AN ANALYSIS 
OF 
A Few Cases of AMomiiial Disease, 
By W. C. VAN BIBBER, M. D. 
Reprinted from tlie Transactions of the Medical and Chirurgical Faculty of 
Maryland, April, 1876. 
BALTIMORE: 
INNES & COMPANY, PRINTERS AND BINDERS. 
1876. An Analysts of cl Few Cases of 
ABDOMINAL DISEASE, 
W. C. VAN BIBBER, M. I). 
It would of course be out of place here to attempt a systematic 
treatise upon any particular class of diseases; but in the archives 
of our State Society, some record should be preserved of rare forms 
or unusual cases of disease which may have been observed amongst 
us. It is incumbent upon each member of this Society to show, 
as far as it is possible, that he is not only endeavoring to keep up 
with the advanced ranks of medical progress, but that he has also 
a hearty desire to be numbered with those who are laboring in the 
field of original inquiry. Certainly, neither the study of medicine, 
nor its practice as an art is likely to stand still in this age of 
industrious men and women. Writers upon medical subjects, as 
well as practitioners, are surrounded by critics who are most active, 
intelligent and observant. General physiology is well and widely 
taught; the names, actions and uses of remedies are familiarly 
known as a favorite study; female physicians and educated nurses 
lend their efficient aid to the cure of disease: and therefore it is 
necessary to be most careful both as to what is written and what 
opinions are orally expressed. 
It is not worth while at present to argue the point whether or 
not the many specialties or subdivisions into which the study 
and practice of medicine are now divided, are in reality a gain to 
the public, to science, or to the practitioner. Students and prac- 
titioners, as well as those to be relieved, are all equally intent 
upon this subject. There are many members of this Society who 
have traced the rapid progress of this change in the plan of study 
and the way of practice of our profession. Those who may be 2 
considered the older members here have watched the migrations of 
their patients from the quondam “ family physician,” and if they 
themselves have not chosen to follow in the flowing current of 
special study, they may soon find themselves temporarily beached 
near the headwaters of primitive medicine. Yet the old status of 
“The Physician” has its pleasing reminiscences, and should not be 
allowed to pass away and be forever extinguished without a sigh 
of regret or an attempt to rekindle the fires of its existence. The 
present mode of studying the profession by sections, as it were, 
may have its day and may fulfil a good purpose. Hereafter, the 
knowledge now being accumulated and recorded may by some 
competent mind be so generalized that new principles may arise, 
and again, give a different direction to the study of medicine. 
It is in a society like this, composed of honorable members, 
both old and young, where the truth of these remarks can be fully 
appreciated. Here each one of us has a hearty desire for the 
advancement of one profession. Here a personal interest in the 
standing of each and all of the members of the Society is felt to 
be a bond of union. Here, therefore, the teachings of the specia- 
lists, and the observations of those whose first trainings were in 
general practice, may mutually assist and correct each other. 
There is one class of diseases upon which all physicians, both 
general practitioners as well as those wrho have devoted themselves 
to any of the special studies, are agreed, or rather are obliged to 
hold as common ground — that is, diseases of the digestive organs. 
These form a link to bind the profession together, even as the 
function of digestion is the common source of life, reproduction 
and repair. I will now invite your attention to an analysis of 
eight cases which happened in my own practice, in all of which 
the diseases occurred in the organs of digestion. My time for 
doing this, according to the rules of this Society, is short; nor do 
I wish to lay too heavy a tax on your patience. I shall therefore 
make but few if any references to authorities, but will only describe 
such things as have come under my own observation, some of 
which are rare, others very common, but all, I trust, may offer 
something suggestive and noteworthy. 
Case I.— Rev. Mr. P., aet. 48, was born in Germany, but for 
many years had led the life of a student and missionary in this 3 
country, having been sometimes engaged in sedentary employment, 
and at others in labors of the most active kind. He had been 
engaged as missionary upon the Western frontier, and in miasmatic 
regions of the Atlantic slope. He had suffered from attacks of both 
remittent and intermittent fevers. His constitution had become 
so much impaired by the effects of malaria, that for several years 
before the violent attack about to be related he had lost energy 
and suffered from indigestion. This latter trouble was manifested 
by irregular attacks of colic. These, although slight at first, had 
gradually become more frequent and violent. 
In May, 1874, he became deeply jaundiced, after an attack of 
colic, which had lasted longer and was more violent than 
any which had preceded it. Notwithstanding the most active 
treatment at the time of the attack, the jaundice continued. In 
June, 1874, I saw him for the first time. He was then salivated. 
The skin, the conjunctive, and the mucous membrane of the 
mouth, were of a peculiarly deep yellow, and all objects within his 
range of vision appeared of a yellow tinge. The urine was loaded 
with bile. The alvine evacuations were white. He had mental 
depression, and frequent abdominal pains, both of which were 
always greatly increased after eating. He had anorexia, pyrosis, 
frequent vomitings, and progressive emaciation and debility. 
Mr. P. was under my professional charge twelve weeks, during 
which time several plans of treatment were devised for his relief. 
It may be well to enumerate some of them, as also the reasonings 
or theories upon which they were based. The diagnosis was an 
obstruction to the ductus communis choledochus, and the first object 
was to remove this if possible. One of the most efficient and 
certain means of removing local indurations is by the exhibition of 
mercury. There are certain forms of circumscribed plastic exuda- 
tions or neoplasms, upon which the constitutional effects of mercury 
seem to have a wonderful power. So far as my experience 
extends, there is no known remedy which has the same effect in 
some cases of this kind. It is not used now as much as it was 
formerly, nor are its effects carried to the same extent. I was not 
responsible for the salivation in this case, but as before stated, I 
found him in this condition. On this account the potass, iodide 
was the first remedy used, and this was given with a view of still 4 
further effecting molecular changes, and thus aid in removing the 
obstruction. Warm poultices were placed over the liver at night 
as an adjunct to this treatment, and seltzer-water was used as a 
drink. All fatty or oleaginous substances were excluded from his 
diet. Moderate exercise was allowed, and friction over the surface 
of the skin was used in order to retain the activity and vigor of 
the general system. This plan of treatment was steadily carried 
out for six weeks, but did not in the least change the nature of the 
symptoms or the aspect of the case. It was then abandoned. The 
next plan adopted for his relief was warm bathing and the exhi- 
bition of quinine. The baths were given twice daily, at the tem- 
perature of 98° F. in the morning, and 99° F. at night. Quinine 
was used for its general tonic effect, as well as for its specific action 
on the liver and spleen. It was given by the stomach, hypoder- 
mically, and by friction upon the skin. The amount given daily 
varied somewhat, but a moderate cinchonism was kept up for 
two weeks. No change in the patient was observed from this 
mode of treatment. After having patiently carried out these plans 
of medication, the other remedies used pro re nata during the course 
of his disease were strychnia, bismuth, and pepsin. These were 
given singly, and in different combinations. No very marked 
change occurred at any time in the condition of the patient until 
the latter part of August, when he died rather suddenly, from 
exhaustion, during a heated term. 
Prof. F. T. Miles made the autopsy eighteen hours after death. 
All the normal white tissues of the body were found of a deep 
yellow color, and every organ examined was changed in its color 
by the retained bile. The head was not examined. The viscera 
of the thorax were healthy and normal, excepting in color. The 
same may be said for those of the abdomen, all of which were of 
normal size, weight and consistence, excepting the ductus com. chol. 
This was obstructed by a small, hard body, not much larger than 
a Lima bean. This occupied the place of the duct, and completely 
obliterated its canal. It was removed, and examined by section 
and microscopically. There was no reason to suppose from the 
microscopic examination that it was a malignant growth; that is 
to say, no cells which are not known as belonging to the normal 
tissues of the body were detected in its substance. Its centre was 5 
not gritty, as if it had been a calculus; none of the adjacent tissues 
or surrounding organs, except the walls of the duct, were impli- 
cated in the hardness. It was situated but a few lines from the 
duodenum, and the minute portion of the duct between the hard- 
ness and the duodenum was healthy. I know of no post-mortem 
examination on record exactly similar to this one. Here the small 
lesion which has been described, was certainly the cause of a 
prolonged disease, and the primary cause of death. What was the 
nature of this obstruction, and how had it been formed in the 
duct? It could not have been originally an impacted gall-stone, 
like those which have been heretofore analyzed. I believe it was 
either some new compound, or a clot of blood, which, owing to its 
long continuance in one place, from the result of pressure, and 
from peculiar morbid actions, had become so changed and amal- 
gamated with the walls of the duct as not to be separated or dis- 
tinguished from it. So small was the offending body, that had not 
the light of physiology foretold its situation and existence, or had 
the anatomist been one less skilful and intelligent, it might easily 
have escaped observation in the ordinary manner in which post- 
mortem examinations are often made in private practice. 
Case II.— Mrs. , aet. 58, weight 110 lbs; had, when 
in health, an unusually clear complexion. She is the mother of 
several children. Enjoyed good health until five years ago, when 
she had, during the fall of 1871, a well-marked attack of tertian 
intermittent fever. During the winter of 1871 and 1872 she had 
frequent attacks of remittent fever; quinine was used freely, but 
failed to restore her health. In the spring of 1872 violent attacks 
of colic began to be frequent; these always terminated in jaundice, 
more or less intense. The diagnosis was “ biliary calculi/’ although 
no gall-stones were ever found in the alvine evacuations. In 
April, 1872, an attack of colic occurred, which was more severe 
than any one which had preceded it. The accompanying jaun- 
dice was also more intense, and did not disappear. The urine 
became loaded with bile, and the alvine discharges were white. 
Repeated attacks of colic now succeeded in quicker succession than 
before, and the diagnosis of malignant disease involving the ductus 
communis choledochus was given. She was supposed to be be- 
yond the possibility of recovery. It was at this time, and in this 6 
extreme condition, that I first saw her. The first suggestion made' 
in her case was, that fats and oils should be excluded from her diet. 
Skimmed milk, oat-meal, cracked wheat, brown bread, and toast 
water were the articles selected for nourishment. These gave 
great relief. This diet was continued five months without an 
attack of colic. The patient improved in vigor, left her bed, and 
commenced driving in the open air. During a visit at one of the 
sea-side summer resorts in 1873, an eminent physician advised a 
change of diet, and recommended the use of nitrogenous and 
oleaginous food. It is to me one of the instructive points in her 
treatment that this change of diet was well borne, and even seemed 
to be beneficial before there was any evidence that the passage 
through the duct. com. chol. had been reestablished. Attacks of 
colic have been more frequent since the diet was allowed, yet the 
general vigor of the system has improved. Coincident with the 
change to a nitrogenous diet, a distressing pruritus occurred, which 
still exists. Gradually the coloring matter appeared in the alvine 
discharges, and the urine became proportionably clearer. The 
skin is still of an unnatural yellow, but many shades lighter than 
before the bile passed naturally into the intestine. The sclero- 
ticse are now white, as a rule, but become yellow in a moderate 
degree during, or after, the attacks of colic, which occasionally 
recur, without oftentimes an appreciable cause. It would be 
tedious beyond your endurance to enumerate successively all the 
plans of treatment which have been resorted to for the cure of the 
jaundice and the relief of the agonizing pruritus. It would give 
a high value to this paper if I could select from the number even 
one which had been prominent in usefulness. The advantages 
gained have been so gradual in coming, the plans of treatment, so 
minutely arranged, have been so often changed, foiled, or for suffi- 
cient reasons abandoned altogether, that the excellence of none 
can be fairly said to stand out in bold relief. Much was expected 
from electricity. A sixteen-cell constant current battery was pro- 
cured, and it was during its use that the coloration of the fieces 
took place. From the nature of the case it is not possible for me 
to say, in all fairness, that the improvement was entirely due to 
this agent. 
The patient is now systematically using the nitro-muriatic acid 7 
pediluvise, taking the choleate of soda in grs. viiss doses internally 
three times a day; and uses locally, for the relief of the pruritus, 
the theobroma cacao. Some of the other remedies which have 
been used systematically are quinia, bismuth, pepsin, narcein, codia, 
and the species de St. Germain. 
The next two cases which will be contrasted are of a different 
character from those which have just been read. They are selected 
as specimens of extremely recondite abdominal trouble ; one ter- 
minating in a sectio-cadaveris, the other in recovery. 
Case III.—J. G., aet. 36. Considered himself to be in his 
ordinary health in December 1874. As proof of this it may be 
said, that being engaged in superintending the training of his 
racing-horses, on the 12th of December, 1874, he walked from 
Barn urn’s Hotel to Pimlico race-course, a distance of about five 
miles. The next day, the 13th, he remained in bed and com- 
plained of fatigue. On the 14th he took purgative medicine, 
which produced no other effect than pain. On the 15th a similar 
remedy was taken with a like result. On the 16th a physician in 
the neigborhood was called, who gave a purgative of a different 
kind, but without producing any evacuation. On the 17th and 
18th other purgatives were given by the mouth, and purgative 
enemata were administered to assist their action, but all without 
the desired effect. Vomiting commenced on the 19th, when Dr. 
O’Donovan took charge of the case. This symptom became gradu- 
ally more urgent and persistent, so that on the 20th nothing could 
be retained in the stomach longer than a few minutes. The diag- 
nosis of “ intestinal obstruction ” was made, and an unfavorable 
prognosis given. I saw the case on the 23d in consultation. 
Powdered alum and Dr. Thomas H. Buckler’s remedy of the 
extract of belladonna given in melted lard, were the last means 
which had been tried ineffectually. It was now determined to use 
electricity. A strong Faradic current was passed over the 
abdomen in a way to excite the most violent contractions of the 
abdominal muscles. It was hoped that by this treatment the 
intestinal obstruction might be loosened, or in some way relieved. 
The case was thought to be desperate, and the pain of the operation 
was disregarded when the result was considered. The operation 8 
was prolonged with the full strength of the battery for more than 
fifteen minutes. On the 24th the same treatment was again 
applied. This proved ineffectual also, and then an effort was made 
to insert a long tube beyond the sigmoid flexure of the colon. 
Whilst making the exploration for this purpose, I detected, lying 
in the hollow of the sacrum, a tumor, which felt like a bundle of 
intestines in a scrotal hernia. I then ventured the diagnosis that 
a portion of the small intestines had fallen into the pelvis, and was 
there retained, thus causing the obstruction. This diagnosis was 
made from the peculiar or characteristic feeling of the tumor. 
Dr. F. Donaldson now advised the inflation of the intestinal 
canal. For this purpose a receiver containing oxygen gas under a 
pressure of twenty atmospheres was used. A rectum-tube was 
inserted as far as it would go into the bowel, and the external 
orifice at the anus was strongly compressed. It was hoped that 
the gas might penetrate beyond the ilio-csecal valve and inflate 
the small intestine. The full force of the instrument was em- 
ployed. The operation was unsuccessful, however, and the patient 
died soon afterwards. 
Dr. Samuel Johnston made the autopsy 36 hours after death. 
It was found that a portion of the ileum had been drawn into the 
pelvis during a previous attack of peritonitis, and was bound there 
by strong bands of lymph. This composed the tumor which has 
been described. The case was in effect like one of strangulated 
hernia, and neither in reading nor in practice have I met with a 
similar lesion. 
Case I V.—Mary M , aet. 47, had enjoyed good health until 
the occasion about to be related. In November last she had an 
acute attack of illness, during the course of which symptoms of 
ileus became most prominent. The attending physician used all 
the ordinary means to relieve this condition. One purgative after 
another was given with judgment, until finally croton oil was used. 
Active purgative injections were also employed. The diagnosis 
was “ intussusception and the case remained under active treat- 
ment for ten days without any operation from the bowels. A 
consultation of three physicians decided that nothing more could 
be done, and they so informed the patient and her friends. They 
had exhausted every means of relief in her case, and declined 9 
making further efforts. I was requested to see her, and found all 
arrangements had already been made for the fatal issue of the case. 
Her friends were gathered around her bed, and the patient herself 
had given up every hope of recovery. The extremities were cold, 
the radial artery pulseless, the abdomen enormously distended, and 
the respiration short and feeble. She appeared indeed to be in 
articulo mortis. I suggested to her physician the application of 
electricity. This being assented to, one pole of a strong Faradic 
battery was placed at an indifferent point upon the abdomen, and 
the current passed rapidly over the abdominal muscles in such a 
manner as to excite the most powerful contractions. This new 
force immediately aroused vitality in the system so far reduced. 
She complained of the pain, whilst the commotion of the bowels 
was evidenced by frequent borborygmi. The greatest pain com- 
plained of, however, was cramps in the lower extremities, as severe 
as those which often occur during parturition. The operation was 
continued twenty minutes. An hour after the application of the 
electrical current, copious evacuations came from the bowels. 
These continued for several days, and the patient completely re- 
covered without further trouble. 
Case V.— Has been selected as one of much interest, both on 
account of some peculiarities which it presents, as well as for the 
rarity of the lesion. Mr. H. F., aet. 68, height 5 ft. 6 in., weight 
180 lbs., well proportioned, physically strong, and somewhat cor- 
pulent. He had been engaged as a distiller, as a manufacturer of 
medicines, and latterly as a lace-finisher. Had three tumors on 
the body, one on the right side over the crest of the ileum, one 
on the left pectoral muscle, and one on the face. These presented 
all the appearances of simple lipomata or fatty tumors, and were so 
regarded. In 1870 he had a fistula in ano, which an operation re- 
lieved ; after this he seemed to have good health until 1873. He 
then began to complain of obstinate constipation, of frequent abdo- 
minal pains, and of the difficult action of purgatives, with intensity 
of pains during defecation. He continued at his work until the 
1st of March, 1875. The annoyance of the symptoms already 
mentioned had then so increased that he determined to abandon 
all further labor. The symptoms of obstinate constipation, and 
violent pain when the bowels were forced by purgatives, were the 10 
most noticeable features of his illness throughout. Many plans 
of diet, and all means ordinarily used to establish a regularity of 
the bowels, were suggested and faithfully carried out. Many peri- 
staltic excitants, as well as powerful purgatives in varied dozes, 
were given a fair trial in his case, according to known principles, 
but no permanent improvement could be observed. On the con- 
trary, the symptoms not only remained constant in kind, but 
steadily increasing in severity, whilst the vigor of the patient be- 
came sensibly diminished. It has already been said that when in 
health he was corpulent, and this condition during the first 
months of his treatment interfered with the use of abdominal palpa- 
tion and percussion as means of diagnosis. As he emaciated this 
difficulty was removed, and then it was found, that upon the right 
side dulness upon percussion extended three or four inches below 
the border of the ribs, and when the abdominal walls were com- 
pletely relaxed, the hand could grasp the edge of an indurated 
body which felt like the edge of the liver. There was no jaundice, 
no appearance of bile in the urine, and no want of color in the 
alvine discharges. A great interest now centred in the diagnosis of 
the case. After many weeks and months of suffering, with all the 
wearing changes attending a malignant disease, death occurred on 
the 21st of last April. Dr. Bevan made a post-mortem examina- 
tion 18 hours afterwards. Before the body was opened, I explained 
to the physicians present the reasons which induced me to believe 
the case before us would be found to be one of cancer of the 
omentum. The differential point in the diagnosis was my ability 
to grasp, through the relaxed abdominal parietes, the hard body 
which felt like the edge of the liver. There were no symptoms of 
disease of the liver, and therefore I thought this body was the can- 
cerous omentum. It will be seen by an abstract from Dr. Bevan’s 
report to me how near this diagnosis was to the real condition. 
(Extract of Dr. Be van’s report.) “Autopsy, &c. . . Omentum 
small and atrophied ; stomach, liver, spleen, pancreas, and kidneys, 
all normal. Small and large intestines normal except in color, 
being a dark pink hue. The transverse colon was drawn from its 
position in situ, and firmly bound down below the lower edge of 
the stomach. The mesentery alone was diseased; it was three 
inches thick by fifteen inches broad, and in consistence harder 11 
than the hardest cartilage. All trace of vessels in it was lost. 
Under the microscope the cells found both by Drs. Bevan and 
Tiffany were of an undefined character. They were not cells like 
those found in any part of the healthy body.” 
When we consider the physiological and anatomical uses of the 
mesentery, and compare it with its analogues in the body, viz. the 
root of the lungs, and the spermatic cord, it is wonderful to con- 
template the power of Nature in supplying a part with vitality 
through remote anastomotic circulation. The body of the liver 
was pushed upward and forward by the hardened mesentery, and 
this caused the error which was made in the anatomy of the diag- 
nosis. 
Case VI.—M. W., aet. 14 years, was born in Norway, of South 
Carolina parents. When he was twelve years old his mother re- 
moved with him to a plantation on the Pedee River. During his 
residence there he had violent attacks of malarial fever, for which 
he was given large quantities of calomel and quinine. He came 
here for treatment last November, and was placed under my care. 
He had then a tertian intermittent, which the change of climate at 
first greatly increased. His lips were blanched, and the skin 
looked like muddy-colored parchment. Besides extreme anaemia, 
he had distressing dyspnoea and troublesome dyspepsia. Percus- 
sion over the abdomen demonstrated the fact that the spleen occu- 
pied a large portion of the abdominal cavity, being enlarged four 
or five times its normal size. The liver also was greatly enlarged. 
In consequence of these anatomical changes the feeling of the ab- 
domen was peculiar. The enormous spleen had so far displaced 
the viscera upon the left side, that the enlarged liver was pushed 
upward and forward so that its edge could be grasped through the 
relaxed abdominal walls. This feeling was quite similar to that 
which has been described in the preceding case (V). It was easy, 
however, to make the diagnosis, which was, “ enlargement of the 
liver and spleen, produced by malarial poisoning.” 
The marked success of the treatment which was used may be a 
point of interest in this case. The remedy selected, and relied 
upon for his cure, was the ferri-ferrocyanuretum. He has taken 
this in one or two grain doses, three times daily, for more than 
five months. The adjuvants which have been used are warm 12 
baths, 98° F. two or three times a week at night; frictions over 
the surface with a salted towel in the morning, after which the 
abdomen over the spleen and liver was rubbed with a solution of 
quinine in spirits. These, together with graduated exercise, a nu- 
tritious diet, warm clothing and agreeable recreations, have com- 
pletely changed his feelings and appearance. Gradually the 
enlarged organs have diminished in volume, the feeling of the 
abdomen is now normal, the lips have become tinged with red, the 
hands are less attenuated, the skin is soft and clear; in short, 
health and energy have been restored, and the youth is at present 
robust, ruddy, and joyous. 
It was my intention to have extended this paper by contrasting 
two cases of abdominal disease which had their origin in emotional 
causes. It was expected by them to call attention to some of the 
more common forms of dsypepsia, and to show how this disease is 
often produced, principally by the cause which has been mentioned. 
It was also expected to call attention to the fact that, by neglect, 
cases of this kind may sometimes result disastrously ; and again, how 
at other times, by a timely and appropriate treatment, they may 
often be entirely relieved. One of the cases referred to resulted in 
death, the other has recovered ; but as no post-mortem examination 
could be made in the fatal case, it has been considered incomplete 
for the purpose intended, and no further mention will be made of 
either of them here in detail. 
In order to make the desired application of what has been 
written, permit me, in conclusion, to recapitulate as follows : I 
have related two cases of chronic jaundice — one was fatal, the other 
recovered; two cases of intestinal obstruction — one died and one 
survives; two cases of abdominal visceral enlargements, in one of 
which, where the diagnosis was obscure, a post-mortem examina- 
tion was made, the other is now quite well; I merely referred to two 
cases of abdominal disease produced by emotional causes — one 
terminated in death, the other has recovered. 
From these cases, as they have been related and purposely 
grouped together, a conclusion might be drawn that the successful 
or the unsuccessful practice of medicine may depend in great part 
upon the result of circumstances over which the physician has but a limited control. This conclusion should not be a satisfactory one 
for the earnest student of medical science. On the contrary, it is 
hoped that these cases may point out to him the necessity for a 
correct diagnosis. Nor ought this conclusion to be accepted as a 
final truth by the intelligent practitioner, who should rather be 
induced to find in them a precedent for a guarded prognosis, as 
well as an encouragement to employ most energetically many 
nicely adapted therapeutic means to relieve patients, even when 
they seem to him at the time to be in a most extreme condition. 
A study of the literature and teachings of medicine in this country 
and in Europe during the present century will show, in general 
terms, that two very opposite methods of treatment have prevailed 
during this period. Early in the century the teachings and prac- 
tice in medicine were in a marked degree more positive than they 
ever were before or have been since. Most of the diseases in the 
nosology were then regarded as the result of active inflammation 
somewhere existing, and inflammation was figuratively represented 
as a devouring monster spreading devastation from the point 
whence it commenced, and only to be subdued by those antipyretic 
means which were then taught and most vigorously employed. 
This practice remained in full force during the first quarter of the 
century, and the reaction from it was the “ expectant plan,” as it 
has been very properly called. This method of treatment origin- 
ated in skepticism concerning the effects of remedies, and to a 
certain extent spread a pall over thought and paralyzed action. 
Its echoing cry from afar was virtually to give up the battle with 
disease. About 1840, Chomel wrote the aphorism that “to do no 
harm is the first law of therapeutics.” This seemed to take a deep 
hold upon the profession, and it has been generally taught since 
that time, and most wisely applied in all doubtful cases. In a 
court of justice in this city about twenty years ago our most dis- 
tinguished surgeon was asked in a certain case, the circumstances of 
which had been in evidence, “whether he would prefer to let a 
patient die rather than make a bold and vigorous effort for his 
relief?” He replied in substance, that “ when an unfavorable prog- 
nosis appeared most reasonable, he preferred the ‘ expectant plan.’ ” 
There are cases in which it is surely better to endeavor to persuade 
rather than force a cure; but one of the most prominent objects of 14 
medical study of the present day is, toward diminishing the number 
of cases which are to be left entirely to preservative medicine. A 
first step in this direction is to give such attention to diagnosis as 
to make it as certain as possible. A systematic arrangement of 
symptoms, continuous advancement in the study of physiology, 
pathology, human and comparative histology, and the many im- 
provements in instruments, are •constantly rendering our means 
for its culture more complete. The exact virtues of remedial 
means and medicines have recently been studied with greater 
care than heretofore, and many valuable facts concerning them 
have already been established. It is now more than ever the 
great aim or desire of many accomplished physicians to obtain 
marked and beneficial results by a bold practice, founded upon 
approved principles and established by experience. 
It was with a view of adding something practical to this line 
of study that these cases were preserved. They have been de- 
scribed as accurately as possible, and if they serve to advance 
the purpose for which they were intended, my object will be 
accomplished.