient to cause
even the youngest child to manifest signs  of distress on being
touched or moved.   In nearly all the cases there has been,
during the first twelve hours, active  vomiting, increased by
raising the head to the erect position; and, in some, co-inci-
dent purging.   These gastric and intestinal symptoms have
seldom continued beyond the  first one  or two days.  The
temperature is generally increased, especially in the back of
the head;  the pulse frequent and firm ; respirations increased
in frequency, and, in most  cases,  panting, like one excess-
ively  fatigued  from  severe exercise;  face  flushed,  and
expression excited  and anxious at  first, but  subsequently
dull, with  dilation  of pupils;  urine generally scanty  and
high-colored, but in some cases  abundant throughout  the
whole duration of the disease ; tongue covered with a white
fur;  mouth moist;  and,  after the  first  one or  two days,
bowels inclining to  constipation, with the abdomen flaccid,
and entirely free from tympanites.   About one-third of the
cases present some  red, erythematic spots on the skin, be-
tween  the  third and seventh days of the disease.  These
spots vary much  in size and number, as well as in shade
of color.  In the milder cases they are bright red, and often
so few  in  number  as  to attract no attention unless looked
for particularly;  and  in others they are so numerous as to
create  the impression that the case may be one of scarlatina.
In the more severe  cases, the spots are darker in color, larger
in size  ; and in two  cases they were accompanied with tume-
faction, from subcutaneous infiltration, as in erysipelas.  In
a young woman who died on the fifth  day after the attack,
but whom I did not see until the day previous to her death,
there were numerous large, purple,  haemorrhagic spots on the
lower extremities, and an oblong, elevated, purplish-red spot,
from one to two inches long, and from half to three-quarters
of an  inch wide, on  the front part  of each ankle, and the 
CEREBRO-SPINAL  DISEASE.       247
 outer face of each wrist.  The head was held rigidly to one
 side, eyes divergent, pupils dilated, and mind entirely un-
 conscious.   In the majority of cases, however, I failed to
 discover any special eruptions or spots on the surface.  Nearly
 all the cases manifested, during their progress, paroxysms
 of excited delirium;  and in the children, the first turns of
 vomiting would be followed by protracted  turns of wild
 screeching and crying, and sometimes trembling, as if under
 the influence  of terrible fright.   In only four cases  were
 there general convulsions, three of which died, and one re-
 covered.
    In regard to the actual pathology or nature of  this form
 of disease,  there is still  much obscurity.   That  it differs
 from simple inflammation of the brain and its membranes, is
 evident both from  the symptoms during life and the post
 mortem appearances after death.  I have had the privilege
 of making  only one post mortem  examination this season.
 It was a case that died in the Mercy Hospital, an adult,
 brought in already unconscious, with rigidity of the muscles
 of the neck,  and all the evidences of cerebro-spinal disease
 strongly marked. He died on the third day after admission,
 being about  one week after the attack.  Autopsy revealed
 a few ounces of reddish serum between  the arachnoid and
 pia mater, and in the lateral ventricles, with the most intense
 and beautiful injection or turgescence of the vessels of the
 pia mater covering the base of the brain, medulla oblongata,
 and upper part of the spinal cord.  The vessels of the brain
 substance were  also fuller than natural; but  there was no
 exudation of lymph or  plastic  material, and  no other  mor-
 bid appearance  apparent to the eye.  In a  case recently
 alluded to by the editor of the Buffalo Medical and Surgical
Journal, the autopsy revealed no morbid appearances  in
the brain or  its membranes.
   Most of  the autopsies reported have  given serous,  sero- 
248        CEREBRO-SPINAL  DISEASE.
sanguineous, and sero-purulent effusions, in moderate quan-
tity, and vascular turgescence, with  only slight appearances
of plastic exudation.  As a general rule, the more rapid the
progress of  the case—that is, the earlier the patient dies—
the less  are the visible post mortem changes.   I  have been
led to regard the  disease  as  consisting in  an exaltation of
the susceptibility or irritability of the structure of the cere-
bro-spinal  axis, including the whole base of the brain, with
diminished  tonicity or contractility of the blood-vessels.  If
the alteration of the property of susceptibility is intense, and
extends  directly to the center of the excito-motory system,
it  cuts short life very speedily—sometimes in  a few hours—.
without  leaving visible alterations in  the brain or its mem-
branes.  But if the morbid action be less intense, or involve
less directly the chief excito-motory center in the medulla
oblongata, life may be prolonged until  either recovery takes
place  or the vascular  engorgement  ends  in effusion of
serum, etc.
   The  first few cases coming under  my care were treated
with leeches to the temples and mastoid spaces;  cold appli-
cations to the head;  a mild cathartic,  and full doses  of the
bromide of potassa, aided by hydrate  of chloral, to procure
rest at night.   After two or three days iodide  of potassa was
added  to  the bromide;   counter-irritation applied  to the
neck.   The  results  of this  kind  of treatment were not
satisfactory.
   The  cephalalgia, muscular rigidity, etc.,  continued, and
though the  febrile action was less, there  was no sign of con-
valescence.  The first case died at  the end of ten or eleven
days.  Another, a girl about  eleven years of age, had lain
with  the head firmly retracted to a  right angle  with the
shoulders;  the hearing dull; mind wandering; sleepless;
and often screeching with pain, for  more than a week; and
the foregoing remedies, with  the addition of alterative doses 
CEREBRO-SPINAL DISEASE.       249
of calomel and Dover's powder  at night, had exerted no
marked change in the progress of the  case.
   Recollecting that the calabar bean had been used with
apparent success in tetanus, and  that I  had used it with
benefit in several cases of muscular rigidity from irritation
of the nervous centers, I made the following prescription:

       R.—Tinct. physostigmatas----------------§ >■
           Ext. ergotae fl_______ -----------'----Iiss-
   M.  Gave half a teaspoonful every two hours, and omitted all other
medicines.
   At  the end of twenty-four hours the patient was found
simply more quiet, the pulse a little slower, and the respira-
tion  more regular.  The treatment was continued  without
change.  At  the  end  of  the second day the patient had
ceased to  complain of pain in  her head ;  had slept several
times  for  half an hour to an hour;  the  retraction of the
head was decidedly less ; mind was clear; the mouth moist;
and  the urine free; but she seemed  feeble.   More simple
nourishment  was ordered, and  the medicine  continued at
intervals of  three  hours.  The case  continued steadily to
improve;   and  on  the  fifth  day after the  commence-
ment  of  the use  of  the  calabar bean and  ergot,  the
muscular  rigidity had  entirely  ceased, and the patient was
convalescent, though emaciated and feeble.   The  medicine
was  continued three times a day several days  longer, and
a combination of  extract of malt and the compound syrup
of hypophosphites, in  addition to nourishment, were given
to aid in restoring nutrition and strength.  Since that time,
I have used the calabar bean, either alone or in combination
with ergot, in nearly all the cases that have come under my
care, and  certainly with more apparent effect in controlling
the  disease than by any other remedies I have tried.
    If  our views in regard  to the essential nature of the 
250        CEREBRO-SPINAL DISEASE.
morbid action constituting this form of disease are correct,
we may expect such remedial agents as have  the power to
diminish excitability, and at the same time increase the vas-
cular tonicity, to exert the most favorable influence over the
active  stages  of  its progress.  Such are  the calabar bean,
cannabis indica, gelsemium,  ergot, etc.  If the disease co-
exists with the prevalence of erysipelas in the community,
it is  probable  that the  free use of the sulphite  of  soda, in
addition to other remedies,  would be beneficial.   I have
noticed in several of  the  patients coming under my care,
a tendency in the disease to assume a chronic form.  The
constant pain in  the  head, the muscular rigidity, and the
general febrile symptoms, gradually disappear during the
first  week or ten days ; but the patients have continued pale,
weak, subject to transient but severe  neuralgic pains, ever
changing in their locality, but most frequent at the head of
the  gastrocnemii  muscles, the abdomen  and  the  head;  a
very peevish, fretful condition of mind ; variable  appetite,
and  disturbed sleep.   In two or three cases of this kind, a
mixture of  the tincture of calabar bean  and  camphorated
tincture of  opium, given each morning, noon, and tea-time,
and  a moderately full dose of Dover's powder and  quinia
at bed-time, appeared to produce very decided and perma-
nent relief.
   In  the active stage  of the disease, I have not found either
opiates or  quinia  to  produce any favorable effects.  Such,
briefly, gentlemen, are  the  results of my observations in
regard to the prevalent cerebro-spinal disease, which may
be said to constitute a moderate epidemic.      , 
LECTURE  XVIII.
CUTANEOUS DISEASES. — Their Classification and Diagno-
   sis—Cases of Psoriasis. — Prurigo. — Porrigo. — Eczema, Etc
   Gentlemen:—Before subjecting to your examination the
case  before us, your attention will be occupied a few mo-
ments with  some  comments  on the  general  subject of
cutaneous diseases.   To most  practitioners this is an unin-
viting topic, and students rarely give it that attention which
its importance demands.
   This class of diseases, although seldom dangerous to life,
are nevertheless of frequent occurrence, many of them pro-
tracted in duration, some of them contagious or communi-
cable, and all of them more or less annoying to the patient.
Hence it is very important for every student to give them
such attention that he may be able to promptly distinguish
one class from another, and  to give such as may apply to
him for relief the most efficient treatment.  Modern writers
on dermatology or cutaneous  diseases appear  not  to agree
on any common principle of classifying the diseases in ques-
tion ;  but some  are grouped together  from a  supposed
analogy in causation, as when they arise from parasitic in-
fluence; others from a common property of communica-
bility or  contagiousness;  and still  others from  something 
252          CUTANEOUS DISEASES.
common in the form of the eruptions.  As an aid in  the
work of diagnosis, we think no better principle of classifica-
tion has been discovered than that which was adopted many
years since by Willan and Bateman, and was founded on the
anatomical structure of the different varieties of cutaneous
eruptions.
    If we omit the modifications dependent on constitutional
syphilis, and the morbid growths, such as tubercle and mol-
luscum, we may arrange all the ordinary cutaneous eruptions
into five classes.   The first will embrace all  those in which
the inflammation  is so superficial  as to produce only a  red
spot of greater or less size, without any appreciable exuda-
tion either into the cutis vera or between it and the cuticle,
consequently there is neither elevation, induration, nor vesi-
cation, in this class, but simple red spots.  These spots may
be very small and generally diffused over the surface, as in
scarlatina; or they maybe small and grouped in clusters, as
in measles; or they may be larger and more isolated, as in
roseola and erythema.   These form the exanthematous class,
The second will embrace all those eruptions  in which the
inflammation is sufficient to  cause a serous exudation be-
tween  the cutis vera and the cuticle, simply elevating the
latter into the form of a vesicle filled with lymph  or serum,
but without any plastic exudation sufficient to give hardness
or  thickening of the cutis vera.   The  vesicles may be very
small,  as  in scabies and eczema,  or larger,  as  in  varicella,
herpes and pemphigus.   These are  called vesiculae, or the
vesicular  class.
    The third will embrace those in which the inflammation
is sufficiently  intense not  only to cause an  exudation of
lymph or serum between the cutis vera and cuticle, forming
a vesicle,  but, in  addition, sufficient plastic  exudation  into
the true skin and  the subjacent tissue  to furnish a more or
less elevated and  indurated base  on which  the vesicle will 
CUTANEOUS DISEA SES.
253
rest.  Suppuration or the  formation of pus in the vesicle,
during some stage of its progress, is also a constant occur-
rence in all the varieties  included in this  group.   Hence
they are  called pustulae, or the  pustular class.  The more
important examples  of this class are  ecthyma, impetigo,
mentagra, porrigo, and  the pustules  of variola and vaccina.
   The fourth  embraces those  eruptions in which the in-
flammation causes a minute amount of plastic exudation into
the cutis vera, causing a slight induration and elevation, but
without either vesication or suppuration.   The small indu-
rated and elevated spots  thus formed  are called  papules;
hence  the  group are called papulae or the papular class.
The chief  varieties  of  disease  included in this  class are
lichen, strofulus and  prurigo.
   The fifth and last class embraces  those affections  of the
skin characterized by such a chronic grade of inflammation
as causes spots of variable size, in which the cutis vera is
more or  less thickened, and from which the cuticle is con-
stantly being exfoliated in  the form of laminae or dry scales.
This latter circumstance has caused  this group to be called
squamae  or  the squamous class.  The  varieties of disease
properly  belonging to this class are ptyriasis, lepra, psori-
asis, and perhaps the leprosy of  the ancients.  Icthyosis, or
fish-skin, which has sometimes been  included in this class,
is generally a congenital defect,  rather than a cutaneous in-
flammation.
   With  these general remarks you will be prepared  to pro-
ceed with the examination of the case before you.  The
patient is a young man of  foreign birth, a sailor by occupa-
tion, and apparently in fair  general health, but presents
gpots of cutaneous disease on his legs, thighs, arms, and a
few on the trunk of the body.   The first step in the matter
of diagnosis is to determine to which of the classes we have
named the case belongs.   As you individually proceed to
       22 
254          CUTANEOUS DISEASES.
examine carefully those spots on the uncovered parts of the
patient's legs, you will readily see that they are not made up
of minute red points, like the rash of measles or scarlet fever,
and  cannot, therefore, belong to the  exanthematous class.
Neither can you find any vesicles either filled with lymph, or
broken and weeping a serous fluid, as in the vesiculae; nor
any pustules filled with pus, and standing on  a hard base, as
in the pustular class.  You look  equally in  vain for the
small,  hard elevations, or papules,  which characterize the
fourth or papular class.
   What, then, have  you  in this case ?  Simply scattered
spots, varying in  size from  the circumference of a pea to
that of a  silver half-dollar, of irregular outline, deep red
color, slightly elevated, and rough, and on the surface of
which  appear dry, white, thin laminae of exfoliating cuticle.
These characteristics place it directly in the class of squama:,
or scaly diseases.   Having designated the class to which it
belongs, the next  step  is to ascertain which variety of that
class it represents.  There being but three varieties of this
class met with in  this country, the identification  is easy.
The ptyriasis seldom if ever exists on any part of the skin
except that covered  with hair, as the  scalp,  arm-pits and
pubes.  It is  accompanied by only slight redness, and the
exfoliating cuticle  is in the form of very small scales, like
dandruff.   None of these circumstances apply to the case
before you.  Lepra may come on any part of the surface in
red,  dry, rough spots, at first the size of a half-dime.  They
spread regularly on the circumference, and heal in the cen-
ter, and thereby soon assume a circular or ring form ; hence
the popular name of  "ring-worm."  The spots before you
have no such regular  ring form; although some of them have
existed, and been slowly increasing, for many months.  The
only remaining variety of the squamous class is psoriasis, of
which  the spots on the legs before you are perfect examples. 
CUTANEOUS DISEASES.          255
You  see  them  variable in size, irregular  in  outline,  dry,
rough, deep red, with large, thin, white laminae of cuticle on
the surface.  The disease is chronic, the spots generally in-
creasing  in size  slowly, and  continuing  for months  and
years, unless  interfered with  by remedies.   Sometimes the
spots come in the palms of the hands, and present a very
hard, rough, and sometimes fissured appearance.  -It is then
called  psoriasis palmaris, or  "baker's itch."  The disease
does not appear to be dependent  on any particular consti-
tutional derangement,  though often connected with consti-
tutional syphilis.   In the latter case, the spots have a more
livid or coppery color.  Except in the latter class of cases,
the most important part of the treatment consists in proper
local applications.  If there is any manifest derangement of
the digestive  or other important functions,  it should be cor-
rected.   In the absence of any special indications, it may be
advantageous to give small doses of some one of the arsen-
ical  preparations.   We shall give  this man eight drops of
Donovan's solution three times a day, for the first ten days,
and  have the spots  rubbed thoroughly night and  morning
with an ointment of iodide of sulphur, twenty grains, to the
ounce of cerate.   After the first ten days, we will substitute
an ointment  of ammoniated  mercury, twenty grains;  pulv.
gum camph., eight  grains;  tinct.  bloodroot, half drachm;
rubbed together and mixed  with  simple cerate, one ounce.
Let  this be  applied every night, and  the surface wet with
glycerine in  the morning.  A full alkaline bath should be
used twice a week; the diet plain, exercise in the open air
moderate,  and all stimulants avoided.
    This next patient, Mr. L., aged  twenty-five years, has just
been admitted into the hospital.  His general health appears
good, but  he has been for a considerable time excessively
annoyed with an itching eruption on the skin.   For three or
four years it  has made its appearance with the cold and wet 
256          CUTANEOUS DISEASES.
weather of autumn, continued through the winter, and dis-
appeared with the coming of  warm weather in  the  spring.
It shows most on the nates, inner and  posterior part of the
thighs, legs, and forearms.  It is in the form of  small, scat-
tered elevations in the skin, only slightly redder than natural,
and  with  no  vesicle or  tendency to  suppurate.  In other
words, it consists of small, isolated papules, many of them
having thin, black scabs on them,  produced by the  patient
having  torn them, by scratching,  until  the blood  started.
The itching,  in these cases, is  entirely  disproportioned to
the external appearances of disease.
   It is increased by warmth, and  is generally worst when
the patient gets warm in bed, often  making the night as
restless as if the bed had been sprinkled with cowage or
nettles.  The fact that the disease  makes its appearance in
this  patient  uniformly in the autumn, shows that it is de-
pendent on the  retention of  some effete matter that ought
to be eliminated through  the skin, but  which is prevented
by the influence of cold and damp on  the  surface.  The
disease is  strictly  papular, and  is  usually  called prurigo.
Cases  of  this kind are  often very persistent, yielding but
slowly to  the influence of remedies.  The treatment most
likely to cure the present case would  be such as would first
restore a free action of  the skin and  kidneys, until all re-
tained effete matter had been eliminated; and then, perhaps,
a cautious use of some arsenical preparation for two or three
weeks.  This patient  has been  using sulphur  vapor-baths
and  liquor arsenicalis, until symptoms  of oedema have, super-
vened, and yet without benefit.   We will direct him to take
a warm alkaline bath every second day,  and to  apply to the
itching surface the following ointment every night:
       5.—Potass, iod.____________________      , j
           Cerati simpl._______                z j;:
   M.                              .......  3 J' 
CUTANEOUS DISEASES.          257
   Internally, also the following :
       fy.—Vin. colchici.............-..........§*•
          Potassas acetatis.............--------3SS-
          Syrupi simpl....._.....-...........-- %l-
          Aquae___________........-.......— Z1)-
   M.  Take a teaspoonful four times a day.
   Should the colchicum  affect the bowels too much, half a
drachm of camphorated tincture of opium can be added to
each dose.
   If, after the ointment  of iodide potassa  has been used
four or five nights, it is found to create too much  irritation
in the skin, as it sometimes does, it may be omitted, and the
following wash substituted in its place :
       IJ.—Hydrarg. bichlor.......--......-.....grs- x-
          Aquae camph._______________________3 V11J-
          Glycerinae__________________________3'J-
   M.  Apply, as a wash, every night and morning.
   In most cases like  this, the foregoing treatment will afford
relief in from ten  days to two weeks.
   The next case  to which I will call  your attention is one
affecting the scalp.  This boy, aged about seven years, has
an appearance of fair general health.   His appetite is good ;
bowels regular;  secretions natural;  and nutrition active.
He complains of nothing but two or three  large patches of
eruption on  his  scalp.  One, you see, occupies the vertex,
and is  an  inch and a half in  diameter.   Another, nearly as
large, over the posterior part of the temporal region of tne
left side ; while a third, a smaller  spot, is found over the
lower part of the  occiput.   These several places  are occu-
pied by  thick, light-brown, and perfectly dry  crusts or
scabs.
   If you examine this on the vertex closely, you will find
most  of the hair gone, the scab  continuous or unbroken,
                            22* 
258          CUTANEOUS DISEASES.
and its surface  presenting numerous dimples or slight con-
cavities, and  emitting a peculiar  odor.   The crust is thick,
firm, and closely adherent to or imbedded in the skin, being in
all respects wholly unlike the patches of psoriasis in the first
patient, and  still more unlike the papular  eruption in the
second.  If we should remove one of these crusts, and ex-
amine the exposed surface of  the scalp, we should find the
primary form of the eruption from which  they have  been
slowly formed.   And even without  this, you can see, here
along the margin of the crust, above the ear, several small,
flattened, yellowish  pustules, imbedded  in  the skin.  They
are not larger in circumference than the head of a pin, and
contain a minute quantity of yellowish or purulent fluid.
These are  good  specimens of  the  primary  form. of the
eruption,  and  the surface under each of these crusts is
thickly studded with the same  minute, flattened pustules.
The latter being only slightly elevated, and the quantity of
matter in them very small, they do not break,  but the mat-
ter  dries into a  small  scab  closely  adherent, and  which
grows gradually thicker and more elevated, from the con-
stant accretion of more  matter to its under surface; and as
the pustules  are closely aggregated, the resulting scabs soon
touch and unite  at the edges,  forming continuous  thick
crusts, as you see in this case.   As the outer layers become
more dry and contracted than the inner part, it causes the
depressions or  little concavities you see on the  surface of the
crust.
    I have seen a few cases in  which the  eruption occupied
the whole of the hairy part of the scalp, causing the whole
to  be covered by a thick  crust, like a cap.   On the other
hand, the simplest form of the  disease is seen  in nursing
children,  consisting of a single patch, covered by a thick, dry
scab, from  half an inch to  one and a half inches in dia- 
CUTANEOUS  DISEASES.          259
meter, generally over or near the anterior fontanelle.   The
nurses will call it " milk-crust."
   From the language already used in describing this case,
you will infer that it belongs to  the class of pustulae.   Its
special name is porrigo.
   There are three varieties  described by  authors, called
porrigo  favosa,  porrigo scutulata, and porrigo granulata.
All the varieties attack, chiefly, the scalp; are chronic, often
continuing several years;  but with  little  or  no  impairment
of the general health.  If the scab is examined microscopi-
cally, it  will appear to consist of an immense growth  of
vegetable sporules or fungoids.  The disease is not generally
contagious.
   The most  efficient  treatment that I have tried consists
in the application of an emollient poultice, onthe surface of
which must be  sprinkled some bi-carbonate of soda, and
letting it  remain  from six  to  ten hours; then remove  it,
and thoroughly wash the affected part with slightly warm water.
By this process the  scab will be so softened and dissolved
as to be  readily washed off, leaving the  surface naked and
clean.   To this clean surface the following ointment may be
applied each morning and evening :
       5.—Hydrarg. ammoniatae........-------- 3 i.
           Camph. g. pulv----------------.....grs- xx-
           Tinct. sanguinariae.--------.........3 "'■
    Miscoe et add
           Cerati simpl----------------------3 nl-
    M.
   After using  this  eight or ten days, we  may sometimes
substitute the ointment of iodide of sulphur  with advantage.
   Another application, which has  succeeded in  rapidly
curing some cases, is ointment  containing tobacco.  It may
be prepared by simmering common chewing tobacco in lard ;
or by mixing the oil of tobacco with  cerate, in the  propor- 
260          CUTANEOUS  DISEASES.
tion of one or two minims to the ounce.  This remedy must
be used cautiously, however, as it may be absorbed in suffi-
cient quantity to induce strong sedative effects with vomiting.
   The case before you has just been  admitted  to  the
hospital;  and  after removing  the crusts  by the  alkaline
poultice, we will apply the ointment first  named, and you
will be able to note  its  effects at your subsequent visits.
No internal treatment  is needed in these cases, unless there
is manifest some  special derangement of the digestive or
excretory organs.
   I will detain you to examine only one more case to-day,
The patient is a female, aged fifty-six years;  rather anaemic
in appearance ; thin in flesh;  and suffering some from indi-
gestion.   The  chief complaint, however, is an exceedingly
annoying eruption on both legs, covering the  greater part of
the surface from the knees to the ankles.  As she takes off
the cloths, you see  them stained  and stiffened  by the ab-
sorption of a yellowish  serous fluid, which has  oozed from
the sore surface.   The latter looks red and inflamed, almost
continuous from  an  inch  below  the knee  to  within  two
inches  of the foot, with a few thin, small scales or partially
formed scabs  on it.   Around  the margin of the  inflamed
surface are numerous distinct, small, pointed vesicles, which
show  the  primary form of the eruption.  It is  these small
vesicles, closely aggregated, with the cuticle rubbed off, that
cover the whole red and inflamed surface, and from which
oozes the yellowish  serous fluid  by which the cloths were
stained, and by the evaporation of which the  thin, dry scales,
seen on, the surface are  formed.  This  eruption is accom-
panied by such a degree of itching  and  burning that the
patient can hardly refrain from violently rubbing and scratch-
ing it;  and yet all such friction only increases the torment.
The character of the primary vesicles, seen  along the mar-
gin of the diseased surface, show the  case to belong to the 
CUTANEOUS DISEASES.
201
class called  vesiculoz j  while  their  small  size, acuminated
shape, and close aggregation in large red patches, identify
it as the variety called eczema rubrum.  This variety of
eczema is one of the most common and most troublesome of
the non-contagious  cutaneous diseases.  It may attack  any
part of the surface, but is much the most frequently seen on
the  face, scalp, legs, hands, and scrotum.  It may run its
course as an acute disease, and  in from seven to  ten days
dry up and disappear, leaving no cicatrices ;  or it may only
partially disappear in the time specified, when a fresh erup-
tion, as itching and  fiery as ever, will appear; and by these
successive eruptions be perpetuated indefinitely months or
years.  It may be limited to one or more  small  patches, or
it may extend over the whole cutaneous surface.  But where-
ever it  appears,  and  whatever its  duration, it is always
characterized by small,  closely aggregated  vesicles, accom-
panied by itching and  burning,  and the weeping  of a  yel-
lowish serous fluid when rubbed or scratched.  In children
it most  frequently attacks  the  scalp, mastoid spaces,  and
ears; while  in adults, and especially in old  persons, it is
seen most frequently on the legs and external genitals.  In
recent acute cases the  treatment may be very simple, con-
sisting  in the use of saline  aperient  and diuretic  remedies
internally, and soothing  emollients or cooling applications
externally.   But when  it has assumed a chronic form, as in
the case before you, it will  seldom get well  without a con-
tinuous and protracted use of some one of the arsenical pre-
parations internally.  The liquor potassa arsenici (Fowler's
solution) is the  one generally used, and  may be  given in
doses of six drops,  gradually increased to  ten, just after
each meal.   Whenever these  doses nauseate the  stomach, or
induce colic pains, it will be better to use the ter-chloride
of arsenic, as in the following formula : 
262          CUTANEOUS  DISEASES.
       IJ.—Liq. arsenici chloridi------------------3 ii-
           Acid, hydrochlor. dil----------.....— 3".
           Syr. simpl_______.....----------------3 ss-
           Aquae_______________________........1 iii.
    M. Give one teaspoonful in sweetened water, just after each meal

   While using  either of these preparations of arsenic, if an
oedematous swelling appears, either in the face or extremities,
or both, the medicine must be omitted, and an equal mix-
ture of tincture  of digitalis and wine of colchicum, in doses
of twenty minims, given three or  four times  a day, in a
little sweetened water.   In old  and  anaemic subjects like
the  present patient, tonics  and nutrients may be  required.
Andof these, none are better than cod-liver oil, or the mix-
ture of two parts of extract of malt and one of the compound
syrup of  hypophosphites.   All  alcoholic  drinks, whether
fermented or distilled,  must  be entirely avoided.  In the
majority  of cases, the best  local applications are the ben-
zoated zinc  ointment,  applied two or three times  a day,
and a wash of sulpho-carbolated  zinc,  twenty grains to the
ounce of water.  In some very chronic cases the following,
applied night and morning,  has afforded much relief:
       I£.—Hydrarg. ammoniatae__________________3i.
            Tinct. sanguinariae____________________3 iss.
    Miscae et add
           Cerati simpl.____......______________^ iii-
    M.
    But the clinic-hour has  passed, and I will detain you no
longer. 
LECTURE  XIX.
MANIA A POTU AND CHRONIC DISEASE OF THE BRAIN.—
   Delirium Tremens with. Fatty Degeneration—Chronic Dis-
   ease of the Brain—Anomalous  Nervous Symptoms.
    Gentlemen :—Delirium tremens, or that form of temporary
 mental derangement caused by the use of alcoholic  drinks,
 is, unfortunately, of frequent occurrence in almost all popu-
 lous communities ; and the wards of our hospital are seldom
 entirely free from cases  of this class.   The  subject  from
 which these morbid specimens were taken, was a man of in-
 telligence, between  twenty-five and thirty years of age, nat-
 urally strong, and well formed, but who had accustomed him-
 self to the  use of alcoholic drinks for  many years.  It was
 stated by his friends, that for three weeks before his admis-
 sion to the  hospital, he had been almost constantly intoxi-
 cated, much of  the time taking from one to two pints of
 brandy per diem, while during the same time he took very
 little food.   At  the  time of his admission, and for three or
 four days previous, he had  been exhibiting all the phenom-
 ena of mania apotu, or the delirium of the drunkard.   When
 first seen in the ward, his face was pale, or rather of a purplish
 color; eyes sunken; the vessels of the conjunctiva distended
with blood; and pupils large; the expression of countenance
haggard;  the extremities cool and blue;  the pulse  small,
weak, and frequent; the stomach so irritable that  almost 
264              MANIA  A POTU AND
everything swallowed was quickly rejected by vomiting, ac-
companied by a dark greenish fluid, mixed with mucus; and
motions indicating great epigastric distress.
    His mind was constantly occupied with all sorts of horrid
images and phantoms, and he was much of the time engaged
in a struggle to get out of bed and away from his attendants.
There was constant  vigilance, and much muscular agitation,
or tremor.  He could not be kept sufficiently quiet to per-
mit a direct physical examination of the cardiac and hypo-
chondriac regions; but the general symptoms justified a very
unfavorable prognosis.   And yet, up ±0 that time, his friends
continued to give him the alcoholic drinks.
    Their further  use  was forbidden;  the attendants  were
directed to use no more  force in restraining him than was
absolutely necessary to prevent him from doing injury to
himself; and the following prescriptions were ordered:
        R.—Acid, carbolic, cryst...............___grs. viij.
            Glycerinae_______..................^ ss-
            Tinct. digitalis...........______.....^i.
            Tinct. opii camph______________________§ iijss
    M.  S. Give one teaspoonful, in a tablespoonful of water,
every  two hours.   It  was hoped that this  might allay the
gastric irritation,  steady and strengthen  the heart's action,
while the camphorated  tincture of opium would lessen the
morbid vigilance, without impairing the action of the kid-
neys, or endangering excessive narcotism.   In the evening,
the narcotic effect was .to be  increased by a single dose of
fifteen grains each of bromide of potassium and  hydrate of
chloral.  Tablespoonful doses of milk with lime-water, were
also directed to be given every two  hours,  alternately with
his medicine.
    On the following day, the condition of the patient was in
no respect improved. The attendants had succeeded only very
partially in carrying  out the directions, the patient resisting 
CHRONIC DISEASE OF THE BRAIN.       265
the taking of either nourishment or medicine ; while one of
his friends had smuggled in a small bottle of what he called
"good brandy," some of which had evidently  been used.
The  matters vomited were becoming more  dark and gru-
mous, his pulse more feeble, and he died on the evening of
the   third day after  admission.  A post-mortem  examin-
ation revealed no important morbid appearance visible to
the unassisted eye, except in the stomach, duodenum, liver
and  kidneys.  These organs are before you,  fresh as they
were taken from the body.  The stomach and duodenum
are laid open; you see the mucous membrane, in its whole
extent, presenting an intensely red and tumefied appearance.
In some places, where most intensely injected  with  blood,
the surface is dark brown, and; apparently, softened.  These
appearances are the result of severe inflammation in the gas-
tro-duodenal mucous membrane.   And this inflammation
was probably the direct cause of death.
   The kidney is seen to be moderately enlarged, rather soft
or flabby to the feel, and, on being laid open,  the cortical,
or secreting structure," is pale,  and  several small masses of
fatty tissue at different points are observable.   No analysis
of the urine was made.
   The liver is seen to be greatly enlarged, being more than
twice its natural size.  Its color is light olive, both inter-
nally and externally, and its increased  bulk is plainly owing
to infiltration, or deposit of fat globules,  constituting  the
most common form of fatty liver.  The heart is also loaded
with fat; and its muscular tissue paler than natural.  These
morbid specimens fully illustrate the two  leading  effects of
alcoholic drinks on the physical organization of the  human
body.  The fatty degenerations in the liver, heart, kidneys,
etc.,  are the  result of the  slow,  long-continued, moderate
influence  of  alcohol,  in  retarding  the oxydation  of  the
carbonaceous matters of the system, and allowing them to
       23 
266
MANIA A POTU AND
accumulate in the form of inert fat; while the acute gastro-
duodenitis is the  result of the direct irritating influence of
strong distilled spirits, taken in large quantities, without or-
dinary food.
    Some have  expressed  doubts as to whether  alcoholic
drinks were capable of producing direct inflammation of the
mucous  membrane of the stomach; but such inflammation
is certainly a frequent complication of delirium tremens, and
adds greatly to the  danger of that disease.   It is very gen-
erally supposed that the delirium and trembling result from
the  sudden  withdrawal of the  so-called stimulating  drink,
and the consequent anaemic condition of the brain.   And it
is certainly true, that, in many cases, the first  indications of
delirium occur from one to five days after the inebriant has
been discontinued.   But  it is  equally certain that, in two-
thirds of all the cases that have come under my observation,
the  symptoms  supervened while  the  patients were still in
the full  supply of their accustomed drink.   Whenever the
alcoholic solution is kept in contact with the brain struc-
tures, constantly retarding the molecular changes for a con-
siderable time, while the supply of nutritive matter through the
digestive organs is suspended, or  greatly deficient, that per-
version of function which is styled delirium  tremens ensues,
whether  the drink is continued  or not.   In simple, ordinary
cases of delirium, not  complicated with any serious disease
in the chest or abdomen, the indications for  treatment are
simple, and easily fulfilled.  The patient  should be kept at
rest, with kind, persuasive,  encouraging  words, and as little
physical  or  forcible restraint  as possible.   All  alcoholic
drinks should be entirely discarded, and, in their place, such
medicines given as will exert a soothing, tranquilizing influ-
ence, favoring sleep at night; and such bland nourishment
as will be most readily retained and assimilated.  From ten
to fifteen grains of bromide of potassium, given  in  solution 
CHRONIC DISEASE OF THE BRAIN.       267
with the same number of minims of the tincture of digitalis,
every two or three hours, according to the degree of excite-
ment, and from fifteen to twenty grains of hydrate of chloral,
between eight and nine o'clock in the evening, will be all the
medicine needed in most of these cases.   Nourishment is of
even more importance than  medicine.  At first, the patient
should be induced to take  two or three tablespoonfuls of
milk, beef-tea, or other simple liquid  nourishment, between
each of the doses of  his medicine; and after he begins to
recover, the food may be  more  varied, and given in larger
quantities. In  cases accompanied  by  paleness, constant
sweating,  a small, weak pulse, and scanty urine, the follow-
ing may be given betweeen each of  the  doses  of the bro-
mide and  digitalis:
       ]$.—Ammon. Carb............----------3 ij.
           Tinct. opii camph------------------§ ij.
           Syr. simpl...............------.....% ss.
           Aquae camph.................------3 iss.
    M. Give one teaspoonful every two or three hours, in a table-
spoonful of water.
    In cases accompanied by such persistent vomiting of thin
mucus, of a green or brownish color, as indicates  special
gastro-duodenal  inflammation,  a powder  containing  one
grain of calomel and  one-quarter of a grain of  sulphate of
morphia,  given  every three  hours, and tablespoonful doses
of cold milk and lime-water, have often succeeded well in
gaining control over both the delirium and gastric irritation.
After the first day, the calomel  should be  omitted, and its
place supplied by five grains of subnitrate of bismuth, or three
grains of oxide of zinc, with  the same  quantity of morphia as
before.  In a few instances,  after the mental excitement and
gastric irritability had much abated, a troublesome hiccough
has supervened, which  has  yielded  to five grain doses of
monobromated  camphor  more  readily than to any other 
268
MANIA A POTU AND
remedy.   There has been, and still  is, a tendency to treat
delirium tremens too heroically;  that is, to give too  large
doses of medicine, either by the mouth or  hypodermically.
   We cannot but regard twenty, thirty, or forty grain doses
of chloral, half-grain, and grain doses of morphine, or fluid
drachm doses of tincture of  digitalis, as dangerous  and un-
necessary.  I have never resorted to such  doses; but sev-
eral cases have come  under my observation in which they
have been resorted to, some of which suddenly  terminated
fatally.   About two years since, a case was admitted into this
hospital, in the  early stage of delirium tremens.   He  was a
middle-aged man, of good physical development; and one
of the assistants in the hospital  gave him, at once,  about
fifty grains of hydrate of chloral.  It  was followed, in a short
time, by narcotism, so profound that artificial respiration had
to be maintained for three hours before he regained a con-
dition of safety.  In  a  disease involving  so much impair-
ment of nutritive and  molecular changes, a milder medica-
tion,  and more attention to nourishment, is the safer course.
    Your attention is next invited to the patient occupying
this bed.  This is a laboring-man ; aged about forty years;
native of Ireland.   He was admitted to this hospital eight or
ten days since.   He had previously been in the county hos-
pital  for a  considerable time,  and  had complained  of ill-
health  for several months.  At the time  of his admission
here, his countenance wore a dull, dejected expression; the
surface  was pale  and cool; pulse soft, regular, and 75 per
minute;  respiration regular,  but  less full than  natural;
tongue clean;  appetite variable;  and urine natural.
    When first visited, after his admission, he was lying in bed,
on his back, with limbs extended,  motionless, and  appar-
ently unable to speak.   After  repeated questions, and some
shaking, he uttered,  slowly,  a few words.  It  appeared,
 from what could be gathered of his history from his friends, 
CHRONIC DISEASE OF THE BRAIN.       269
 that, several months since, he began to complain of an almost
 constant pain in the region of the occiput and posterior fon-
 tanels, with  depression of spirits, mental apprehension, and,
 often,  sleeplessness at night.  These symptoms increased,
 until  he was wholly  unable to  work, and was  sent to  the
 county hospital for treatment.  In addition to constant pain
 in the  posterior part of his head, and  mental depression, he
 would have periods, lasting  from an hour to a whole day, in
 which  he would  neither move nor talk, nor pay any heed to
 the fullness of his bladder, as though  he was in a profound
 stupor; and yet, his respiration and  circulation continued
 quiet, and he evidently heard much that was said to him.  Al-
 most every night he had one or more paroxysms of suddenly
 crying out with barking, or very unusual sounds, ending in al-
 ternately opening wide the mouth, and shutting it, with a few
 rapid protrusions of the tongue.  These paroxysms generally
 lasted but a few minutes.  He also complained of frequently
 seeing objects or  persons in the room, and  feeling the ap-
 prehension that the latter were coming to injure him.  He
 was disposed to  remain in  bed;  and, when  induced  to get
 up, his muscular movements were slightly unsteady, with oc-
 casional  sudden  contractions.  There was  some hyperaes-
 thesia of the  scalp, over  the seat of pain in  his head; and
 the pupil of the left eye was one-third  larger than that of the
 right.
   The patient had been accustomed, for years, before get-
 ting sick, to more or less use of  alcoholic  drinks,  and to-
 bacco.   The  pathology of the case was seen to  be obscure.
   But the pain in the upper and posterior part of the head,
 the dilatation of the left  pupil, the paroxysms of irregular
 muscular motion in the extremities, etc., suggested the idea
 that there was a low grade of inflammation  or irritation in
the membranes covering the cerebellum, and extending to
the tubercula quadrigemina.  This suggested an alterative
                           23* 
270               MANIA A POTU AND
and mildly anodyne  treatment.   He was  required to avoid
all stimulating drinks;  live on milk  and farinaceous diet;
and to take a teaspoonful of the following prescription each
morning, noon, and tea-time :

        B.—Sodii iod...........................3 iij-
            Hydrarg. bichlor.....................gr. j.
            Ext. conii fl.........................3 iv.
            Syr. prun.  virg.......................§ ij.
    M.      Aquae..............................§ iss.

   He  was also directed  to take from fifteen to  twenty
grains of bromide of potassium, at bed-time, to  secure better
sleep.
   He  has now been under the influence of this treatment
about ten  days, and  is certainly much improved.  He com-
plains of much less pain in his head;  sleeps better at night;
and  his periods of mental abstraction and irregular muscular
movements, are less frequent and  less severe;  there is also
a little  less dilatation of the pupil of the left  eye.  The same
treatment  was continued.*
   We  have here another patient, a boy aged ten years, who
has been  brought in from the  country, and is presented to
the clinical class by the request of  his attending physician.

   History.—Up to  the time he was eight years of age (two
years since), he is represented to have been a healthy, robust
boy, physically, and  bright and active mentally.
   About  two years since, while attending school, he began
to exhibit certain nervous symptoms, or singular  mental
traits, that soon developed into incoherent laughing, which,
after  a  few days, was followed by equally incoherent or un-

   * Note.—The patient has now been under the above treatment for five or six
weeks, and is  up, going in  and out, with the appearance of being well, although
he still has spells of strange feelings, and fearful apprehensions,  especially in the
night. 
CHRONIC DISEASE OF THE BRAIN.
 controllable crying, with wringing of the hands, pulling and
 twisting of the clothes, etc.  These symptoms were followed
 by some irregular muscular movements and facial contor-
 tions, resembling slight chorea, which still continue.
    After a few weeks he was found  to have, almost every
 night,  one or more paroxysms of suddenly crying out, with
 strange sounds, and muscular contortions, though not like
 ordinary spasms or convulsions, and  not followed  by any
 period of unconsciousness.  About two months after the boy
 was noticed  to be unwell, a slight swelling  was discovered
 by his  attending physician, in  the right inguinal  region,
 which, the boy said, was tender, and sometimes painful; and
 the doctor found that pressure with the finger on the swell-
 ing, uniformly caused symptoms similar to his nightly par-
 oxysms.  After the use of some alterative and cathartic rem-
 edies, this swelling, and all  local symptoms in the inguinal
 region, disappeared.  The nightly paroxysms, however, have
 continued, with gradually increasing frequency, until, at pres-
 ent, they average six or seven each night.  They consist in
 starting suddenly from sleep, with crying out, and, generally,
 violent  swinging out of his arms,  kicking  with  the feet;
 sometimes bending  the  body forward, followed by violent
 extension, and reckless tossing, but no frothing at the mouth,
 stertorous breathing, or stupor.   The individual paroxysms
 last but a  few minutes, at most;  and the boy retains a good
 appetite—a good degree of  general nutrition; but his gait,
 in walking, has  become awkward,  his  nervous system im-
 paired, with little power to fix his attention, and little  appar-
 ent inclination to talk.  He  is very  restless during the day,
 moving  about almost constantly,  but to no definite  purpose.
 His bowels are nearly regular ; but there occurs, about once
 in six or seven days, a mucous or slimy discharge, as though
there was still some point of irritation in the mucous mem-
brane of the colon. 
272
MANIA A POTU AND
   Pathology.—From the preceding history, it will be con-
ceded that the nature of this case is somewhat obscure.  As
is  usual in such cases, the boy has been treated by several
medical men, and subjected to a great variety of medica-
tion.  The gradual impairment of his mental faculties, and
altered  muscular movements, with the nightly paroxysms,
are sufficient to show, not  only  a  morbid condition of  the
brain, but  that long continuance of such irritation or con-
dition  has induced morbid or  defective nutrition of  the
cerebral substance; and, unless  it  can be removed,  it will
end  in arrest  of cerebral  growth, and dementia.  In its
commencement, the grade  of morbid action appeared to
be intermediate between that of chorea  and  epilepsy;  but,
in its progress, it has approximated more and more to  the
latter disease.
   If this view of its pathology be correct, the question would
still  arise, whether the  cerebral irritation was primary, or
reflex from some point of disease elsewhere, more especially
in the caecum, or some part of the ileo-caecal junction, as sug-
gested by the swelling and tenderness discovered over that re-
gion, about two months after the boy began to complain.   As
a general rule, reflex irritation in the nervous centers does
not lead to as marked evidences  of impairment of nutrition,
and  of mental faculties,  as is presented in this case ; yet, the
fact  that indications of special local disease in the right
inguinal region were noticed  early in the  case, and  that
there still occurs,  every week, a single  mucous discharge
from the bowels, should  not be entirely overlooked.
   Treatment.—There are  three leading ideas that  should
govern our treatment of the case, in its present stage:  one,
to remove, as far as practicable,  any present existing local
disease in the mucous membrane of the intestines; another,
to overcome  the  morbid sensitiveness, or irritation, in the
cerebral center;  and the other, to  restore a  healthy, active, 
CHRONIC DISEASE OF THE BRAIN.        273
nutrition of the brain substance.   To meet the first indica-
tion, the following prescription was suggested :
       B.—Argenti. nit.........................gr. x.
           Ext.  hyoscyam.................-----gr. xv.
    M.  Fiant pilulae xxx.   Give one pill before each meal.
    At the same time, for the second indication, the following
was directed:
        5. —Potass, brom........................3iv.
           Tinct. digitalis...................... 3 iv.
           Ext. Scutellariae fl____..........------1 j.
           Syr.  prun. virg_______...............1 iiss.
    M.  A teaspoonful to be  given half an hour after breakfast, and
dinner, and at  bed-time, in a little water.
    The dose at bed-time might be increased to a teaspoon-
ful and a half, if found necessary, to interrupt the night par-
oxysms.  The first prescription might be discontinued, after
the first two weeks,  and  a teaspoonful of the compound
syrup of the  hypophosphites, with an excess of the phospho-
rous acid, given instead of the pills, which would meet the
 third indication named.   To have a fair chance of success,
 the second prescription and the hypophosphites should be
 continued several months, with a diet of milk,  farinaceous
 articles, vegetables, and  fruit,  but without either meat or
 stimulating drinks.   He should  be allowed to  take a  fair
 amount of out-door exercise, daily, and be subjected to mild,
 cheerful, mental discipline. 
LECTURE  XX.
PNEUMONIA.— Double Pneumonia — Sthenic and Typhoid
                     Pneumonia.
    Gentlemen :   Mr. G----, a laboring man, aged about 30
years, was  admitted into the hospital November 3d, 1873.
He informed the house physician that he had been attacked,
only three  days previously, with headache, pains in the back
and limbs,  followed by fever, some  cough, with soreness in
the chest and a loose condition of the bowels.   At the time
of his admission his expression was  dull, with slight flush on
the cheeks; tongue slightly  coated ;  skin but little above
the natural temperature; respiration short and quick; pulse
100, soft and weak; bowels moving at the rate of eight or
ten times in the twenty-four hours; abdomen moderately
full and tympanitic; expectoration  scanty and tinged with
blood, though the cough was not severe.   He was directed a
teaspoonful of  the  emulsion of turpentine  and laudanum
every three hours,  and wheat-flour and milk-porridge for
nourishment.
   The same  evening, however, he became extremely de-
pressed; his  skin cool; lips  bluish; breathing  short, hur-
ried, and accompanied by a great sense  of oppression;
pulse  small, frequent and  feeble;  and  his  expectoration 
PNEUMONIA.
275
 bloody mucus.  Percussion revealed almost entire dullness
 over  the  greater part of the right side of the chest, with a
 lesser degree of the same at the lower, lateral part of the left
 side.   There was also strong vibration of voice, or broncho-
 phony, over the right side, and tubular, respiratory sounds.
 These symptoms and physical signs indicated extensive and
 rapidly-increasing pneumonic  exudation :  so extensive, in-
 deed, as to threaten speedily fatal  results.  Sinapisms were
 applied freely,  both to the chest and extremities;  and
 six grains of carbonate of ammonia dissolved in camphor-
 water, with  the addition of a little camphorated tincture of
 opium, were given between each of the doses of the emul-
 sion.   He also  took, during that night, a few times, small
 doses of brandy in sweetened water.
    At my visit on the following  day,  which was yesterday,
 the surface and extremities had become warm, but the coun-
 tenance was still depressed, and  lips leaden-hue; the pulse
 soft and frequent; breathing short and imperfect; mind dull
 and drowsy;  bowels loose; some cough, and  expectoration
 composed  of frothy mucus mixed  with  blood, with the
 physical signs the same as just described.  The carbonate
 of ammonia mixture, alternately with  the emulsion, was di-
 rected to be continued, with two grains of sulphate of qui-
 nine added to each dose of the latter, and  a blister-plaster
 applied to the right side of the chest.   To-day you find him
 still with a depressed, dull  expression  of countenance, pro-
 labia not quite so bluish, and  the  respiration a little  more
 full; pulse still soft and weak, but less frequent;  expectora-
 tion more  free and less bloody, with nearly the same phys-
 ical signs as yesterday.  After the members of the class had
 examined the patient, it was stated that the principal objects
of further  treatment were to sustain the  patient—more
especially the tone of the vascular system—and to promote
the  re-absorption  of the  pulmonary  exudations.  As the 
276
PNE UMONI A.
looseness of  the bowels had  ceased, the emulsion of oil of
turpentine and laudanum was omitted; but the two grains
of quinine was continued, in  connection with the carbonate
of ammonia  solution, every four hours, and  a teaspoonful of
the ordinary  muriate of ammonia mixture given alternately
with it.  The regular administration of simple nourishment
was also enjoined, as of equal importance with the giving of
medicine.*
    This case presents  strongly-marked typhoid or asthenic
symptoms, which are increased  by the unusual looseness of
the bowels, and consequently cannot be regarded as a fair
representative of ordinary pneumonia.  In such cases as
this, the first stage, characterized by exalted susceptibility
or irritability of the structure with intense congestion of the
blood in the  capillary net-work surrounding the air  cells, is
generally of very short  duration.  Exudation takes place
early and copiously,   sometimes,  as in the  present case,
threatening to suffocate the patient, and giving rise to  that
purolish or leaden hue of countenance;  soft, quick pulse;
oppressed breathing, and rapidly increasing  dullness  on per-
cussion, that was seen in this  patient at  the time of his
admission.   In the more  common  and  active or  sthenic
cases of pneumonia, the  attack  is generally ushered in with
a decided chill, followed by high febrile action; deep-seated
and severe pain in one side of the chest; a rapid increase of
temperature, often  reaching 1020 F. by the  end of the  first
twenty-four hours; the face suffused with redness;  respira-
tion short and frequent;  pulse  from 90 to  110 per  minute,
and moderately full;  some cough, with  a  scanty  mucous
expectoration, afterwards becoming  more  in quantity  and
mixed with blood; urine scant and high-colored, with defi-
ciency of the chlorine  salts ;  tongue covered with  a white
* This patient continued to improve slowly until convalescence was established 
PNEUMONIA.
277
 coat, and bowels either natural or slightly costive.   During
 the  first twenty-four hours auscultation  reveals a fine, dry,
 crepitant rale over the affected part of the lung, with  only
 slightly diminished resonance.   But during the next  three
 days the crepitant rale gradually disappears and is replaced
 by a  mucous  rhonchus, and  the dullness  becomes  more
 strongly marked.   During the same time the temperature
 usually increases  to  104 or 105 ;  the expectoration  more
 copious  and bloody;  the urine  more scanty, with  greater
 deficiency of chlorides, and often containing some albumen.
 In most cases of  active pneumonia  the  fever and  other
 active  symptoms reach their climax between the fifth and
 seventh days after the  initial chill, and  from that time the
 temperature  begins to decline; the  expectoration is less
 bloody; the skin often a little  yellow;  the bowels  more
 free, and the urine more natural in quantity, with less defi-
 ciency of the chlorides.  The shortness and frequency of
 respiration,  and the dullness on percussion generally  con-
 tinue, and sometimes even increase for two  or three  days
 after the temperature abates and the secretions have become
 more free.   Most recent writers describe three varieties of
 pneumonia—the croupous, the catarrhal, and the interstitial
 or chronic  form.  The second  variety differs  from the first
 chiefly in the fact that the inflammation involves the smaller
 bronchial tubes  and air vesicles, as well as the structure of
 the lung.
   The third is a sub-acute grade of inflammation in the
 connective  tissue,  capable  of persisting in a  chronic  form,
 and  inducing  either carnification or caseous  degeneration.
 Clinically, we have thought it of much greater practical im-
 portance to group or classify our cases of pneumonia in ac-
 cordance with the  accompanying  state of the system and the
grade of fever.   In one series of cases we find the accompa-
nying fever active ; the pains acute; the flush of the face red;
       24 
278
PNEUMONIA .
pulse firm;  the  temperature high;  the crepitations sharp
and  dry,  and  the  sensibilities of  the  patient  acute.  In
another series  of cases, the febrile  reaction is  less acute;
the pains  more dull and obscure ; the flush of the face pur-
plish or dingy;  pulse frequent, but soft  and weak; mind
dull; and the expression of countenance dejected and care-
less.  The first of these series we call active or sthenic pneu-
monia,  and the  second, typhoid or asthenic.   But in the
more malarious  districts of our  country, another class of
cases are  frequently met with, which differ from the first se-
ries  chiefly in the more decidedly remitting character of the
fever; the more  rapid exudation  into the lung tissue;  thin-
ner  and more copious bloody expectoration, and the earlier
and more decided appearance of yellowness of the skin and
eyes.  The essential pathological changes which take place
in the lung  are the same in kind in all these classes of cases,
differing in  degree  and in the  rapidity  of their  progress on
account of the coincident condition of  the blood and prop-
erties of the tissues generally.
    During the first  stage, lasting from  one to three days in
different cases, there is intense congestion of the capillaries,
with increased irritability  of the inflamed structure,  com-
pressing  the air-cells and  giving rise to the characteristic
crepitant rale.   The continued vascular distension is soon
accompanied by exudation, more or less rapid, both into the
air-cells and the interstitial spaces of the tissues.  Some of
this  exudative material passes from the  air-cells into the
bronchial tubes,  and appears in the expectoration, while the
remainder accumulates in the tissue, rendering it dense, par-
tially impermeable to air, deep red  color, and two or three
times as heavy as natural.   This is the second  stage of the
disease, and reaches its climax, generally, in from three to
five  days, or in from five to nine  days from the initial chill.
Early in  this  stage the crepitant rale is superseded by the 
PNEUMONIA.
279
sub-mucous and mucous rhonchi, with decided dullness on
percussion.  When  this stage is completed, and no further
exudation takes place, the temperature of the body begins to
decline; the restlessness and pain diminish; the expectora-
tion continues free, but less bloody ;  the chlorides soon begin
to increase in the urine, and the dullness on percussion also
slowly diminishes, until, in about one week from the end of
the second stage, in favorable  cases, convalescence is estab-
lished.  This is the  third  stage  or  period of resolution,
during which  the exudation  taking place in the second is
removed byre-absorption  and expectoration.  In such cases
as are not  tending towards a favorable result, the commence-
ment of the third stage is marked by great oppression  of
breathing, the respiratory movement being mostly abdominal
and accompanied by coarse mucous rhonchus;  a soft, weak
and frequent pulse ; a leaden or purplish hue of the face and
lips;  often profuse sweating;  and more or less delirium.
The expectoration  in some  cases becomes purulent;  in
others, thin, dark red, and copious; and in still other cases
the lung tissue becomes rapidly filled with a semi-cedematous
infiltration, with  only a scanty expectoration of frothy mu-
cus.  In  these unfavorable  cases,  the dullness on  percus-
sion is not only persistent, but generally  increases, both in
extent and completeness, and the urine remains scanty,  defi-
cient  in chlorides,  and containing more or less albumen
during the second week after the attack.
   While the essential  changes taking place in the inflamed
pulmonary tissue, such as morbid sensitiveness of the struc-
ture and accumulation of blood, with some degree of exuda-
tion, are  the same  in  kind in all  cases, there are certain
other morbid processes or changes that are determined by
the co-existing conditions of the general properties of the
solids  and fluids of  the system, and the sanitary influences
surrounding the patient. 
280                 PNEUMONIA.
   Thus, the rapidity and extent of the exudation ;  the ten-
dency of the exudative  material to plastic organization and
subsequent  resolution, or to purulent or caseous degenera-
tion, will depend on the  condition of the blood and vital
properties of the patient at the time of the  attack,  and the
sanitary influences that had  surrounded him.   Therefore,
no  plan of treatment  can be devised  that will be appli-
cable to  all  cases  of pneumonia.  The  leading indica-
tions to  be fulfilled, are  the  same  in the first and second
stages of  the disease in  all cases, it  is  true;   but the
means best adapted for fulfilling them  may differ much in
different cases.
   To lessen the irritability of the  inflamed tissues; to re-
lieve the intense vascular  fullness, and thereby limit the
amount of  exudation, are the special objects to be accom-
plished in the first stage.  If  the patient, previous to the at-
tack, has been healthy, his blood plastic, and his  sanitary
surroundings free from the causes of typhoidal diseases, one
prompt, free bleeding from  the  arm,  followed by arterial
sedatives  sufficient  to  control the  circulation, united with
just  enough anodynes  to lessen  irritability  and pain, will
constitute the most efficient  treatment that  can be devised
for checking the progress of the disease, and limiting the
amount of  exudation.  The  earlier these  means  are em-
ployed the better will they succeed in the accomplishment
of their object.  In most cases  of pneumonia, exudation
from the congested  pulmonary capillaries begins early, and
reaches its full completion by the end of the  third, or during
the fourth  day after  the  attack.  Practically, therefore,
bleeding and direct  sedatives  must be limited mostly to the
first  three  days of the disease.   That a prompt  and free
bleeding in the first or congestive stage of active pneumonia,
followed judiciously by sedatives and anodynes, is capable
of greatly lessening the tendency to exudation, and favorably 
PNEUMONIA.                 281
modifying the  whole subsequent progress of the disease,
even to the extent of materially shortening its duration, I
have no doubt.  I have seen it demonstrated so  frequently
at the bed-side in former years, when practicing in a rugged,
non-malarious district of country, that to doubt is to distrust
the evidence of my senses.  That many cases, even of the
active  class, can be treated safely without bleeding, is true.
But it is equally true  that to omit it in the first stage of the
more active and severe cases, is to greatly increase the dan-
ger and protract the sickness of the patient.  It  must be
admitted that the chief danger in  pneumonia arises from the
extent  of the exudation, filling up the pulmonary tissues, and
obstructing the respiratory function.   If, by taking sixteen
or twenty ounces of blood from the arm during the first day
or two, we can prevent half that quantity of exudation from
the capillary vessels of the lungs, we shall both conserve the
strength of the patient and shorten the duration of the third
stage of his sickness.  For the  lodgment of half a pint of
blood in the form of exudation, will result in a much greater
tax upon the patient's strength during the second and third
stages, than the abstraction of three times that amount from
the arm in the  beginning.  You  will bear in mind, gentle-
men, that all my remarks in reference to bleeding  and arte-
rial sedatives, such as veratrum, aconite, gelseminum, etc., are
applicable to active sthenic pneumonia  in its first stage only.
When  the disease is associated with a typhoid condition of
the system, as  is often the  case in densely populated cities,
manufacturing  towns, etc., these remedies (and  especially
bleeding) are not well borne, and may be injurious.   I have
seen a  patient  of this class  bled  during the first stage of the
disease, who fainted before a teacupful of blood  had been
obtained from  the arm, and who required the prompt use of
diffusible stimulants, as  carbonate of  ammonia,  camphor,
and nourishment, to prevent fatal exhaustion.  In this class
                           24* 
282
PNE UMONIA .
of cases I have succeeded best by giving, during the first two
or three  days, the two following prescriptions :

       B.—Ammon. hychochlor.................3 iii-
           Antim. et potass, tart................grs. ii.
           Mophiae sulph.......................grs. iii.
           Syr. glycyrrhiz......................^iv.
   M.  Take one teaspoonful every four hours.
        IJ.—Hydrarg. chloridi mitis_______________grs. vi.
           Ipecac, pulv............____________grs. vi.
           Opii pulv.__________...............grs. iii.
           Sacch. alb.___________....._________grs. xxx.
   M.  Fiant pulveres vi.  Give one  powder every four hours alternately
with the preceding prescription.  At the same time cover the chest with
emollient  poultices.

    At the  end of  twenty-four hours the powders should be
omitted, and if the bowels have not been moved a mild lax-
ative should be given, sufficient to procure one or two intes-
tinal evacuations ; but the hydrochlorate of ammonia mix-
ture may be  continued every three or four hours for several
days.  If the symptoms are not favorably  modified by the
third or fourth day, a blister from  three to six inches square
should be  drawn on the side of the chest most  affected.  If
the pulse becomes soft and frequent, the breathing abdominal,
and the  lips leaden hue, two-grain doses of quinine with car-
bonate of  ammonia or camphor, or both, may be given with
advantage between  the  doses  of the  other  medicine.  If
delirium or morbid vigilance becomes troublesome, as some-
times happens, ten or twelve minims of chloroform added to
each dose  of the  hydrochlorate of ammonia mixture will
generally procure  sleep, and greatly improve the condition
of the patient.
    Those  cases of pneumonia  that occur in patients influ-
enced by malaria,  may be treated in the same manner as the
active sthenic cases, except that bleeding must be restricted 
PNEUMONIA.
283
more rigidly to the first or second day, and fair anti-periodic
doses of quinine  should be given during the  time of each
diurnal remission  in the fever.
   The hour will  not permit me to pursue the subject fur-
ther  at  present.  If you  remember that pneumonia may
attack persons presenting widely different conditions of  the
solids and fluids of the  system, and in the midst of equally
different sanitary  surroundings, and that each stage of  the
disease has its special indications for treatment, you will  not
find it difficult to treat each case on its own merits  ration-
ally,  and avoid that blind routine which is the bane of clin-
ical medicine. 
 
INDEX-
PAGE.
Agur, Chronic — its Sequels, etc.,   .      .      .      -  50
Alimentary Tract, Diseases of,   .      .                 114
Asthma,  .      .      -      -      -      -      -      -97
An.emia and Anasarca,     .      -             -      .    187

Bronchitis, Chronic,    .      .      .      -      -      -  93
Bilious Colic,       -       -      -       -      -       .129
Biliary Calculi, _      .      -      -      -      -      . 189
Bronchitis, Complicating  Typhoid Fever,       .            35
Brain, Affections of,          -      -      -      -      - 227
Brain, Probable Softening of,           .      -       -    231
Belladonna and Chloral Hydrate Enemas, .            . 132

Cardiac Disease, Cases of,               -      -       -    *77
Cathartics, Bad Effects of, in Continued Fever,  .      .  n
Calabar Bean — its Use in Ceeebro - Spinal Disease,      .    242
Chloral Hydrate and Belladonna Enemas,  .            -  132
Children,  Summer Complaints of, .      -      -       139.  J53
Cholera Infantum,     .      -             -      -      -  I39
Continued  Fevers,         -     -      -     -      -  7»  27
Chloroform —its Internal Use in Typhus,  .      .    18,  48
Chronic Rheumatism,       -----      9
Croup, Case of,  .                   -
Cerebro - Spinal Disease,   .             -      -            241
Cutaneous  Diseases, Classification and Diagnosis,   .      .251 
INDEX.
 PAGE,
. 122
Diarrhcea,  Chronic Army,
                   Sequel of Typhoid  Fever,  .           124
Diabetes Mellitus,     .      -      -      -     -      .  184
Diphtheria, Case of,       .      -      -      -      -     °4
Diarrhcea,  Infantile,   .      -      -      -     -      -  !39
Dropsy, the Pathological  Conditions that give rise to it,  165
Dysentery, Acute,     -      -      -      -     -      .120
Delirium Tremens,      ,   -      -      "      -      -    263
Emboli, Complicating Typhoid Fever,    .            .     27
Epilepsy,  .     _     .      -      -      -     -      -  227
Ergot and Calabar Bean  in Cerebro - Spinal Disease,  .     242
Eczema, Case of,       ......  260

Gastritis, Case of,  .             .      -      -      -     114

Hemiplegia,     .      .      -      -       -      -      -  2I3
           Partial, ------     2i7
Hydrocephalus, Chronic,      .      .       -      -      -  236

Intestinal Irritation,     .      .      -      -      .129
           Ulceration following Typhoid Fever,  .      -   39
      "    Rheumatism,    ....      -     88
Inflammation — its Treatment,       .       -      -      -  T35

Measles,     -------     8o
Mania a Potu,  -      -      -      -      -      -      -  263
Nervous Affections,    .      .      -       -      -      - 210
Neuralgia of Rectum,    ..      ...    207
     "     an Obscure Case,  .      .       .      .     . 192

Paraplegia,  _______    220
Periodical Fevers,     .      _      _      _      .      .50
Pneumonic Inflammation,  Complicating  Typhoid Fever, _     41
 Progressive Locomotor Ataxia,      _       _      _      .222
 Pleurisy,     ______            g8 
INDEX.
PAGE.
Prurigo, Case of,      _      -      -      -      -      - 255
Porrigo,   "   "
Psoriasis,              -      -      -      -      -      "  "
Pneumonia,   -                                             ™
Renal Dropsy, following Scarlatina,                      74
Respiratory Affections        .      -      -      -      -  84
Rubeola, Case of,   .      -      -      -      -      .80
Rectum, Neuralgia of,  _      .      -      -      -      - 207
Rheumatic Fever,   ------     6o
Rheumatism,  Acute Articular,       -      -      -      -60
            Bronchial,   ...      -        9b>  64
     "      Chronic,  .       .      -      -      -      -  6g
     "      Intestinal,   .      .      -      -            68
Rheumatic Inflammation of  Spinal Nerves, _
.  66
Scirrhus, of Pyloric Orifice of Stomach,       .           116
Sciatica,  _      .      -      -      -      -      -      - x99
Spinal Nerves, Rheumatic Inflammation of,     .      .      66
Scarlatina, Renal Dropsy following,      .      -      -  74
Suppression of Urine in Renal Dropsy following Scarlatina,  79
Softening of Brain,    .      -      -      -      -      - 23x
Spinal Irritation,   .      -      -      -      -      .210
Strychnia, its Value in Certain Stages of Typhus,      _  16
Summer Complaints of Children,     _       -          J53. x39
Stomach, Chronic Inflammation of,
120
Tobacco Enemas in Intestinal Obstructions,    _     -    129
Typhoid Fever, Cases of,      .      -      -      -      -  22
   «      «•    Chronic Dysentery following,  .     -    124
Typho - Malarial Fever,       -             -             -  23
Typhus Fever, Cases of,                             -      7
Tuberculosis, its Pathology,  Diagnosis and  Treatment,    . 100

Uterine Irritation, ...      -      -     -    I32 
 
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