WB J78c 1871
63430390R

NLM  DSmflBT?   M
    NATIONAL LIBRARY OF MEDICINE

NLM051482974 
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@BEP&mjm fq»e "the Press.
ebiral ^ Surgical
       JOSEPH  JONES,  M
Professor of Chemistry, Medical Department,  University of Louisiana.
      This work will embrace the investigations of Fifteen Years into the
    Causes,  Geographical Distribution, Natural His-
       tory and Treatment of Intermittent, Remittent
       and  Congestive Malarial Fevers, Yellow Fever,
       Typhoid and Typhus Fevers, Small Pox, Spuri-
       ous  Vaccination, Measles, Pneumonia, Diar-
,       rha-a,  Dysentery,  Scurvy,  Tetanus,^ Cerebro-
       spinal-Meningitis, Diseases supervening upon
       Gun-Shot  Hounds,  Pyaemia,  Hospital  Gan-
       grene,  'Erysipelas,  Etc.
     The  results  of the  investigation of the DISEASES  of  the
   CONFEDERATE ARMY, during the AMERICAN CIVIL WAR,
   i86"i —1865, will occupy a prominent portion of the Work.
     These investigations have  been prosecuted unremittingly during the
   past 15  years; and the author  proposes to lay the results before  the
   Medical profession,  as soon as a  sufficient number of subscribers
   HAVE  BEEN OBTAINED.
     Physicians and others desiring to  become subscribers, will please for-
   ward their names ; and those  receiving this Circular are respectfully re-
I   quested to call the attention of their friends, and also of the Cbuntv and
   State Medical Societies to the  proposed work.
                          Address,
                      JOSEPH  JONES,  M. D.
                              Glass Box 1542,
                                    NEW ORLEANS, LA.
   lr.fi St. Chailts Sti.ct April 1st. 1871.
1 Fr'iXze Terrain, 11-2 flravior St., N. O. 
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CLINICAL    MEMORANDA.
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Memoranda of Medical  Clinic at  Charity Hospital, Neys Orleans,
    Louisiana, 1869-1870:  By  Joseph Jones, \^D ,  Profes-
    sor of Chemistry in  the Medical Department of the University of
    Louisiana, New Orleans.

      Section I.—Diseases of the Xervous System.

                        summary.

Loss of Mental Power (partial insanity)  ending in coma, delirium,
    and death ; and attended with structural alterations of Brain.
Temporary Insanity followed finally by loss of mental power, para-
    lysis,  and death ; structural alterations discovered in the brain
    and spinal cord.
Insanity caused by Effects of Syphilis on Brain ; death,  Structural
    Alterations of Brain.
Dementia, Paralysis, and  Death; Clots  in  Corpora Striata ani
    Optic Thalami.
Effects of  Superstition upon Negro Race.
Practice of Obeah or Witchcraft by Negroes ; Effects upon mind and
    body.
Epilepsy ; Death—induration of Cerebellum.  Treatment of Epilepsy.
Remarkable case of Cerebrospinal Disease, attended with  Convul'
    sions, recurring at short intervals, and attended with protracted
    Somnolence.
Traumatic Tetanus ; structural alterations of Cerebrospinal nervous
    system in Tetanus.
     5 
2
Clinical Memoranda.
 Paralysis—progressive, failure  of muscular and  nervous power ;
     structural alterations in spinal cord.
 Paralysis of lower extremities,  following Epileptic  Seizures.
 Lead Colic, Epilepsy, Paralysis and Death.
 Mechanical  Injury of Spine, resulting in paralysis of lower ex-
     tremities.
 Chorea—effects of Snake Bite.
 Facts from various authors, illustrating the importance of the study
     of Diseases of the Nervous System.
 Facts illustrating the influence of the Nervous System and mental im-
     pressions in the production and cure of diseases.

 Case T.—Loss of Mental Power (partial insanity), ending in Coma,
   Delirium and Death, and attended with  Structural  Alterations of
   the Brain.
 Charles TL,  aged 28 years; native of Dublin,  Ireland;  has
 been in the United States Army  for several years, served during
 the recent war, and worked his way up from the ranks  to the
 position of 1st Lieutenant; was mustered out of service at Green-
 ville, in March 1868, at which time he  moved to New Orleans,
 and entered the family of Mrs. A.  Patient assisted Mrs. A.  in
 various ways, doing work about  the house as directed.  After a
 time, about six months before his final illness, it was noticed that
 the patient exhibited less intelligence than formerly.  The intel-
 lectual powers appeared to fail  gradually, and the patient be-
 came "unreliable," and when sent on an errand, would go to some
 other place than  the one  specified.   Three weeks before his en-
 trance into the Charity Hospital became delirious aud insensible,
 with short lucid intervals, when  he appeared to recognize Mrs.
 A. and her family. Bowels constipated, and during three weeks,
 is said to have had only one action from the bowels. The attend-
 ing physician applied a blister  over the  head, and  administered
 purgatives, but without any apparent benefit.
   Entered Charity Hospital March 8th, 1869, ward 29, bed 430.
 Medium height; blue eyes, light hair,  red beard; reduced  in
 flesh; lies in a state of delirium and apparent insensibility;  can-
not be aroused; twitching of tendons and picking at bed-clothes.
Bowels  obstinately  constipated; passes his urine in  the bed,
has a powerful ammoniacal odor. 
Jones—Medical.
3
   Purgatives were freely administered, and a blister was applied
 to his head; these measures, however,  produced no perceptible
 benefit, and the patient died on the fourth day after  his admis-
 sion.
   Autopsy Eight  Hours after Death.—The Brain and Spinal  Mar-
 row were carefully removed.  The pia-mater and arachnoid were
 thickened, with fibrinous deposits  thrown out, especially along
 the track of the blood-vessels.
   The two hemispheres of the brain were firmly  adherent, and
 could only be separated by dissection with the scalpel.
   Blood-vessels of pia-mater greatly congested with blood.  Grey
 matter of brain congested; white matter somewhat  softened.
 Fibrinous effusion around base of brain.
   Pia-mater and arachnoid of spinal cord, greatly congested with
 blood and the bloodvessels of the spinal cord were not only dis-
 tended to their full capacity with blood, but they  also presented
 a tortuous and varicose appearance. Grey matter of cord some-
 what congested; white matter softened.  The spinal cord was
 removed and examined throughout its entire length.
   The blood-vessels of the brain presented not only an enlarged
 appearance, but thickened walls.
   Microscopical examination showed that the fibrinous effusion
 was being organized, and that the changes in the membranes of
 the brain were of  slow development, and dated  back in  their
 origin, weeks and even months.
   The two hemispheres of the cerebrum, were so  completely ad-
 herent,  that the longitudinal fissure could be  displayed only by
 the use of the scalpel and considerable force.
   The sympathetic nervous  system was  dissected out, and ex-
 amined microscopically, no evidence of disease was discovered
 in it.
   The lungs and heart were normal.   The abdominal viscera pre-
 sented nothing unusual,  with the exception  of a light bronze
 color of the liver, and some enlargement "of the spleen.
  These changes of the spleen and  liver however, were of long
 standing and had no connection  whatever with the fatal attack.
 The liver and spleen, when cut and exposed to the action of the
atmosphere, assumed a bright arterial hue. 
4
Clinical Memoranda.
  Kidneys congested, but otherwise healthy.
  In this case we have an instance of the connection of deranged
mental action with  structural alteration of the  brain and its
membranes.

Case II.—Temporary Insanity,  occurring occasionally during a
  period of years, folloived finally by Loss of Mental Power, Para-
  lysis and Death.  Structural Alterations discovered in the Brain
  and Spinal Cord.
  John L. B., native of Mississippi,  aged 50 years, admitted to
ward Xo.  28, bed 416, October 20th,  1868;  was in comfortable
circumstances previous to the recent civil war, and  has a  wife
and family.
  Twelve  years ago attempted to take the life of his partner,
without any known cause, and since this time has had occasional
fits of temporary insanity, although he has continued in business.
  Three years after the attack on his partner with fire-arms, he
killed his  horse, cutting its throat in  the road, whilst harnessed
in his buggy, without (as in the first  instance),  any known rea-
son for the outburst of passion.  The patient is said to have con-
tinued in a wild delirious state for several days after  these vio-
lent manifestations.  During the war lost his property, and  at
its close roamed about the country in a demented but harmless
state.
  At the  time of  his  entrance into the hospital, walked with
great difficulty,—spoke slowly and with effort, mind obtuse, and
patient gives no rational history of his past life, each time giving
a new story.  In attempting to walk about the wards,  tell several
times; motions feeble and unsteady;  apparent want of co-odina-
tion  of the muscular motions; cannot turn without help in bed
requires assistance  in dressing.  Sensation apparently inpaired.
General appearance that of a large, stout man, with full limbs
but  in a  low  cachectic  state,  with pale,  sallow complexion.
Passes his urine and faeces in bed at  night.
  The powers continued gradually to fail, and with this progres-
sive  loss of muscular and nervous power, the  circulation in the
extremities appeared to grow more sluggish.  January 1st,  1869,
the patient has several large bed-sores upon the hips, caused by
pressure, and the action of the involuntary discharges of urine. 
Jones—Medical.
5
The bed-sores  were dressed  with a  cerate composed of one
drachm of crystallized Carbolic  acid  mixed with  one ounce  of
Simple cerate.  The internal treatment  consisted of one-twentieth
of a grain of Strychnine, and  fifteen drops of the tincture of the
Sesqui-Chloride of iron, three times a day, together with the most
nutritious diet afforded by the hospital; under this treatment,
with attention to the state of the bowels, and to the personal
cleanliness of the patient, with occasional blisters to the back of
the neck, the  general health improved in  a marked  manner;
there was a temporary increase of muscular power, the patient
became more cheerful and  rested better at night; and at the
 same time, the effects of the iron  were manifested in an improve-
ment in the complexion.  The bed-sores also, healed rapidly and
fully.  This improvement, however, was only temporary, and in
the early part of February, the difficulty of walking became so
great,  and the tendency to fall, even when sitting  in a chair, so
constant,  that the patient was compelled to lie the most of the
time in bed.  Eemains as usual in a vacant,  listless state.
  The  powers have progressively failed up to the present time,
February, 19th, when the patient lies in a state of mental vacuity,
with mouth open, and eyes staring, unable to answer the simplest
question intelligently; with almost  complete  loss of  muscular
power  in the lower extremities, and with large bed-sores forming
upon the exposed parts of the  trunk,  notwithstanding  every
effort to  prevent their appearance, by friction  and stimulating
applications.
  The  students had daily opportunities of witnessing the gradual
and progressive failure of the intellect, and muscidar and nervous
forces  in this patient; the progressive loss of power, was also
clearly shown in the fact that in December, the patient was able,
with supports on either side,  to walk down from the third story
of the  hospital to the floor of the  amphitheatre on  the first floor.
In January it was necessary to bring the patient down in a chair;
and at the present time he lies prostrate unable to sit up.
  It is worthy of note that up to the present time, there has been
no fever, no  increase of respiration or circulation, or of animal
temperature, and the nutritive functions have been performed
with regularity. 
6
Clinical Memoranda.
   From the history of this case, we are justified in the conclusion
 that the disease of the brain has been of long standing; that the
 insanity was dependent  upon some structural alteration of the
 brain ; and that the alteration, degeneration or softening of the
 brain has gradually extended to, and affected the spinal system.
   This case presents a progressive failure  of the  intellectual,
 nervous and muscular  forces, without any sudden  paralysis or
 contraction of the muscles, and  the  only sudden  and violent
 nervous agitation with which the patient was  afflicted since his
 entrance into the hospital Avas a slight convulsion about noon on
 the 12th of February, after making unusual efforts  at sitting up
 and attempting to  walk.   So far as  could be learned from  a
 member of the medical class, this was the  only attack of this
 kind  that he had ever had, and we are led to exclude epilepsy as
 the cause of the progressive failure of the intellectual and nervous
 powers.
  The patient  continued  progressively to fail;  lay in an un-
 conscious condition,  occasionally  groaning  and crying  aloud,
 especially at night,  when he disturbed the entire  ward.   One
 fourth of a  grain  of Morphine, was tried  at bed-time, without
 any special benefit.  The patient does not reply when addressed,
 and appears to be   wholly  unconscious of  any thing passing
 around him, and is oblivious of his distressing condition.  Urine
 and fseces passed in bed;  bed-sore forming upon back over
 sacrum; circulation  sluggish; surface of the skin in dependent
 portions of  the body, of a purplish  red,  mottled   appearance.
 Patient unable  to turn in bed, or to move his lower  extremities.
 When the feet and  legs are pinched, the  patient contorts the
 face, and evidently suffers pain.
  The patient continued to  sink;  gradually  lost the power of
 swallowing, and could take no nourishment; breath  became very
 offensive, and the teeth loaded with sordes; four  days before
 death, the right thigh was contracted and drawn up towards the
 trunk.  Patient appeared to  suffer pain when the attempt  was
 made to straighten the limb.
  Died March 3d, at  8 o'clock, p. m.
  A careful autopsy was made the next  morning, at 8 A. m., with
the following result: 
Jones—Medical.
1
   Exterior, full and not wasted; heart normal; lungs pale, but
 perfectly healthy,  with no  deposits; alimentary canal and all
 the abdominal organs, liver, spleen,  and kidneys normal in ap-
 pearance.
   Head.—Well-formed and large cranium, with a  symmetrical
 arch.  Nothing peculiar, however, was  noted with reference to
 the cranium.
   Dura mater, firmly adherent to the bony structure; pia mater,
 greatly congested and thickened; the arachnoid was in like man-
 ner thickened,  and presented much more of an opalescent ap-
 pearance than usual.
   Brain, large, well formed, and unusually firm.  The blood-
 vessels of the nutritive membrane of the brain, were everywhere
 larger, more numerous and more  congested than in  healthy
 brains.  This condition was  in  no manner connected with  the
 mere stasis of blood, because it was as great in the most elevated
 portions of the brain, as in the most dependent.  When  cut, sec-
 tions of the brain revealed a state of remarkable congestion.
 The congestion was greatest in the  grey matter of  the convolu-
 tions and  of the optic thalami, giving to those collections of
 ganglionic water a pink high-colored appearance.
   The blood-vessels of the  brain  in all parts, were larger and
 more numerous and more congested, than in healthy brains. The
 blood vessels were not only congested, but they were permanently
 enlarged.
   The large size of the small blood-vessels and  even of the ca-
 pillaries, as well as the state of congestion, imparted to the grey
 matter a deep pinkish tint.
   Under the microscope, the ganglionic cells,  of the grey matter, and
 ganglia of the brain appeared to be diminished in number, whilst the
 capillaries were increased in size, with thickened walls.  Exudation
 corpuscles were observed amongst the brain structures, and especially
 along the tracks of the blood-vessels.
  The pia mater of the spinal cord was congested in  a similar
 manner.   The spinal cord was covered all around by a net-work
 of large anastomosing (varicose) blood-vessels, engorged with
blood.  The blood-vessels appeared to be fourfold more numerous 
8
Clinical Memoranda.
than in health.  Upon  section, the  blood-vessels of the  spinal
cord, in all parts, were found to be similar to those  of the cere-
brum and cerebellum.  They were greatly enlarged and  congest-
ed with blood.
  The vessels were largest, most numerous and most congested
in the  grey matter (ganglionic  central columns), of the interior
of the  cord.   So marked was  the enlargement of the blood-vessels
of the  cord, and so great was the congestion of blood  in them,
that the grey matter of the cord, everywhere presented a bright-
red color, wholly different from the grey  color of health.  The
cord was firm in texture.  Under the microscope, the ganglionic
cells appeared  to be  more numerous in the grey matter of the
spinal cord, than the grey matter of the brain; and the capillaries
were  enlarged  and  their  walls  greatly  thickened. Exudation
corpuscles, were also seen in the neighborhood and  around the capil-
laries ; and both in the spinal cord, and in the brain, some fragments
of the  coloring matter of the blood were  discovered in the  textures.
  It is a question whether the  insanity was caused by this  con-
gested and enlarged capillary circulation.   The temporary nature
of the fits, as well as their violence, would indicate that the primary
lesion  existed in the circulatory  apparatus of the  brain and spinal
cord.
  In this case, we have as in the preceding one, an instance of
the  connection of deranged mental action with structural alterations
of the brain.
  It is of great importance to the science of medicine, that every
case of insanity, should not only be subjected  to the most rigid
investigation during life, but also that the most careful examina-
tion of the nerve structures, should be made after death.
  The  brain  is  liable to disease, as well as any other  organ in
the  body,  and as it is the  organ of the intellectual faculties, it
makes a vast and important  difference in our pathological views
and therapeutical principles,  whether we regard insanity as  con-
nected with and dependent  upon structural alterations, or as a
disorder of the intellectual  faculties and moral power.
  Whilst various causes may be active in the production of that
terrible state, in which man is degraded to the level or the brute,
by the loss of those powers which enable him to direct and  con- 
Jones—Medical.
9
trol the forces of matter, and even immaterial agents; it is cer-
tainly of great importance to medical science to  determine with
utmost  accuracy the structural lesions of the brain and spinal
cord, in all the various forms of insanity.
  A wide and important field of research is opened to  the medi-
cal  superintendents, directors and attending physicians or the
various Insane Asylums in this country.   Each case of insanity
should be subjected  to rigid scrutiny;  accurate measurements
should be made of the cranium, and all peculiarities of conforma-
tion and of physiognomy should be noted and compared with.
the peculiar  phases of the insanity;  and this careful examina-
tion should be completed by a thorough examination of the brain
after death. If a small portion of the funds of each State Asylum
were devoted to the careful investigation and delineation of the
peculiar conformation of the cranium and countenance (by photo-
graphy), and to the publication of the annual results of the patho-
logical labors conducted by  competent men, important  results
would be achieved for the science  of medicine.
  Two  other cases of mental derangement came under the ob-
servation of the students of the Medical  Department of tlie
University of Louisiana, illustrating the connection of mental
derangement with structural alteration of the brain.
  Case III.—Insanity caused by Syphilis: Structural Alteration  of
Brain.
  The   case  was  that  of  a white  female,  who  had  had
syphilis, and the mental derangement came on, after the super-
vention of constitutional  symptioms, and appeared to be directly
referable to the structural changes induced in the brain by the
syphilitic poison.
  It was observed during the life of the patient, that she was
insensible to bad odors.  Thus, as she was suffering from diar-
rhoea, the excrementitious matters were frequently daubed upon
her nose and face, by her own hands, and the patient appeared
even in  the lucid  moments,  to  be  wholly  oblivious  to their
presence and offensive odor.
  After death, it was found that the structures of the brain, were
extensively softened  and altered in the neighborhood of the
origin of the olfactory nerves.
     2 
10
Clinical Memoranda.
   The alterations of the brain and the symptoms of insanity, in
 this case, were referred to the action of the syphilitic poison.
   It has been established by the researches of various observers,
 that the brain may be affected indirectly by syphilis, as in caries,
 necrosis,  exostosis of the  cranial bones,  gummy tumor of  the
 skull, or  deposits in the dura-mater, which membrane has been
 compared to an internal periosteum.
   These lesions  may excite inflammation  of the  dura-mater,
 which may extend to the arachnoid, pia-mater and surface of the
• hemispheres.
   It has  in  like manner  been shown that the brain may be
 directly affected by syphilis; the nervous substance being  the
 seat of syphilitic gummy deposit followed by softening, and cases
 have been recorded, in which white and red softening of  the
 cerebral substance have been caused by syphilis.
   In the neuralgic affections,  paralysis, epilepsy and dementia,
 following the appearance of the constitutional effects of syphilis,
 good results and even  effectual cures may be obtained by  the
judicious  use of the Bi-chloride and Bin-iodide of Mercury and
 the Iodide of Potassium.
   Several cases of an intractable character, attended  with  in-
 tense pain in the head, cerebral  syptoms and partial paralysis,
 have  occured in my hospital  practice during the  past fifteen
months,  and have  been relieved by mercurials and the Iodide
of Potassium.
   One sixteenth of a grain of the Bichloride or of the Bin-iodide of
Mercury has been administered in  combination with Iodide of
Potassium three times a day.  In the severest cases of nervous
derangement the Iodide of Potassium has been used freely, in
doses varying from one to two scruples three times a day.
   Case IV.—Dementia, Paralysis  and Death ; Clots in Corpora
 Striata and Optic Thalami.
   In the other case the patient, a negro-woman, was brought into
the hospital in a dull listless, speechless state, with loss of muscular
power, and want of co-ordination of the  muscular movements
and it was said by her companions that she had been the victim
of sorcery or witchcraft.  The  disease was said to have  been 
Jones—Medical.
11
  suddenly induced in a state^of health, by an agea negress who

  practiced witchcraft.

    After death it was found that blood-vessels had been ruptured,

  and blood extravasated into the grey  matter arid  nervous struc-

  tures of the optic thalami and corpora striata.   The patient was a

  large stout old woman, apparently near seventy years of age, and

  the ruptured blood-vessels were found to be degenerated, having

  undergone fatty degeneration.   It is  possible that the rupture of

  the blood-vessels may have been the result of some unusual men-

  tal or physical effort.

    As the practice of sorcery and witchcraft  amongst the negroes

  in certain sections of the South, is thought to have been revived

  and extended since the war, we reproduce one of the fullest and

  most accurate accounts of the superstitious practices  of the ne-

  groes.

    The following very curious  account of the extraordinary super-

  stition of the African race, was transmitted -by  the agent of Ja-

  maica to the Lords of the Committee of Privy Council,  and  by

 them subjoined to their report on the slave trade;  and it is said

 to have been  the result of the dilligent  researches  and accurate

 pen of Mr.  Long.

    The term Obeah, Obiah, or Obi*, (for it is variously ■written), we  conceive to  be the ad-
 jective, and Obe or Obi the noun substantive ; and that by the word Obia—men  or women,
 are meant, those who  practice Obi.  The origin of the term wo  should consider as of no
 importance in our answer to the questions proposed, if, in search of it, we were not led to
 disquisitions that are highly gratifying to  curiosity.  From the learned  Mr.  Bryant's *
 Commentary upon the wind Oph, we obtain a very p obable etymology of the term.—A
 serpent in the Egyptian language was called Ob or Aub—Obion is still the Eg\ ptian name
 for a serpent.—Moses, in the name of God,  forbids the  Israelites ever to inquire  of the
 demon Ob, which is translated in our Bible, Charmer or Wizard, Divinator and Sorcilegus.—
 The woman at Endor is called Oub or Ob, translated Pythonissa; and Obbaios (he  cites from
 Horus Apollo) was the name of the  Basilisk or lioyal  Serpent, emblem  of the sun, and an
 ancient oracular Deity of Africa. This derivation, which applies to one particular sect, the
 remnant probably of a very celebrated religious order in remote ages, is  now become in Ja-
 maica the general term to denote those Africans  who in that Island  practice witchcraft or
 sorcery, comprehending also the class of what are called Myal-men, or those who, by means
 of a narcotic potion, made with the juice  of an herb (said to be the branched  Calalue or
 species of Solatium) which occasions a trance or  profound sleep  of a certain duration, en-
 deavor to convince the deluded spectators of their power to re-animate dead bodies.
    " As far as we are able to decide from our own experience and  information, when we
 lived in the Island, and from the current testimony of all the negroes we have  ever con-
 versed wilh on the subject, the  professors of Obi are, and always were,  natives of Africa,
 and none other; and they have brought the science with thern  from thence to Jamaica,
 where it is so universally practiced, that we believe that there are few of the large estates
 possessing native Africans, which have not one or more of them.  The oldest and most
 crafty are those who usually attract the  Rreatest devotion and  confidence; those whose
 hoary   heads,   and  somewhat peculiary harsh  and forbidding  aspect,  together
with some skill in plants of the medicinal  and  poisonous species have  qualified them for
successful imposition upon the weak and credulous, The negroes  in general, whether
Africans or Creoles, revere, consult and fear them ; to these oracles they resort,  and with
the most implicit faith,  upon all occasions, whether for the cure of  disorders, the obtaining
revenge for injuries or insults, the conciliating of favors, the discovery and punishment of
* Mythology, vol. 1, pages 48, 475 and 478. 
12
Clnicial  Memoranda.
the thief or the adulterer, and the prediction of future events.  The  trade  which these im-
porters carry on is extremely lucrative; they manufacture and sell their  Obies adopted to
different cases, and at different prices.  A veil of mystery is studiously thrown  over their
incantations, ti> which the midnight hours  are allotted, and every precaution is taken to
conceal them from the knowledge and discovery of the white  people. The deluded negroes,
who thoroughly believe in their supernatural power, become the willing accomplices in this
concealment, and the stoutest among them tremble at tho very sight of the ragged bundle,
the bottle or the egg-shells, which are stuck in the thatch, or hung over the door oi  a hut,
or upon the branch ot a plantain tree, to deter marauder.). In cases of poison, the natural
effects of it are by the ignorant negroes, ascribed entirely  to the potent workings ot  Obi.
The wiser negroes hesitate to reveal their suspicions, through  a dread of incurring the ter-
rible vengeance which is fulminated by the  Obeah-men against any who should betray them ;
it is very difficult therefore, for the white proprietor, to distinguish the Obeah professor from
any other negro upon his plantation ; and so infatuated are the blacks in general, that but
few instances occur of their bavins assumed courage enough to impeach these miscreants.
With minds so tirmly prepossessed^ they no sooner find Obi set for them near the door of their
houses,  or in the path  which leads to it, than  they give themselves up for lost. When a
negro is robbed of a fowl  or a hog, he  applies directly to the Obeah man or woman.  it is
then made known among his fellow blacks,  that Obi is set for the thief; and as soon as the
latter hears the dreadluf news, his terrified  imagination begins to work, no resource is left
but in the superior skill of some more eminent Obeah-men of the  neighborhood, who may
counteract the magical operations of the other; but if no  one can  be found of higher rank
and ability,  or alter gaining 6uch an ally, he should still fancy himself affected, he presently
falls into a decline, under the incessant horror of impending calamities. The slightest painful
sensation in the head, the bowels, or any other part, any  casual loss  or hurt, confirms his
apprehensions, and  he believes himself' the devoted victim of an invisible and irresistible
agency.  Sleep, appetite and cheerfulness forsake  him, his strength decays, his disturbed
imagination is haunted without respite, his features wear the settled gloom of despondency;
dirt, or any other unwholesome substance become his only food, he contracts a morbid habit
of body, aiid gradually sinks into the grave.  A negro,  who  is taken  ill,  inquires  of the
Obeah-man the cause of his sickness, whether it will prove mortal or not, and  within what
time he snail die or recover? The oracle generally ascribes the distemper to the malice of
some particular person; but if no hopes are given of recovery, immediate  despair takes
place, which no medicine  can remove,  and death is the certain consequence.  Those ano-
malous symptoms, which originate from causes deeply footed in the mind, such as the terrors
of Obi, or from poisons, whoso operation  is  slow anil intricate, will baffle the skill  of the
ablest physician.
  " Considering the multitude of occasions which may provoke the negroes to exerciso tho
powers of Obi against eaeh other, and the astonishing influence of this superstition upon
their minds, we cannot but attribute a very considerable portion of ,the annual mortality
among the negroes of Jamaica to this fascinating mischief."
  '• The Obi is usually composed of a farrago of material, most of which are enumerated in
the Jamaica law,* viz., blood feathers, parrots beaks, dogs teeth,  alligators teeth, broken
bottles, grave dirt rum and egg-shells."
  Pete Labat,\  in his his history of Martinico, has mentioned some instances of this practice
which are very remarkable.
  '■ It may seem very extraordinary, that a practice alleged to be  so frequent in Jamaica
should not have received  an earlier check from the legislature   The truth is, that the skill
of some negroes, in  the art of poisoning, bus been noticed here since the chemists became
much acquainted with them,  Sloan and Barham, who practised physic in Jamaica in the
lastceutury, have mentioned particular instances of it.  The secret, and insiduons  manner
in which this crime is generally peipetrated, makes the legal proof of it extremely difficult.
Suspicions therefore  have been frequent, but  detections  rare; these murderers have some-
times  been brought to justice,  but it is reasonable to believe that a far greater number have
escaped with impunity.  In regard to the other and more common tricks of Obi, such as
hanging up  leathers, bottles, egg-shells, etc., etc., in order to intimidate negroes of a  thiev-
ish (lisp isitio'j from plundering huts, hog-styes or provision grounds, these were laughed at
by the nhite inhabitants as harmless stratagems, contrived by ihe more sagacious  lor de-
terring the more simple and superstitious blacks, and serving for much the same purpose, as
th_- scare-crows which ate in general used among our English  iaruiers and gardeners.  But
in the year 176 i, when a very "formidable insurrection of the Koromantyn or Gold ('oast ne-
groes broke out in the parish of St. Mary, and spread through almost every other district of
*,he Island  an old Koiomant.wi negro, the chief instigator and oracle of the insurgents in
(hat paiish, who had admiuisteied the fetish or solemn oath to the conspirators,  and
furnished  them with a magical preparation which was to render  them invulnerable',  was
fortunately apprehended, convicted, and hungup with all his feathers and trumperies about
him ;  and his execution struck the insurgents with a general panic, from which they never
aftei waids recovered.  The examinations which were taken at that period, firstopeied the
eyes of the public to the very  dangerous tendency of the Obeah practices, and gave birth to
tiio law which was then enacted for their suppression and  punishment.  But neither the
tenor of this law, the strict investigation which has ever since been made  after the profes-
sors of Obi, nor the many examples of those who from time  to time have  been  hanged «,r
transported, have hitherto produced the desired effect.  We conclude, therefore' that cither
this ^ct, like others in the world, has  flourished under petsecutiou ; or that fresh supplies
are annually introduced liomthe African seminaries.
♦Passed 17C3.
t Jome 11, p. 59, 447, 409, 50U. 
Jones—Medical
13
    Bryan  Edwards in his  " History,  Civil and Commercial, of the

 British  Colonies  in  the West Indies (1806, vol. ii. p. 303"), quotes

 the following narrative  from  a  planter  in  Jamaica,  whom he

 characterizes, as a gentleman of the strictest veracity.

   "Upon returning to Jamaica in the year 1773, he found that a great many of his negroes
 had died during his absence- and that of such a-i regained alive, at least one-half were
 debilitated bloated and in a very deplorable condition. The mortality continued after his
 arrival, and two or three were frequently buried in one  day; others were taken ill, and
 began to decline under the same symptoms.  Every means were tried by medicines, and the
 most careful nursing, to preserve the Jives of the feeblest; but in spite of all his endeavors,
 this depopulation went on for above a twelve months longer, with more or less intermission,
 and without his being able to ascertain the real cause, though the Obeah practice was strongly
 suspected, as well by himself as by the doctor, and other white persons upon the plantation,
 as it was known to have been very  common in that part of the Island, and particularly
 among the negroes of the Papaw or" Popo country. Still he was unable to verity his suspi-
 cious, because the patients constantly denied their having any thing to do with persons of
 that order, or any knowledge of them".   Atlength a negress, who had been ill for some time,
 came one day, and informed him, that feeling it was impossible for her to live much longer,
 she thought herself bound in duty, before she died, to impart a very great secret, and ac-
 quaint him with the true cause of her disorder, in hopes  that  the disclosure might prove
 the means of stopping that mischief, which had already swept away such a number of her
 fellow-slaves   She proceeded to say, that her step.mother (a woman of the Popo country,
 above eighty years old, but still hale and active) had put Obi upon her, as she had also done
 upon those who had recently died ; and that the old woman had practiced Obi for as many
 years as she could remember.
     " The other negroes of the plantation, no sooner  heard of this impeachment, than they
 ran in a body to their master, and confirmed the truth of it, adding, that she had carried on
 this  business ever since her arrival from Africa, and was the terror of the whole ueighbo- -
 hood.  Upon this he repaired directly, with  six white  servants, to the old woman's house,
 and forcing open the door, observed the whole inside of the roof, (which was of thatch), and
 every crevice of the walls, stuck with the  implements of her trade, consisting of rags,
 feathers, bones of cats, and a thousand  other articles.  Examining further, a large earthen
 pot or jar, close covered, was found concealed  under li3r bed.  It contained a prodigious
 quantity ot round balls of earth or clay of various dimensions, large and small, whitened on
 the outside, and variously compounded, some with hair or  rags, or feathers of all sorts, and
 strongly bound with  twine;  others blended with the upper section of the skulls of cats, or
 stuck round with cats teeth and claws, or with human or dogs teeth, and  some glass beads
 of different colors; there were also a  great many egg-shells filled with a viscous or gummy
 substai ce,  the qualities of which he neglected to examine, and many little bags str.ffed with
 a variety of articles, the particulars of which cannot at this istance of time ue recollected,
 The house was instantly pulled down and with the whole of its contents committed to the
 flames, amidst the general acclamations of all his  other negroes.  In regard to the old wo-
 man, lie declined brinoing her to trial, under the law of the island, which would have pun-
 ished her with death; but from a principle of humanity delivered her into the hands of a party
 of tipaniards, who, (as she was thought not incapable of doing some trifling kind of work),
 were very glad to accept and  carry her with them to Cuba-  From the moment of her de-
 parture, his negroes seemed all to be animated with new spirits, and the malady spread no
 further among tbem.   The total of his losses in the course  of about fifteen years preceding
 the discovery, and imputable solely to the Obeah practice, he estimates at least one  hundred
 negroes."


   Case  Y. — Epilepsy.—Death.—Atrophy  and Induration of the

 Cerebellum.


   The patient, a young man, died  suddenly in an epileptic fit; or

 rather the patient became comatose  after the convulsions and

 lay in an insensible state  for eighteen  hours before death.

   The cerebrum was normal  in its  structure and appearance;  the

 cerebellum on the other hand, was atrophied,  and the  grey and

 white matter hardened.

   The grey matter of the cerebellum  was  greatly  diminished in

amount,  and the hardening  was  of the  most  marked character. 
14
Clinical Memoranda.
 A large amount of serous fluid, was effused  between the  dura-
 mater and the arachnoid membranes of the brain and spinal cord.
 The liver spleen and alimentary canal, appeared  to be healthy;
 but both kidneys were atrophied, being not more than one-half
 the natural size, with numerous  cysts, (containing light yellow
 fluid), scattered over the surface,  and throughout the secreting
 structures; the surface of the kidneys  presented  a granular ap-
 pearance.  Both kidneys presented a pale color, more nearly re-
 sembling that of fatty degeneration than the normal color.   The
 kidneys have been preserved in the Pathological  Department of
 the Museum, University of Louisiana.
  The results of the autopsy in this case are interesting,  for in
 the great proportion of the brains of epileptic patients that have
 been examined, the structure of that organ has been said to have
 been in all respects healthy; and this terrible disease has been
 regarded as merely functional, the particular seat of lesion  not
 being determined.
  It must be admitted, however, that in some cases the brain and
 its membranes have been  found in every state of disease to which
 these parts are liable; the former being  indurated, or softened,
 the seat of various  structural diseases, as abscess, cancer or
 tubercle, the latter being inflamed, thickened or ossified; and
 Wenzel has stated that the epileptic state has been invariably
 found associated with a morbid state of the pituitary body, in the
 cella tursica.
  The occurrence of the epileptiform convulsion in this case, in
 connection with  the  marked pathological  alterations and de-
 generations of the kidneys, appear to support the theoy of this
 disease proposed by  Dr.  Todd.   He referred the particular fea-
 tures of epileptic seizures to the general accumulation of a morbid
 material in  the blood, from the cessation or impairment of  the
 depurative functions  of the kidneys,  until it reaches such an
 amount as to operate upon the brain, as it were in an  explosive
 manner, exciting a highly  polarized state of the brain, or of cer-
 tain parts of  it, so that the nervous power  is discharged upon
 certain other parts of the cerebro-spinal centre, in such a way as
to give rise to the phenomenon of fit.  A connection has clearly
been established between defective renal action, the presence 
Jokes—Medical
15
of urea in the blood and epileptic convulsions;  and in the pre-
sent case, the most  rational explanation appears to be to refer
the fatal convulsions, to the arrest of the eliminative action of
the kidneys.
  This case illustrates in a striking manner, the importance of a
critical  examination of the amount, character and chemical
constitution of the  urine, in  each case of epilepsy.  Such in-
vestigations should  not be limited to  the paroxysms, but should
extend also to the free intervals.
  With  reference to the treatment of epilepsy,  it is important
that the physician should make minute inquiry into the condition
of all the orgaus and functions and habits of the patients; and
establish the  treatment upon  correct  diagnosis  and general
principles.  Almost  every potent agent  in the  materia medica
has been recommended  for the cure of epilepsy, ahd cures have
been recorded sustaining  the recommendation; but it will be
found upon a careful study of the disease, that a  certain per cent.
of cases, get well gradually and  spontaneously without the use
of drugs; in females the affection is sometimes connected with
derangement of the  menstrual function,  and when that is  regu-
lated, the disease may disappear, without  farther treatment; in
males masturbation and excessive venery may be causes of epi-
lepsy which are to a  certain extent controllable.  Some cases are
clearly referable to gastric and intestinal irritations and derange-
ments,  which may  be removed or greatly benefitted by treat-
ment ; whilst a certain  proportion of cases are dependent  upon
structural alterations of the kidneys, and  upon both structural
and  functional derangements of the cerebrospinal nervous sys-
tem, and often march steadily on to  insanity, idiocy or sudden
death, uninfluenced  by the most  potent  drugs.  When epilepsy
is clearly the result of the action of the syphilitic  poison, the
disease may be cured by mercurials and iodide of potassium.
  Minute attention to the menstrual  function, to the moral and
mental  habits of the patients, to the state of the digestion and
bowels with rigid rules-for diet, exercise and sleep, are all impor-
tant.
  Amongst drugs, Bromide of Potassium holds at present a high
place with some practitioners;  and certainly does good in some 
16
Clinical  Memoranda.
 cases, but like all remedies  in this affection, its action  is  un-
 certain, and many cases are wholly uninfluenced by it.   In  the
 case of a stout young man, twenty-six years of age, afflicted with
 epilepsy, and  treated in this hospital  before the Medical Class,
 Bromide of Potassium in large and repeated doses were tried,
 without avail;  as much  as three  drachms (180 grains) having
 been  administered just before a  paroxysm,  without any per-
 ceptible effect.  I have employed the Bromide of Potassium, with
 marked  benefit in some  cases, whilst in  others,  no  beneficial
 effects could be perceived.  I have employed Bromide of Potas-
 sium in my wards, with apparent good effects in the treatment of
 delirium tremens.  Milk punch and nutritious  diet was also of
 great benefit in such  cases, for the patients  as a  general rule had
 neglected  their aliment.  A mixture of tincture of Assafcetida,
 fluid extract of Valerian, and Acetate of Ammonia, had also given
 satisfactory results in the treatment of delirium tremens.
   Arsenic, Nitrate of Silver, Atropia and Iron, deservedly hold the
 first place in the treatment of epilepsy, especially when combined
 with proper exercise of mind and body, change  of climate, sea-
 voyage, and foreign travel.
   The following case  of convulsive nervous disease, although not
 occurring in this hospital, is of so singular a nature, that we record
 it in connection with  these investigations upon  the  Diseases of
 the Nervous System.

   Case VI.—Remarkable Case of Cerebrospinal Disease, attended
 with Convulsions, recurring  at  short  Intervals,  and  attended with
 Protracted Somnolence.
   The patient, Miss Susan C. fJodsa, was exhibited at the Mansion House in the Citv of
Nashville, during the month of November, 1867; and at the request of her relatives and of
a number of physicians a careful examination of the singular phenomena presented'l>v thin
 unfortunate voung woman was made.                            *        y "ul°
   History of the case as detailed by her relatives.—Miss Susan C. Godsa now in her twentv
seventh year, has been asleep for the last eighteen years, only awaking' at certain intorvnls
in the dty, and then only remaining awake liom seven to ten minutes  Native  of ftilwvn
Co.. Tennessee.  Her father was a respectable hard working blacksmith, noted for his rnXt
muscular strength, and general health and vigor of body.  The only  members of her imme
diate family now living, are a married sister and brother, who are With her at the \Zinn
House and appear to lie in the enjoyment of good health.  Up to the time she was sixvears
old, she was remarkable for her sprighlnness and vivacity of manner,  and the ffeneral rW.
fulness of her disposition. During her sixth year, she was'attacked  with ague  and fvZtr
with which she suffered for three years.                            °     " luv er>
   The physician who attended her, failed to arrest the disease. Her eyelids becimn nf
fectod in such a manner, as to  fall over her eyes defying every effort on her part  to odVti nr
close them ; this affection howerer, appeared to be only temporary in  its  nature, and dis™
peared, whilst the chills continued.                                     *"o*u-
   Another physician was called in, who administered for the relief of the chills, lar«-e do«P«
ofquinine and morphine, in doses which he stated would have killed any other person.  The 
Jones—Medical
17
  exact amount of quinine was not remembered, and appeared to have been excessive for a
  child of nine years; as forty pills were made, each of which was of the  size of a buck-shot
  and five or six of these were administered at a dose.
     After the continuance of the chills and fever fir  three years, and at the  age of nine
  years, and just after these large doses of quinine, Miss Godsa fell into  the sleepiug state,
  which rendered her case so  remarkable.                                                ,
     The physician  who had  first attended her, was again called in, and after an examination,
  attributed her condition to  the medicines which she had taken, and  stated that it would re-
  quire at least seven years for her system to be  cleared of the poweiful doses  which she had
  been required to swal'ow.
     During the period of three years, she  continued to have violent, attacks of chills  and
  was attended by various physicians, none of whom afforded her relief.  Fiua ly  aft,3r a tem-
  porary improvement, Miss Godsa was compelled to betake  herself to bed where she has since
  remained.
     When the disposition to long slumbers began to manifest itself, she was frequently
  seized with painlul cramps,  and suffered great agony.  Her heels would oe suddenly driven
  up towards the head, and then thrust back again suddenly, the motion appearing to be en-
  tirely involuntary.  Since the patient has been confined to  bed she has grown three feet, the
  present height being five and one-half feet.
     She never asks for food, and eats only when strongly  urged by her attendants. A small
  quantity of water imb:bed at long intervals, satisfies her thirst."  She is fond  of tea and
  coffee and drinks these beverages with relish.  She expresses no choice as to food, and e its
  without objection,  what is given her.  She never complains voluntarily, though when asked
  whether she suffers any pain, complains of pain in the head, back and left side, and of the
  nervous tooth-ache; she has said that she would rather be dead, than thus  linger out her
  existence.  Her periods of consciousness are said io be very regular; waking at 6 a. m. and
  every hour thereafter until 12 M . when she lal's into a slumber which lasts until 3 o'clock
 P. M.; returns to consciousness at the time of the setting of the sun ; waking again at 9 p.
 M., and once or twice before morning.  Her finger and  toe-nails a e  s rid, not. to have grown
 for tho last eighteen yes rs.  The strength is not stiflicient to bear tin weight ot the body.
     Miss Godsa, has resided  during her somnolent state, in  Obion county, six miles South of
 Hickman, Ky   Those having her in charge, have been led to hope that tiavel will benefit
 her health, and the expenses are to be defrayed by the exhibitions.
     The above facts wore corroborated by several respectable citizens of Hickman, Ky.,
 and one year after this examination,  as I was passing through this place, on my way to New
 Orleans, I learned that Miss Godsa was in  feeble health and dropsical.  The exhibitions did
 not defrav the travelling expenses, and the relatives had returned with her to Obion County.
     Results of the Examination of Miss Susan  G.  Godsa.—I examined Miss Godsa, in the
 presence of various medical  men and students, upon two occasions; each examination ex-
 tended over a period of two  hours.
     Up.,n entering the room, a delicate frail woman, with dark hair, combed neatly back
 from her forehead, was observed reclining  upon a  small bed, with her eyelids closed, and
 her arms crossed upon her breast. The features of the face presented the appearance of
 repose and of deep sleep ; whilst the  arms and hands crossed upon  the breast, were inces-
 santly agitated by spasmodic contractions  of the muscles. The incessant phak'ing of tho
 hands which agitated the bed-clothing, appeared to suffer no abatement or periods of repose.
    Shaking, loud talking and the tnagueto-electric interrupted current,  failed  ti  arouse
 the patient, and when the eyelids were drawn back, the pupils were expanded, but responded
 to the stimulus of light and slowly contracted.
    At the expiration of eight minutes, the head and neck were thrown violently from side
 to side, by rapid lateral convulsive motions of the muscles.
    These convulsive jerking motions of the head from side to side, were so rapid and vio-
 lent, as t« shake the entire bed upon  which she lav- and  even to jar the floor of the room.
 The respiration appeared to  be impeded, and the face grew livid.  Such was the rapidity of
 the motions that it  was impossible to distinguish the features, and the face presented a dim
 constantly changing outline.
    The convulsive  movements of the head lasted about one minute, and were followed by a
 short period of repose, of about the same duration, when  the muscles of the back, neck and
 trunk generally were powerfully contracted, raising the head in short spasmodic jerks from
 the pillow, and drawing it forcibly forwards upon the chest, until the chin rested upon the
 breast.   It was found even  with the exertion  of considerable force, wholly  impssible to
 straighten the bent neck.  During these tonic contractions  of the muscles, as the head was
 drawn upon the breast, the inspirations were attended with peculiar spasmodic  gasping
 croupy sounds issuing from  the rigid larynx and throat. These strange sounds varied in
 number during each paroxysm from ten to fourteen.
    The spasms of the muscles ceased as suddenly  as  they had commenced, the head fell
 upon the pillow, only to give rise again,  to the peculiar  round of phenomena, with the
 same suddenness and precision of a piece of machinery, wot king back and forth in a socket
 and  guaged to regular and set distances.
    During both series of convulsive  and tetanic movements the patient remained  uncon-
 scious.  We were told however, that the spa'sm of the  head and neck sometimes occurred
 during the few brief moments, when the patient was awake, accompanied by the  same pecu-
 liar sound from the  throat, which seemed to give her great pain, and often appaiently to
threaten her life with strangulation.  The.se phenomena were repeated in the  order men-
tioned at regular intervals, with the suddenness and precision of  a piece of machinery.
   Miss Godsa awoke at  intervals of about one hour,  during these examinations, cast her
deep blue eyes around the room, noticed every person and recognized all her attendants,
3 
18
Clnicial Memoranda.
called them by name, and answered questions rationally.  The periods of conscionsnesi
lasted only a few minutes ; the voioo was weak and trembling, but the replies to questions
were rational.  We gathered from certain remarks, that the heart of the "Sleeping Beauty,
was not insensible to the tender passion.                               ,  .
   During these periods of consciousness, the patient expressed no desire for food, out in-
variably expressed a desire for water, and when questioned, complained of pam in the back,
head arid stomach.                                            ,   ,   .
   The urinary secretion was examined, and found to be scant and high colored, ana not
deficient in urea.                                                ,.
   This curious case presents many points of profound interest; and an exhaustive discus-
sion of its nature and causes, and of its relations to the action of malaria, and of large doses
of quinine, and of the seat and cause of those wonderful automatic and stereotyped mechan-
ical movements, would consume more space than these " Clinical Memoranda' afford.
   Case  VII.—Traumatic Tetanus; death;  cerebrospinal system
examined after death ; structural lesions discovered.—Julia Jackson,
colored, aged nineteen, stout athletic  negro  woman.  Has never
borne children.
   On the 5th of March, 1869, a clothes-line pole, fell upon her left
shoulder, and a splinter passed downwards  and forwards, under
the  skin,  over the deltoid muscle.  On the  15th of March, after
the wound had apparently entirely healed (the injury was very
slight,  and the splinter was  removed  immediately after the
reception of the blow), the jaws became  stiff, and tetanic  symp-
toms manifested themselves.
   Entered the Charity Hospital, New  Orleans,  March 19th, two
weeks after the reception of the  injury, external wound healed.
Locked jaw and tetanic spasms, body drawn towards the left arm
and side; that which had been injured.   Patient complained of
pain in left arm, shoulder and side.
   The  attending physician administered  Opium and Bromide of
Potassium, beef-tea and brandy.  One grain and a half of Opium
 and ten grains of  the Bromide of Potassium every three  hours.
The opium appeared to quiet the spasms, and  the patient  en-
joyed some rest.
   On the  21st of March, this plan of treatment was changed, and
one-twelfth of a grain  of Strychnine,  administered every four
hours.  The patient took only two pills, and died soon  after the
administration of the second pill, on the 22d of March.   The con-
traction of the muscles of the left side and arm, continued up to
the moment of death;  and the patient  appeared  to die from
 spasm of  the respiratory muscles and asphyxia.  The preceding
 facts were furnished by the attending physician:
   Autopsy six hours after death.—The brain and entire spinal cord
 were  removed from this stout young negro woman,  whose form 
Jones—Medical.
19
 possessed the fulness and roundness of great muscular power and
 the most robust health.
   The pia-mater of the brain and spinal cord, were greatly con-
 gested with blood;  the  congestion was greatest at the  base of
 the brain around the medulla  oblongata.  The grey  and white
 matter of the cerebrum presented the usual consistence, but the
 cerebellum  appeared to  be somewhat altered, being softer than
 usual.  The grey matter of the spinal cord, was universally con-
 gested, whilst the white  matter was softened.  The white matter
 protruded from the smallest puncture of pia-mater and arachnoid
 membrane of the cord.
   The most marked alterations were discovered in the floor of the
 fourth ventricle.   The blood-vessels of the fourth ventricle were
 not only greatly congested, but  a small quantity of blood was
 effused about the middle and upper third of the fourth ventricle,
 beneath the arachnoid  membrane, and into the meshes of the
 pia-mater.
   The internal viscera were healthy, and  upon careful examina-
 tion presented nothing abnormal, with the exception of the dark
 colored blood resulting  from the sudden arrest of the process of
 respiration.
   The lung on the left side, was congested with dark  blood and
 presented a marked difference in this respect from the right lung;
 which presented  some congestion  only in  its most  dependent
 portions.  This condition of the left lung appeared to be due in a
 measure to the contraction of the muscles upon this side, and the
 consequent interference with respiration;  but it is also probable
 that the impairment of the function of  the pneumogastric nerve
 on this side, may have been one of the causes.
   The seat  of the wound was examined with great care.  Two
 cicatrices were observed, the one of entrance,  near  the  upper
 border of the deltoid, and the other near the axillary fold.
   An incision between these two points, revealed thickening of
 the texture, but the injury had healed entirely.
   Continuing the incision downwards, an abscess, with indurated
 walls,  and filled with about two drachms of thick foetid  bloody
 pus, or rather a  grumous fluid, apparently resulting from the
liquefaction or disintegration of the textures, was revealed oo« 
20
Clinical Memoranda.
cupying  the  upper surface of the biceps muscle.  Within the
abscess, two  pieces of cloth were found, about half an inch in
diameter, and apparently detached from her calico dress and
undergarment, by the splinter, and driven into the flesh.  These
particles of cloth were the only  apparent cause of  the abscess,
as no splinter or other foreign body was discovered upon careful
and minute dissection.
  This case presents the following points of interest :
  1st. The strychnine accomplished no good, and appeared rather
to aggravate  the symptoms.
  2d. The disease appeared to have been caused by the presence
of the particles of clothing.  If the existence of the abscess caus-
ing the tetanic spasms had been diagnosed during life, it might
have been possible to relieve  the patient by laying it open, and
exciting healthy suppuration.
  3d. The muscles  were most  affected upon the side to which the
injured arm was attached.
  The nerves coming off from the muscles around the abscess,
were more congested than  those supplying healthy structures;
and it appeared that the irritation was reflected most strongly
upon  those muscles supplied with motor and sensitive nerves
from the same lateral half of the spinal cord.
  4th. The pus,  or rather foetid fluid contained in the abscess
differed widely from the product of healthy inflammation,  and
the absorption of this matter, may have been one of the exciting
causes of the  tetanic spasms.
  5th. The medulla oblongata, and spinal cord, exhibited palpable
lesions, in the congestion of the blood-vessels, and the softening
of the white matter.
  Case VIII.—Traumatic Tetanus; Life of the patient preserved
temporarily by Marshall HalVs Ready Method ; post-mortem examina-
tion, Structural Alteration of Cord.
  Although this case did not  occur in the Charity Hospital, it is
nevertheless of great interest in its relations to the preceding
case, and in this connection  was brought to the notice of the
Medical Class of the University of Louisiana.
  J.  A. Kouk, Company K., 1st Alabama Cavalry, Hagan's Regi-
ment; private;  age, twenty-one;  black hair, fair complexion; 
Jones—Medical
21
 nervous temperament; admitted into the Third Georgia Hospital,
 Augusta, Ga., February 11,1865.  Was wounded February 2d, in
 a skirmish, near Alendale, S. C, by a ball from  a Spencer rifle.
 The ball passed through the abdominal muscles of the right side,
 one inch above the crest of the ileum, entering anteriorly.  Dis-
 tance from one orifice of the wound to the other,about four inches.
 From all appearance the ball passed entirely within the muscular
 structures of the wall of the abdomen,  and did not penetrate the
 cavity.   Patient's health good, before  the reception and at the
 time of this wound.   After being wounded, he was sent to the
 Division Hospital, in which he remained  nine days, moving along
 with the hospital in ambulance to Augusta, Georgia.  During this
 time the  wound was dressed once a day, and kept moist with a
 wet rag.  Patient felt well during that time, but when entering
 the hospital, complained of cramps (to use the patient's own ex-
 pression) in the wounded side and back.
   On the 12th of February, opisthotonos gradually commenced.
 From 10  o'clock A. M., one tea-spoonful of Laudanum (Tincture of
 Opium) was administered every  one  and a half hours, until 6
 o'clock P. M., (the whole quantity of Laudanum given up to this
 time was about one wineglassful, which produced no  perceptible
 effect.)  No medicine given during the  night—patient slept very
 little.  One natural evacuation of bowels this day.
   February 13th.  Trismus commenced this day, Chloroform was
 given by inhalation, which allayed the nervous irritation for about
 one hour.  This was continued during the day, with the addition
 of one tea-spoonful of Chloroform, and another of Laudanum, ad-
 ministered internally every three hours,  until  three  doses were
 taken, when the trismus increased to such an extent as to prevent
 deglutition.   The Chloroform appeared to diminish the volume
 of the pulse.  Respiration during the day, tolerably easy.  The
 tongue, as far as could be seen, natural.   Condition of skin natu-
 ral, sometimes moist.  Bowels constipated.  Urine natural,  in
 color and  quantity.
  February 14th.   Trismus and opisthotonos increased.  Respira^
tion more labored. Injection  of Turpentine and Castor Oil given
with no effect.  One tea-spoonful of Chloroform, Laudanum and 
22                  Clinical Memoranda.
Ether, mixed in equal quantities, were given by the mouth, every
three hours, with no perceptible effect.
  February 15th. Tetanic symptoms increased. Respiration more
labored—no evacuation of bowels.  An enema composed  of one
tea spoonful each of Tincture of Camphor and Tincture of Opium
(Laudanum) was given every three hours.  No benefit appeared
to be derived from this mode of medication  and  it was discon-
tinued.
  Patient continually kept under the influence of Chloroform, to
relieve his sufferings—no sleep obtained without Chloroform.
  February 16th.  Symptoms increased in severity—deglutition
more difficult—Chloroform continued by inhalation.
  An attempt was made to administer egg-nogg, by the mouth,
but failed—patient could not swallow, and immediately after the
efforts, was seized by a violent tetanic spasm. *In the spasm, the
muscles of respiration became involved, which soon arrested the
thoracic respiration, so  that  the latter function was only per-
formed by the diaphragm and  abdominal muscles.  At length,
however, these muscles also became involved,  and respiration
ceased entirely.  The  patient's face turned blue and  livid, the
black blood overcame the cerebro-spinal system, the  eyes were
fixed—all signs of life  disappeared, and death from asphyxia ap-
peared already to have taken place.
  Artificial respiration after the method of Marshall Hall, was
established and kept  up for a  few minutes, when the patient
gradually  revived.   The spasms of the respiratory muscles  also
gradually  relaxed, and after some time, the  patient commenced
to breathe again naturally.
  At this time, two ounces of  whisky with  one teaspoonful of
chloroform, were administered by enema.   This was kept up with
the addition of half a pint of beef tea, every two hours until the
evening; with the exception of the chloroform, the supply in the
hospital being out.
  Evening—patient more quiet—pulse  100; respiration more
eaSy—conversed and swallowed half a glass  of water.  Patient
remained  in  this comfortable   condition, affected with an oc-
casional slight spasm.   About three o'clock,  A. m., he  asked for
water—a little  was given to him,  which brought on another 
Jones—Medical
23
slight spasm, during which he  expired about ten minutes after
taking the water.  This spasm was similar in its nature to the
one already described, and it  is  highly  probable  that  if the
method of  artificial respiration, had been practiced, the  life of
the patient might again have been prolonged.
  Autopsy six hours afttr death.—Spare but muscular man; rigor-
mortis  very strongly  marked—hands  contorted  and  fingers
clenched ;  and feet twisted as in strychnine poisoning.
  The brain and spinal marrow were carefully  removed.  The
nerves leading from the spinal  marrow, to the wound, were also
carefully dissected and examined in  situ. The entire mass of
flesh surrounding the wound, was then examined, and together
with the spinal cord and  its nerves and muscular attachments
were removed.
   Condition of the wound.—The wound was  a superficial flesh
wound.  The  ball was a small  one, apparently not larger than
a pistol ball, and had passed  directly through the structures
without lacerating them.
   When the tetanus first  manifested itself, the  discharge from
the wound is  said to have greatly diminished, and almost entirely
disappeared.  Several days before death, however, and up to the
close of life, the wound secreted small quantities of pus.  When
the entire tract was laid  open, it was found to be  granulating
throughout its  entire extent.   The granulations were carefully
examined with a magnifying glass. They were small and rather
pale.  The wound was  dryer than usual, that is there was less
discharge than in healthy wounds.
   Under  the  microscope, the  pus presented an unhealty ap-
pearance.  The  corpuscles were small, few  in number and im-
perfectly formed, and amorphous granules abounded.
   The wounded surface was surrounded or underlaid by  a thick
fibrous wall, the result of  inflammatory action.
   In  the  track of the ball, numerous sharp filaments of wool,
were found sticking into the granulations, and passing in some
cases, entirely through the fibrous wall, to the muscular structures
beneath.
   Nerves supplying the diseased parts.—These were dissected, and
traced into the parts immediatly surrounding the wound.  These 
24                   Clinical Memoranda.
 nerves presented no distinct evidence of congestion or inflamma-
 tion.
   Spinal marrow.—The nerve leading from the diseased  and
 wounded part, was the last dorsal.  This  sent off a branch to
 the  lumbar plexus; for two inches above its junction with the
 spinal cord, the  blood-vessels of the cord  were engorged  with
 blood, and the vessels presented a marked enlargement.
   The congestion extended from thence, to the termination of the
 spinal cord, and  the  corda  equinse was  also much  congested.
 The thigh upon the affected (right  side), had been  quite  stiff at
 the  hip.  The congestion was  greatest upon the posterior sur-
 face of the cord.
   Sections of the cord were made at various parts, from the junc-
 tion of the medulla oblongata, with the pons varioli, to the ter-
 mination of the spinal cord, and the grey matter presented a pink-
 ish, deep colored  congested appearance.
   Both the grey and white substances, were  examined carefully
 under the microscope, the nerve  fibres presented the usual ap-
 pearance ; the cells of the grey matter appeared indistinct.
   The blood-vessels of the grey matter were filled with red cor-
 puscles.
   This case presented the following points of interest:
   1st. The restoration of the patient,  after apparent death, by
 artificial respiration, was a matter of importance.
   The life of the patient was prolonged  at least eighteen hours
 by this method.
   A large proportion of the cases of tetanus, terminate  fatally
 from spasm of the respiratory  muscles.  If  artificial respiration
 had been practiced the second time, it is probable that the patient
 would again have  been  restored.  The  narcotic effects  of the
 Carbonic Acid of the blood, tends to overcome  the  spasms, and
 hence the possibility of instituting artificial respiration.
   This subject is worthy of the most careful consideration,  and
 of practical application in this terrible disease.
   2d. The granulations and the pus of the wounded surface were
imperfectly formed;  and it is not unreasonable to  suppose  that
the irritation of the injured nerves may have arisen in a measure
from these unhealthy products of inflammation.  The particles 
Jones—Medical.
25
  When a section of the cord was made, the great and char-
acteristic alteration was observed in the ganglionic matter.  The
grey matter, presented a pinkish appearance; under the micro-
scope the grey cells were found not only to be greatly diminished,
but many of them were entirely altered, being filled with colored
granular masses, and some also contained oil globules.  Masses
of hoematin, were  also seen in the intermediate spaces.  The
blood-vessels (capillaries), were greatly increased in  size,  with
thickened  walls, to  which colorless exudations and  spindle-
shaped corpuscles were attached.  The change in the capillaries
was marked.
  Case  X.—Loss of Muscular and Nervous Power—Paralysis —
Death ; Structural Lesions of Nervous System.
  The history of this case, resembled in  some respects, that of
.the preceding; the  subject being in like manner, a negro man
(aged 50 years); who had been working during the last two years
upon a rice plantation, his duties compelling him to  stand in
water above his knees.  Previous to this occupation, had  been
a healthy stout man.
  During the spring months, he began to suffer from " rheumatism
in the left  knee," which extended to left elbow, and right  knee
and elbow, and  the use of the extremities was  gradually lost-
The paralysis appears to have  begun in the lower extremities,
and the lower extremities were said to  have been  cedematous
before being paralyzed.
  In the month of August, the power of locomotion was lort, and
the patient became bed-ridden.
  The oedema of the lower  extremities disappeared  during rest;
the rheumatic pains however, have continued to harass the pa-
tient up to the present time, and the  muscles of the extremities
have gradually emaciated,  until they  are now much  reduced in
size.  Has had no trouble in defecation or urination.
  At the present time skin warm and moist, temperature of axilla
99°.5, and patient  lies on his  back;  subsultug tendinum, and
pains in the shoulders, the former only  occasionally, the latter
persistent;  paralysis of upper extremities, flexors of left arm
partially contracted, paralysis  of extensors of left arm, more.
complete than in right; extensors of lower extremities unaffected
          3 
26
Clnicial Memoranda.
flexors paralyzed; tongue slightly furred; appetite good; bowels
regular; respiration regular, about twenty per minute;  pulse
seventy-two, small.
  The treatment has consisted of Iron and  Strychnine; and the
patient has gradually improved since  his entrance into the hos-
pital, and the power over the voluntary muscles, appears  to be
slowly returning.   As  in the preceding case,  this patient had
been exposed to the action of malaria, and to cold and wet in a
low, unhealthy  region; and  in like manner, the gradual loss of
power in the  extremities, was preceded and  accompanied by
rheumatic pains,  which  were more decided, and attended with
more marked local inflammation;  in like manner there is asthenia,
with  no loss of sensation or intelligence.  It  appears to  be
reasonable to refer the nervous derangement to the same causes,
in both cases.
  The paralysis progressively increased, until the patient became
utterly powerless, and was confined to  bed.
  The flexors of the fore-arm were firmly  contracted; and the
muscles of the fore-arms and legs wasted considerably.  Strych-
nine and Iron, appeared to accomplish no good in this case, and
death occurred March 31st, 1869.  Up  to the time of death, there
was no  alteration of sensation, notwithstanding the paralysis of
motion.
  Autopsy five hours ajter death.—The brain  and spinal cord were
carefully removed.  The grey matter of the brain and spinal cord,
was of a deep  reddish grey color. Blood-vessels of  arachnoid
and pia-mater  congested with  blood.  The  arachnoid  of the
medulla oblongata and superior portion of  spinal cord, was dis-
colored, presenting the appearance  as if it had been washed over
with a weak solution of the Nitrate of Silver.  Spinal cord  some-
what atrophied, with the white matter  firmer than usual, and the
grey matter, softened.
  The brain  and spinal cord of a patient that had died with
phthisis pulmonalis, were removed and compared with the one
under consideration, and it was observed that  it was far lighter
in color; and it was especially observed that the grey matter of
both the brain and spinal cord were far lighter.  Spleen  some- 
Jones—Medical.
27
 of wool penetrating  the tissues, may  also  have been  exciting
 causes of the peculiar nervous disturbances. It is important that
 the most careful examination should be instituted of the wounded
 parts and products of the consequent inflammatory action.
  3d. The grey matter of the spinal cord, was decidedly congested
 with blood; and the congestion was so great, as to  render this
 portion of the cord of a decidedly reddish pink  color.
  Tetanic spasms are attended with great waste of the  nervous
 and muscular elements, and especially of the former, as I have
 shown by careful analysis of the urinary excretion in this disease.'
  The grey cells of the spinal cord, and medulla oblongata, dur-
 ing the stages of action, excitement and change, need an increased
 and sufficient supply of blood.
  4th. The tetanic spasms in this case, were attended with pal-
 pable lesions of the spinal cord ; and  the most prominent condi-
 tion of this state was hyperemia.
  Case IX.—Paralysis; progressive failure of muscular and nervous
 power; Death; Structural Lesion in Spinal Cord.
  Negro-man----; aged forty-five years ; native of  Louisiana;
 has lived and worked all his life on a sugar plantation, where
 he was often necessitated to work in  water, and was subjected
 to the action of malaria.
  Admitted  to Charity Hospital, January 8th, 1869; patient
 states that he has suffered during his life with frequent attacks
 of malarial fever, of the intermittent form ; last July, whilst work-
 ing every day in deep water, often without eating food until night,
 began to suffer with pains in different parts of his body, but more
 especially in the lower extremities; these pains grew worse from
 day to day, and about Christmas he found  that he had lost the
 power of using his legs, not being able to  walk without  great
 difficulty.
  During the summer  and fall  months, the  patient  had suffered
 much with cephalalgia and  intermittent  fever.   Has never had
 syphilis. At the time of his  admission  suffered from constipation
of the bowels;  but the bowels were regulated under  the use  of
 Strychnia, Iron and Alloes.
  Magneto-electric  shocks,  seemed rather  to increase,  than  to
benefit the loss of nervous power, and  this agent was conse- 
28
Clinical Memoranda.
quently abandoned.  The patient has been kept upon small doses
of Strychnia and Iron, with benefit.   At the present  time, the
patient has but  little use of the lower extremities, cannot raise
himself from  a sitting to a standing posture, except by climbing
as it were, up the bedpost, raising nearly the whole weight by
the muscles of the arms and shoulders; after getting to an erect
position, cannot take a step, without holding to a  support;  by
the aid of two walking canes he can walk slowly across the floor,
by moving his feet about two inches at a time, dragging his toes
along the floor.  Paralysis of the flexors of his legs in his  efforts
to walk, the feet appear to be raised by lifting the entire leg, by
means of the muscles attached to the hips; subsultus tendinum
in left leg.  General sensation and reflex action, unimpaired;  no
failure of  special senses;  intellect as bright  as  is usual in his
race; digestion normal; thoracic and abdominal viscera in healthy
condition.
  In this case,  the  prolonged action of  malaria,  repeated  at-
tacks of intermittent fever, together with the depressing effects
of working in water, knee deep, were attended with rheumatic
pains,  gradual loss of power in  lower extremities, constipation,
general asthenia, subsultus tendinum in  legs, and inability to
rise from the sitting posture.  It is possible that the affection of
the spinal cord,  may have been  due to rheumatic inflammation
of its membranes, as well  as to the slow and prolonged action of
malaria and other depressing agencies.
  This  patient  died on the 6th of  May,  1869.   The  powers
gradually failed  and he died apparently from exhaustion of the
circulatory and respiratory systems.
  The  brain  and spinal cord, were  taken out and  carefully ex-
amined.  Nothing special was noticed in the cerebrum and cere-
bellum, but the pia-mater  and arachnoid membrane  of the spinal
cord, in several  portions, presented a light brownish discolored
appearance, as if discolored by a weak solution of the Nitrate of
Silver.
  This discoloration was  found to be due to the deposition of
minute crystalline dark masses of hsematin in the cellular tissue.
  The blood-vessels of the pia-mater of the spinal cord,  appeared
to be larger and  more numerous than normal. 
Jones—Medical.
29
 but the  muscular fibres were generally healthy in appearance,
 and presented well marked striae; the  oil globules were most
 abundant between the muscular fasiculi.
   Nothing  abnormal was discovered in  the valves of the heart
 and pulmonic artery and aorta, the feeble irregular action of the
 heart, with its abnormal sounds during life, were clearly referrable
 to the  anseniic condition of the blood, and  to incipient  fatty
 degeneration.
   All the cavities of the heart contained clots firmly attached to
 the muscular columns, and  valvular cords.  The right auricle
 was especially distended with  an  enormous  clot, which when
 removed presented a complete cast of its  interior.  These clots
 were composed of two portions; a well defined  fibrous,  light
 colored dense elastic portion  and coagulated blood.  From their
 compound and luminated structure, they  had evidently been
 partly formed  during the last  hours of existence.  The  spleen
 was enlarged to twice the size, and slightly softened.  The liver
 and alimentary canal appeared healthy;  so also the kidneys.
   The affected muscles were  exhibited, and presented  a red,
 healthy  appearance quite different from that  of muscles under-
 going fatty  degeneration, or progressive atrophy.  After careful
 microscopical examination, it  was impossible to discover any
 marks of disease in the muscles, even in those which had been
 most completely paralyzed.
   The entire brain and spinal cord were exposed and exhibited
 to the Medical Class.  To the naked eye, no structural alterations
 could be perceived upon the exterior.  There  were no marks of
 inflammation of the membranes  and no deposit or tumor,  or ab-
 scess, which would account for the paralysis of the arms, and of
the extensors of the forearms, and inability to  rise from the
 sitting posture, and loss of power in the lower extremities,  and
 want of  control over the bladder and sphincter of the anus  and
rectum, during life.
  Great  difficulty is  experienced in  such  examinations, as the
modes of hardening the nervous structures, and the act of mak-
ing sections of  the brain and spinal cord,  may, if not carefully
performed, lead to deceptive appearances and  erroneous conclu-
sions.  In many  cases pathologists have failed  to detect  well 
30
Cilnical Memoranda.
marked lesions of the cerebrospinal system,  in the paralysis of
lead-poisoning, of mercurial cachexia, and in the tetanus pro-
duced by wounds and stychnia.
  The cerebral functions in this case was unimpaired,  and sensa-
tion and reflex action were intact;  it appeared  reasonable  to re-
fer the loss of power, chiefly to some lesion of the  motor ganglia
of the spinal cord.  And as the upper  extremities were more af-
fected than the lower, whilst the impulses of  the will were unim-
paired, and sensitive impressions were communicated with the
usual intensity, it seemed most  reasonable to refer the lesion  to
some alteration or loss of power in the ganglionic cells of the an-
terior horns of the spinal  cord, which may be considered as the
origin of the anterior roots of the moter nerves.
  Microscopical investigation was directed to the determination
of the condition of the ganglionic  cells of  the anterior horns of
the spinal cord; it appeared that they were  diminished in num-
ber. The grey matter of the spinal cord also presented a redder
color than in health, and the capillaries supplying the ganglionic
cells were larger, and their walls thicker than in healthy nervous
structures.
  Case XII.—Paralysis of Lower Extremities, following Epileptic
Seizures ; gradual improvement under the use of Tonics and Elec-
tricity.
  William  Aul;  aged  fifty-five years;  height,  five feet  seven
inches; weight 180 pounds; sandy hair; color of eyes,  greyish
yellow; fair complexion;  native of Charleston, South Carolina;
occupation,  overseer  on plantation.  Has lived in this State,  on
the banks of the Mississippi River since  1849.  Was  attacked
according to his statement with congestive chill and convulsions
in 1865.  The convulsions which  appeared  to be epileptic re-
curred at long intervals.
  Sixteen months before  entering  the Charity  Hospital the
patient states, that whilst in the act of striking a snake he fell
and since  that time his control over  the lower  limbs and his
ability to stand  and walk has progressively  diminished and at
the end of four months  he was compelled  to use crutches • and
was finally confined to his bed from the loss of power in the lower
extremities.  The epileptic seizures have occurred monthly.  Ad- 
Jones—Medical
31
what enlarged and  softened.   Liver of slate  and bronze  color,
with a patch of incipient fatty degeneration.
  Microscopical examination of Nervous Structures.—The colored por-
tions of the spinal cord, were due to a deposit of coloring matters
in the form of granules or crystalline masses  in and around the
meshes of the blood-vessels of the dura-mater.  The coloring mat-
ter appeared to have been derived  from the  colored blood cor-
puscles.
   The grey matter of the cerebellum,  medulla,  oblongata and
spinal cord, was entirely changed  in its appearance, as in the
case of insanity and tetanus.  It presented a deep reddish, grey-
ish and pink color,  from the  great  enlargement and increase of
the capillaries.  The ganglionic cells had disappeared to a great
extent, and their place was occupied  by enlarged capillaries.
Masses of  haematin were also discovered  amongst the nervous
structures.  Many of the  nerve cells  were filled with granular
matter.
   Comparative examinations were made with a healthy brain and
medulla and spinal cord, and it was thus clearly shown that the
nerve cells in  the diseased brain and spinal cord, were diminished
and altered in the most marked manner, and appeared to be not
one-fourth as numerous as in healthy nerve structures.
   We have here as in the preceding cases, groundsfor referring
the aberrated nervous phenomena  and  paralysis during life, to
palpable structural alterations of the ganglionic cells and capil-
laries.
   Case XL—Negro-man, aged 63,  a  cooper  by trade, who had
been quartered in a low damp locality, with poor  diet, consisting
chiefly of salt pork and bread; habits intemperate. Has suffered
for some months with pain in  back, located chiefly in lumbar
regions.  About one month ago was attacked with intermittent
fever of tertian type; suffered with three  paroxysms, and up to
the present time has been subjected to " light fevers at  night."
Suffered with constipation of bowels for two weeks from the first
chill.   Says that pains in the arms and knees came on about the
time of the first chill, and these have gradually  increased in in-
tensity.  During the last four weeks, the patient has gradually
lost power in the upper extremities. 
32
Clinical Memoranda.
  February 6th.  The patient complains of sensations of cold in
arms, and keeps them wrapped up  in flannel; pains in lower ex-
tremities and back, in lumbar region ; some subsultus tendinum
in arms ; paralysis of both arms  and of extensors of fore-arms 5
want of full control of lower extremities ; when walking inclines
his body forwards, and walks with an unsteady  swinging gait;
complains of stiffness in the back,  and of inability of standing
erect;  unable to rise from the sitting posture; unable  to retain
his water and fasces; involuntary micturition and defecation, oc-
curring if he does  not  obey the calls of nature  at once; arcus
senilis present; some enlargement  of the  parotid gland on the
right side; no loss of sensation; tongue moist, back  of tongue
coated with yellow fur, tip and  edges clean and  red; appetite
good, bowels regular; slight cough with bronchial expectoration;
sounds of heart feeble, and not well defined; pulse soft, weak,
irregular and intermittent, eighty-four to the minute.
  The patient was put on Cod-Liver Oil,  Strychnine  and Iron,
with nutritious diet, and the arms rubbed with Volatile Liniment
combined with minute portions of Strychnine.
  Patient continued to improve slowly, with an increase of power
in the arms, and was able to get the left  hand to his mouth in
eating, until the 15th of February,  when he had a chill, followed
by fever.  On the night of the 15th, the patient took ten grains
of Blue Mass, which was  followed  by fifteen grains of the Sul-
phate of  Quinia, on the 16th. The bowels were moved frequently
and the discharge passed involuntarily; and the patient appeared
much exhausted; and in  sleeping the left cheek appeared flabby,
and there was a puffing of the left buccinator  during respiration.
  Stimulants and nutritious diet appeared to exert no beneficial
effects, and the  patient gradually sank and died on  the 18th.
Consciousness and intelligence were retained to the last moment.
  Autopsy  three hours  after death.—The  postmortem  was per-
formed three hour after death, and the brain and spinal cord
and viscera, exhibited to the Medical Class. Structures anaemic •
heart pale  and apparently undergoing fatty degeneration.  The
degeneration appeared to be greatest in the muscular structures
of the auricles.  Under the microscope, the fat  globules were
more abundant in many  portions of the heart,  than in health 
Jones—Medical
33
mitted into the Charity Hospital February  8th, 1869.  At this
time the patient  was suffering with fever and diarrhoea;  which
symptoms were relieved in a few days.  At the time of his ad-
mission was confined to the bed, on account of the loss of power
in the lower extremities.   Whilst lying in bed,  manifests both
muscular power and sensation in the lower extremities being able to
draw the limbs  up with considerable  power; but is unable to
walk, the lower extremities apparently  being under no control in
the standing posture.  The  upper extremities have lost power,
but not to so great an extent as the lower, and  are to a greater
extent  under the control of the  will.  Complexion clear, and
general appearance, that of health; complains of pain in back of
head and in the  face.   Vision dim, and the patient says that he
has a sensation of dizziness or turning round in his head. Whilst
sitting  up  the head  inclines to fall forward. Under the use of
Iron, Strychnine and  Magneto-Electricity, the patient gradually
improved, and was able to walk about the ward, supporting him-
self in a measure by his hands on the bed-posts.
  In the month of June the patient was so far improved that at
his  own request  he  was discharged and returned home.  The
temperature in this case  did not vary from that of health, being
98.6 in the hand and 99.25 in the axilla.   The urine also appeared
to be normal in amount, color and specific gravity.
  Case XIII.—Lead Colic, Epiltpsy, Paralysis, Fatal Termination.
  Ralph Bodilly, aged sixty-eight years, height five feet, eight
and three-fourth inches,  weight 170 pounds; auburn hair, now
grey; hazel eyes;  fair complexion; native of Ohio ; has resided
in New Orleans thirty years;  painter by occupation.  Fifteen
years ago had the first attack of lead  colic, and has had six at-
tacks since, the last attack occurred in  December, 1867.
  The patient states  that he was greatly prostrated in this at-
tack.  In the month of June 1868, had an attack of fever which
was followed by diarrhoea and dysentery of  an obstinate charac-
ter.  About the time of  the appearance of the dysentery the
patient began to lose the use of the lower extremities; walked
with great difficulty, and finally had to use two canes in walking.
The patient states that, in addition to  the lead colic, he has also
had attacks of epilepsy occurring at long intervals,
      5 
34
Clinical Memoranda,
   Entered Charity  Hospital  January 26th, 1869, with chronic
 dysentery and paralysis of lower  extremities.  The dysentery
 yielded readily to treatment.  The patient was then placed upon
 Iodide  of Potassium,  and upon a tonic pill compound of Nux
 Vomica,  Quinine and  Iron.  Cod-Liver Oil and good diet were
 also administered.  At the time of his admission into the hospital,
 the patient presented a pale anaemic, sallow unhealthy hue, and
 his weight had been reduced from 170 pounds to 145 pounds.
   The muscles of the leg flabby and apparently degenerated.
 The left leg was affected first  and the loss of flesh was greater
 than in the right leg.   The muscles of both legs were affected
 with irregular contractions and  twitchings, which varied in in-
 tensity  at different  times.  Bowels were frequently discharged
 involuntarily in bed and the rectum and its  attached sphincter
 appeared to be partially paralyzed.  The  pulse  was  normal;
 being on an average 70 beats per minute, and the respiration 18
 per  minute; the temperature  in  the axilla ranged from 99°.5 F,
 to 100°.5 F; the temperature of the right leg was slightly higher
 than that of the left, being in the region of the posterior portion
 of the knee-joint 964° F. to 96° F. in the left  leg.   Uuder the
 use of the Tonic Pills, Iodide of Potassium, Cod-Liver Oil and
 nutritious diet, the  patient gained a  little strength and  flesh,
 On the  12th of May, some swelling was observed in the lower
 extremities, and the  patient complained of  pain along the spine,
 which had existed with various degrees of intensity.  The Magneto-
 Electric current was at this time  ordered  daily.   The patient
 states that in 1850, his wife found him at night in an insensible
 condition; face purple and disfigured, with spasmodic twitchings
 of the muscles.  The physician who was called in pronounced the
 attack epilepsy.  The next morning the patient felt sore in all his
 muscles, as if he had been beaten.  Had a similar attack at night
 in 1853, and since this period has had  a number of epileptic
 seizures.  In 1859, while painting the state-room of a ship  he
 suddenly fell.andlbecame unconscious, and after being carried on
 deck and after the  administration of stimulants,  the patient
 revived and then attempted to paint the captain of the ship and
 only discovered his mistake after being aroused by the voice of
the captain. After this attack felt great soreness in his limbs. 
Jones—Medical
35
  During the recent war was employed in secret service and his
health appeared to improve during his connection with the army.
  The measures instituted produced only temporary improvement,
and the patient gradually lost nervous and muscular power and
died during the month of January, 1870.
  Case XIV.—Injury of Spine, resulting in Paralysis of Lower
Extremities.
  David Younge;  age,  twenty; height,  five feet  six  inches;
weight, 156 pounds; dark brown hair; grey eyes, fair complexion;
native of Ireland; occupation,  carriage driver.  October,  1868
received an  injury in the back, from some men unexpectedly
throwing a sack of salt on his shoulders.  At the time of the in-
jury, felt a cold chill run over his body, with a feeling as if the
spinal column had given way.  The  patient, however, was  able
to continue his ordinary occupation, until March, 1867, when he
suffered severe pain in the small of the back, with difficulty in
urination.  At this time he gradually lost the use of the lower
extremities which began  to waste away.   Entered the Charity
Hospital, February 23d, 1868, with complete paralysis of the lower
extremities, which confined him to his bed.   The patient  came
under my treatment, April 1869.  At this time he was pale anae-
mic, and confined to his bed from  paralysis of the lower extremi-
ties.
  Under the daily use of the Magneto-Electric, interrupted  cur-
rent, and of Strychnine and Iron,  the patient's  general condition
improved, and he was able to sit up in a chair and! to wheel him-
self about the wards and  hospital entry.  At the present  time,
April 1870, the condition of the patient is favorable, although he
is  still unable  to  stand  alone.  No  marked variations of the
pulse or respiration were observed in this case ; the temperature
of the axilla being 109° F; temperature of hand 99°; and of
knee-joint 97.5.
  Case XV.—-Chorea—Effects of Snake Bite.
  John  Powers; aged thirteen years; dark-brown hair,; hazel
eyes; fair complexion; native of New  Orleans.  Patient states
that a needle stuck into his  head when a child, before he could
recollect.  The needle appears to have entered near the junction 
36
Cilnical Memoranda.
of the parietal and temporal bones on the left side of the head.
About two months before entering the Charity Hospital, the
patient was bitten by a snake.  The snake bite was followed by
twitchings of the muscles, pain in the stomach and vomiting.
  Admitted into the  Charity  Hospital  May  7th,  1869, with
irregular twitchings and jerking of the muscles of the face, neck
and extremities, and  with glandular  swellings of  lymphatics of
neck.  Complexion pale  anaemic.  The bowels  were kept open,
and the patient placed upon Iron, Quinine and Strychnine, and
the best diet which the hospital afforded.
  Under this treatment the twitchings as well  as the glandular
swellings disappeared.
  A number of other cases of nervous diseases were bouught be-
fore the Medical Class, but those which we have just recorded,
presented the points of chief interest, and illustrate  the import-
ance of the careful study of Diseases of the Nervous System.
  The force of this recommendation is evident, when  it is remem-
bered that the nervous system is not only the centre and channel
of sensitive and moter impulses, conducting the moter influence
of the will, to  the muscles,  receiving and transmitting to  the
cerebral ganglia, sensitive impressions from the exterior world,
and balancing and co-ordinating the motions of the body; but is
also intimately related to the acts of circulation and respiration,
and the nutrition and secretion of the organs.
!f; If the statements of pathologists are to be credited, there  is a
steady and marked increase of diseases of the brain and nervous
system,  which appears  to be referrable to the excitements and
vices of the present form of civilization. The ever restless ambi-
tion engendered by the  enterprise  and physical activity of  the
present day, in the fierce struggle for wealth and  pre-eminence,
necessitates a constant wear and tear of body and mind in this
great and never-ending battle of  modern civilization.  At  the
present  day,  the brain is unduly strained and  taxed, in  the
severe  struggle  for  intellectual supremacy,  and professional
emolument.
  The importance of the study of diseases of the nervous system,
is well illustrated by  the force of imagination, and the power of
fear over the animal economy. 
Jones—Medical.
37
   Schenckins relates  the  instance of a  noble  Spaniard,  Don
 Diego Osorio, who, being in love with a young lady, of the Court,
 had prevailed with  her  for  a private  conference  within  the
 gardens of the King; but by the barking of a little dog their
 privacy was betrayed, the young gentleman seized by the King's
 guard and imprisoned.  It was a  capital offence  to be found in
 that place, and Osorio was condemned to die.  He was so terrified
 at hearing this sentence, that one and the same  night, saw the
 same person young and old, being turned grey, as in those stricken
 in years.  Moved at the sight, the goaler, related the accident to
„King  Ferdinand as a prodigy, who thereupon nardoned  him,
 saying he had been sufficiently punished for his fault.
   A similar circumstance is related of a nobleman of the Roman
 Court, in the time of the Emperor Caesar, who was also detected
 in an intrigue, cast into prison and sentenced to be decapitated
 on the morrow.
   Dr.  Marshall Hall has recorded the case of a gentleman, who
 was suddenly affected with epileptic seizures,  the effect of /<?ar—-
 the fear of the cholera.   After each epileptic seizure, the hemiplegic
 paralysis of the right side took place; but this yielded completely,
 except that the patient could  not  direct his mind from the  idea
 that the feeling of the affected side was somewhat different from
 that of the other.  At length,  a fourth attack proved fatal; and
 on a post-mortem examination, the arachnoid was found slightly
 opaque, the ventricles containing serum, whilst in the left corpus
 striatum there was the remnant of a small clot of blood in a cyst
 slightly dispolored.   The arachnoid was raised in one part by
 serum, resembling a vesicle, and a small vesicle was attached to
 the plexus choroides.
   On  the other hand, the effects of strong  mental and moral
 emotions, as the heroic enthusiasm of the excited warrior and the
 devoted martyr, may  completely deaden the  nervous sy'stem to
 fear and pain  so that the dreadful  wound and the burning flames
 are alike disregarded.  In the dancing mania  of the middle ages,
 described by Hecker, the patients at the height of their  excite-
 ment, seemed  to have had  their external senses literally sealed,
 "While dancing" says Hecker, "they  neither saw nor heard,
 being insensible to external impressions through the senses." 
38
Clinical Memoranda.
  Under the influence of fear and fright, paralyzed muscles and
limbs that were useless, have suddenly been thrown into action,
haemorrhages have been instantaneously checked, and fits of the
gout, ague and other disorders of a periodic character have been
cured.
  Anger accelerates the progress of the blood, hurrying  on the
circulation with such fearful impetuosity, as to threaten the brain,
and the organs contained in the chest; grief depresses the action
of the  heart,  and  causes  serious accumulations  in  the large
vessels and  lungs, and gradually undermines the health of the
body, by weakening the energy of the nervous system, and caus-
ing the functions to be carried on in a slow and unequal manner;
even  excessive joy has  been known to occasion as strange  and
fatal results as anger and grief.
  Ficnus mentions an instance of a malefactor who was carried
out, as he conceived, to  execution; and in order thereto  his cap
was pulled over his eyes, and a cold wet cloth being struck hastily
about his neck, he fell down dead, under the conceit of his decapita-
tion.  A similar case is recorded  by Charron;—a man having his
eyes covered to  be put to death,  as  he  imagined—being  con-
demned—and  uncovering them again to receive his pardon, was
found really dead on the scaffold.
  It is said, and the statement has been often repeated,  that a
person was directed to be bled to death; his eyes were blinded
and he was  made to believe, by water trickling down  his arms,
that the sentence was being  carried into effect.  The mimicry is
said  to  have  produced his  death as effectually as would the
real operation ; the  powers of life were destroyed by the power
of imagination.
  Sophocles, at an  advanced age and in full possession of his
intellectual power, composed a tragedy, which was crowned with
such success, that he died through joy; Chilon, of Lacedemon,.
died from joy whilst embracing his son, who had borne away the
prize  at the Olympic Games;  Juventms Thalma, to whom  a
triumph  was decreed for subjugating Corsica, fell down dead at
the foot of the altar, at which he was offering up his thanks-
giving ;  and Fouquet, upon  receiving the intelligence of Louis
XIV, having restored him to liberty, fell down dead. 
Jones—Medical.                    39
   These and many other cases of sudden death, from powerful
 emotions and unexpected joys and sorrows, are doubtless to be
 attributed to the effects produced by the nervous system upon
 the sanguiferous system.  Dissection has shown that in  a large
 proportion of such cases, the heart and large blood-vessels, are
 either structurally altered or engorged with blood; in some cases,
 death is  clearly referrable to  effusions upon the brain, and  es-
 pecially at the base of this  organ in the neighborhood of the
 origin of the respiratory nerves.
   I have, by  numerous  experiments upon living animals, de-
 monstrated to  the   Medical  Students of the University,  the
 sudden fatal effects of  the arrest of the  circulation and respira-
 tion,  by destruction of the respiratory ganglia, and by the action
 of such poisons as Hydrocyamic Acid, which act directly upon
 the medulla oblongata.
   The sudden  withdrawal of  the  influence  of the medulla ob-
 longata, during fright or excessive joy, may be also  assigned as
 one cause of sudden death.
   Numerous examples of the production of convulsions, hysteria,
 epilepsy,  madness and idiocy, have  been recorded  by various
 writers, as being produced directly and  absolutely by fear and
 terror; but it will be  sufficient for the illustration of this subject,
 to record some instances illustrating the effects over disease of
 the imagination.
   Mr. Coleridge relates  the following anecdote to Dr. Paris:
   As soon as the powers of Nitrous Oxide w^ere discovered, Dr.
 Beddoes at once concluded that it must necessarily be a  specific
 for paralysis; a patient was selected for the trial, and the man-
 agement of it was entrusted to Sir Humphrey Davy.  Previous to
 the administration of the gas, he inserted a small pocket thermo-
 meter under the tongue of the patient, as he was accustomed to
 do upon such occasions, to ascertain the degree of animal tem-
 perature,  with a view to future comparison.  The paralytic man,
 wholly ignorant of the nature  of the process to which he was to
 submit, but deeply impressed from the representation of Dr. Bed-
 does,  with, the certainty of its success, no sooner felt the thermo-
meter under his tongue than  he concluded the talisman  was in
full operation, and in a burst of enthusiasm, declared that  he 
40
Clnicial Memoranda.
already experienced the effect of its benign influence throughout
his whole body; the opportunity was too  tempting to be lost;
Davy cast an intelligent glance at Coleridge and desired his pa-
tient to renew his visit on the following day, when the same cere-
mony was performed, and repeated every  succeeding  day for a
fortnight, the  patient gradually improving during that period,
when he was dismissed as  cured, no  other application having
been used.
  At the time that Nitrous Oxide excited almost universal atten-
tion, several persons were exceedingly anxious  to breathe the
gas; and Professor Woodhouse administered  to them, ten gal-
lons of atmospheric air, in doses of from four to six quarts.  Im-
pressed with the idea, that they were inhaling the Nitrous Oxide,
quickness  of the  pulse, dizziness, vertigo, tinitus aurium,  diffi
culty of breathing, anxiety about the breast, a  sensation similar
to that of swinging, faintness, weakness of the knees and nausea,
which lasted from six to eight hours were produced;  symptoms
entirely caused by the breathing of common  air,  under the in-
fluence of an excited imagination.
  At the commencement of the present century, a man by the
name of Perkins, introduced certain pieces of metal, called trac-
tors, which he contended would cure certain diseases  by merely
drawing them over the affected parts.  The extraordinary effects
which were said to have been produced by their  operation,  were
referred to galvanic, electric or magnetic influences.
  Dr. Haggarth resolved upon putting the metallic tractors  to
the test of experiment, and selecting five patients from the gene-
ral Hospital at Bath, he submitted them  to the operation of a
pair of false tractors, composed not of metal but of wood, yet  so
painted as to resemble the metallic ones in color.  The patients
thus selected had been ill several months  with various diseases
of a chronic character, as gout and rheumatism.  Upon the affected
parts being stroked in the slightest  manner by  these pieces of
wood,  the  patients  all declared themselves relieved; three of
them were particularly benefitted, and one immediately improved
so much in his walking that he had  great pleasure  in  exhibiting
proofs of the benefit he had received. One  said he felt a tingling
sensation for two  hours.  Similar experiments  with wood, slate- 
Jones.—Medical
41
pencil, tobacco-pipes, etc., were made at the Bristol Infirmary
with the same results; and the fame attending these cases was
so spread abroad, that more patients crowded for relief than time
could be afforded to bestow upon them.  Men that were unable
to lift their arms and legs, were  speedily restored to their use,
after the application of the supposed metallic tractors.
  Such  examples explain the miraculous cures ascribed to em-
pirical and inert remedies.  It has been well said, " it is the con-
fidence of the quack, and the hope of the patient which  work the
cure. Disease is well known to depress the powers of the under-
standing as well as the digestion.  A sick person is, in particular
extremely  credulous about  the object of his hopes and  fears.
Whatever promises him health, may easily obtain his confidence,
and he soon becomes the dupe of quacks and ignorant pretenders.'
   Dr. Reid has said that he who in the study or the treatment of
the human machinery overlooks the intellectual part of it, can-
not  but entertain very  incorrect notions  of its nature, and fall
into gross and sometimes fatal blunders in  the means which he
adopts for its regulation  or repair.  Intellect is not omnipotent;
but its actual power  over the organized  matter, to which it is
attached is much greater than is usually imagined.  The anatomy
of the mind,  therefore should be learned,  as well as that  of the
body; the study of its constitution in general and its  peculiari-
ties, or what may be technically  called idiosyncrasies, in any
individual case, ought to be regarded as one of the most essential
branches of a medical education.
   Plato says :  " The  office of the physician extends equally to
the purification of the mind and body; to neglect the one, is to
expose  the other to evident peril.  It is not only the body, that
by its sound constitution strengthens the soul, but the  well-regu-
lated soul  by its authoritative power maintains the body in per-
fect health."
   Hyppocrates, admitted  that that physician  performed most
cures, in whom the patients placed the greatest reliance.
        6 
42                      Clinical Memoranda.
Section II.—Dropsy Considered as a Symptom of Various
                              Diseases.

                               STJMMAKY.

1.  Dropsy arising from Derangements in the Nutrition of the Tissues, leading
    either to an Increase of Secretion, or Diminution of Absorption.
Acute Dropsy.
Case XVI.—Sudden Accumulation of Fluid in  the  Peritoneum.  Researches
    of Andral, Becquerel and Rodier on the causes of Acute Dropsy.  Consti-
    tution of  the Blood in Acute Dropsy.  Treatment of Acute Dropsy.
2.  Dropsy arising from Derangements or Alterations of the Blood, leading to
    Derangement of the Nutrition of  the Tissues,  with an increa-e of Secre-
    tion or a diminution  of Absorption.  Effects of the prolonged action of
    the Malarial Poison in Deranging the Constitution of the Blood, and in
    inducing  Dropsy.   Constitution of the Blood in  Malarial  Fever.  Con-
    stitution of the Blood in Marsh Cachexia.   Treatment of Dropsy arising
    from the action of the Malarial Poison.
3.  Dropsy arising from Derangements of the Circulatory Apparatus, attended
    with Venous Obstruction and Congestion, increased Serous Effusion from
    the Distended Blood-vessels and Diminished Absorption.
(a)  Cardiac Dropsy resulting from Structural Alterations of the Heart  and
    large Blood-vessels.
Case XVII.—Cardiac Dropsy ; Dilatation of Heart; Death.
Case XVIII.—Cardiac Dropsy.
Case XIX.—Dilatation of Heart;  General Anasarca; Death.
Case XX.—Dilatation of Cavities of Heart; Universal Dropsy.
Case XXI.—Articular Rheumatism ; Valvular Disease.
Case XXII.—Aneurism of Internal Iliac.
Case XXIII.—Aneurism of Descending Aorta.
Case XXIV.—Aneurism of Ascending Aorta.
Case XXV.—Aneurism of Arch of Aorta.
Case XXVI.—Aneurism of Arch of Aorta.
Case XXVII.—Aneurism of Arch of Aorta and Ascending Aorta j Dilatation
    of Heart.
Treatment of Cardiac Dropsy. .
(b)  Hepatic Dropsy, arising from some Obstruction to the Circulation of the
    Blood, through  the Liver.  Cirrhosis, Fatty Degeneration  and Atrophy
    of the Liver.
Case XXVIII.—Dropsy resulting from Obstruction of the Portal Circulation
    in Cirrhosis of the Liver. 
Jones—Medical
43
Case XXIX.—\Dropsy  resulting from Cirrhosis of the  Liver  and Cardiac
    Disease.
Treatment of Hepatic Dropsy.
4.   Dropsy arising from Derangement or Lesion of those Organs which regulate
    the amount of the Blood, as well as its Constitution, by regulating  the
    amount of the Watery Element,  and by the  elimination of Excremen-
    titious Material.  Dropsy arising frcm Diseases of the Kidney.
Case XXX.—Dropsy resulting from Bight's Disease of Kidney.
Case XXXI.—Bright's Disease of Kidney.  Anasarca.
Case XXXII.—Bright's Disease of Kidney.
Case XXXIII —Bright's Disease of Kidney.
Treatment of Dropsy arising from Disease cf Kidneys.
Tabular Statement of Cases treated in Charity Hospital, in Medical Service of
    Joseph  Jones.
Pathological Preparations preserved and deposited in the Medical Department
    of the University of  Louisiana, illustrating the  Clinical Memoranda of
    Joseph  Jones.
Acknowledgment of the Services rendered by the  Medical Class of the Uni-
    versity  of Louisiana.

Section II.—Dropsy Considered as  a Symptom of Various
                           Diseases.

  Useful results in clinical instruction, may  sometimes be  ob-
tained, by grouping together the more important facts relating to
some grave and  striking symptom, and  by  investigating the rela-
tions of this symptom to a large number of diseases.  No symptom
is more striking or more uniformly grave, than dropsy, and as the
practitioner is often tempted  to treat this distressing complica-
tion of a number of dissimilar diseases, upon a uniform plan of
routine practice, it was thought important to demonstrate to the
students,  its connection with various diseased  states,   We are
thus enabled to group together many of the  most  interesting
cases of disease  of the heart and circulatory system,  and of  the
abdominal organs,  occurring in our medical service in the Charity
Hospital.
  Each of the diseases, illustrated under the present section, has
received special consideration of itself, and  has been  carefully
described and  illustrated in the daily lectures at the bedside in
the  wards.   Thus during the  last  course  of lectures of the 
44
Clinical Memoranda.
Medical Department of the University of Louisiana, I  delivered
in the wards and in  the amphitheatre, one hundred and twenty
clinical lectures,  which embraced amongst other subjects  and
diseases, the following:  Method of investigating disease and of
recording cases; instruments employed in the investigation of
diseases;  the value and use of the thermometer in the investiga-
tion  and diaguosis of diseases; chemical  and microscopical  ex-
amination, and analysis of blood and urine;  methods of physical
exploration;  auscultation  and  percussion;  the mechanical  ap-
pliances  and instruments employed by  the general practitioner
in the investigation  and  treatment of disease; fevers; inter-
mittent,  remittent,  congestive or  pernicious  malarial  fevers;
yellow fever; typhus  and typhoid fevers ; small-pox; vaccination;
spurious vaccination  ; measles; scarlet fever : diphtheria; pneu"
monia; bronchitis; pleuritis; peritonitis; cerebro-spinal menin-
gitis; tetanus ; paralysis; epilepsy; insanity; neuralgia; diseases
of heart; diseases of abdominal viscera and genito-urinary appara-
tus ;  acute and chronic diarrhoea and dysentery; diseases of the
liver; hepatitis; jaundice;  abscess of liver; various deposits in
the liver,  as  cancerous tuberculous and  syphilitic;   atrophy,
waxy degeneration,  cirrhosis and fatty degeneration  of  liver;
Bright's disease of  kidney;  waxy  and fatty degeneration of
kidney;  phthisis; cancer; scurvy;  scrofula;  syphilis; gonor-
rhoea; ulcers;  mortification;  composition and  variations of the
blood and urine in various diseases.
  In the present section therefore, whilst the cases recorded  are
grouped so as to illustrate one of  the most  striking symptoms
common to a number of diseased  states, at the same time, the
facts  and  commentaries, will  serve to recall  to the  students,
many points illustrated in  the daily  systematic lectures by the
bedside.
  Whilst the student is  thus taught  by experience, that oftimes
no small difficulty  is  encountered, in  determining to which of its
many sources, a particular symptom, common to many diseases
should be referred; at the same time, he is  impressed with the
absolute necessity of acquiring definite notions of the special
disease, or condition  on which the symptom depends. 
Jones—Medical
45
  It has been proposed to erase dropsy from the list of substan-
tive diseases, and to place it in the catalogue of mere symptoms,
and connect it  with the  original  maladies  upon which  the
effusions or  accumulatious  of fluids depend.   It would  appear
however, that it is destined  to be considered as a special  disease
or diseased state by systematic writers, from the great difficulty
experienced in many cases, of determining during the life of the
patient, the  lesions upon which it depends, and also because to
the practitioner, dropsy is in all cases, something more than an
effect or symptom of disease, as the dropsical effusion, may  become
the  cause  of other and  most distressing  symptoms, causing, in
some cases,  extensive destruction of tissue, and in others, em-
barrassing by its pressure, important functions,  and even ex-
tinguishing life;  and finally because the removal of the  dropsy,
even when the original cause remains, may restore  the  patient
to a state of comparative comfort and health.
  We do not propose to enter into an exhaustive consideration of
all the causes of dropsy, but desire chiefly to examine the causes
which were illustrated by cases actually observed by the students,
of the Medical Department of the University of Louisiana.
  It will be necessary in the first place, to recall the attention of
the  students, to the definition  of  certain  terms employed by
systematic  writers.   Dropsy,  (formerly  written hydropisy,
whence  by  contraction,  dropsy):  a  morbid  accumulation  of
watery  or  serous fluid in the areolar tissue or serous cavities,
arising  either from increased exhalation,  or  from diminished
absorption, each of which  conditions depend  upon antecedent
states of disease.  When limited to one part, the term oedema is
employed,  denoting swelling produced by the accumulation of
serous fluid  in  the interstices  of  the  areolar texture, which
swelling is soft, yields under the finger, preserves the impression
for  some time, and is  pale and without pain.  When the dropsy
is extensive,  the term anasarca, is employe 1 and by some  writers
as synonymous with general  dropsy.  When limited to the perito-
neum, it is  called abdominal dropsy, or ascites. Specific names are
also applied,  as descriptive of the sack, tissue or organ involved;
as when it  affects the pleura, hydrothorax, or dropsy of the" chest;
when the pericardium, hydropericardium, or  dropsy  of the heart, 
46
Clinical Memoranda.
when the arachnoid, hydrocephalus, or dropsy  of the brain; when
•the spine, hydrorachitis; when the  testicle, hydrocele ; when the
uterus, hydrometia; dropsy dependent upon disease  of the liver,
hydrops hepaticus; dropsy dependent upon disease of the kidney;
hydrops renalis.
  During life, there is a continuous circulation of the fluids and
elements of nutrition, not only by means of the heart and blood-
vessels, but interstitially by a slower process of osmosis through
the walls of the blood-vessels  and absorbents,  and through the
individual constituents, the cells and fibres of the various- organs
and tissues.   Although not so rapid or so manifest to the senses
as the greater circulation, the constant and slow interchange of
the fluids of the body is of great if not of equal importance.  The
fluid  constantly  secreted by the closed cavities and interstitial
tissues, is as constantly re-absorbed into the circulation : wThen,
therefore, the  serous fluid  accumulates in the tissues or  cavities,
without  active inflammation, either the quantity of fluid secreted
has been abnormally increased, without a corresponding increase
in the process of absorption, or it may be with an actual diminu-
tion of absorption,—or else the secretion  has continued  the same
as in health, whilst the absorption has been diminished,
  Derangements of the due relationship of secretion to absorption
in the tissues  and cavities of the body, may depend upon__
  1st.  Derangements in the nutrition of the tissues, leading either
to a^ increase of secretion or a diminution of absorption.
  2d.  Derangements or alterations of the blood, leading to derange-
ment of the nutrition of the tissues, with an increase of secretion or
a diminution of absorption.
  3d.   Derangements of the circulalory apparatus, attended with
venous obstruction and congestion, increased serous effusion from the
distended blood-vessels and diminished absorption.
  4th.  Derangement of the function of those organs, which regulate
the amount of  the blood, as well as its constitution, by regulating the
amount of the watery element, and by the elimination of excrementi-
tious materials.
  It is important that  the student should bear in mind the dis-
tinction between transudations and  exudations:
  Transudations are not,  properly,  liquor  sanguinis, although 
Jones—Medical.
47
derived from the blood, but consist of water containing more or
less of the constituents of the serum of the blood—the salts and*
albumen—without any appreciable amount of the fibrin or coag-
ulable element.  They, therefore, preserve the liquid state;  and
the act of transudation relates chiefly to the physical  properties
of the tissues.
  In transudation, there is no solution of continuity or rupture,
the watery portion of the serum of the blood  simply percolating
through the porous walls of the blood-vessels; and transudation
is usually the result  either of  a diminution of  the albumenoid
elements  and salts of the  serum of the blood,  or of undue hy-
draulic pressure, or of both causes combined.  Effusions, or  exu-
dations, devoid of fibrin and cytoblasts, and incapable of organi-
zation, when retained, are characteristic of dropsy.  Occurring
upon mucous surfaces which communicate' with the exterior,
they constitute fluxes.
  Exudations contain, on the other hand,  fibrin and cytoblasts
or germ cells, and are capable of coagulation and organization.
Exudations are the result of inflammation, whilst in true dropsy
this morbid process is wanting.
  Inflammation of serous membranes may be attended with more
or less effusion,  but the liquid is turbid  from the admixture of
coagulable lymph, and in this respect differs from the clear serous
liquid of true dropsy.

1.  Dropsy arising from derangements in the Nutrition of the Tissues
    leading either to an increase of Secretion,  or  a diminution of
    Absorption.
This  division is placed first, not only because it should  include
the most  simple  and  uncomplicated cases of dropsy, but  also
because  the progress of pathological anatomy and chemistry
during.the past thirty years,  has greatly modified the ideas, for-
merly entertained respecting dropsy, and  the class of dropsies
long regarded as idiopathic or essential, has become so restricted,
as almost to  have disappeared from  nosological classifications.
Some pathologists have so  far restricted the causes, as to admit
only two species ot dropsy, viz: the so called mechanical dropsies,
7 
48
Clinical Memoranda.
the result of an obstacle presented to the flow  of blood, whether
in the central organ of the circulation, or in a vascular trunk of
a certain size; and dropsies symptomatic of a special modification
of the blood, consisting exclusively in a decrease in the propor-
tion of the albumen to the serum.
  The  question  iuvolved  in the  preceding  division, does  not
appear to have  been definitely settled; and  even  in the  appa-
rent simple form in which  it is now stated, important questions
relating to the process of secretion and nutrition,  and the con-
nection of the blood with these acts  are involved.
  Cases of dropsy are not.infrequently observed, both in hospital
and private practice, which are for the  most   part acute, and in
which no trace of  albumen is found in the  urine, and the de-
pendence of which, upon some alteration of the blood, or derange-
ment of the action  of the kidneys has not been fully established.
   Sir Thomas  Watson has described a form of  dropsy which he
calls active ascites, where fluid is rapidly thrown  out into the
peritoneum and cellular tissue of the extremities, after exposure
to cold and wet, without fever or any sign of inflammation, and
independent of any  disease of the heart,  liver or  kidneys; and
where  after a  short time  the fluid  is again absorbed. And he
gives the following as a typical case of the phenomena of active
dropsy ; a laborer  is engaged in some employment, which, while
it requires  considerable  bodily  exertion, and  causes copious
perspiration, necessarily  exposes him also  to  the influence of
external cold and  moisture; he has been  digging  (perhaps) in a
wet ditch, in winter time, and he pauses to take his meal;  or he
has been unloading his wagon, and rides home, some miles, in a
heavy  rain that wets him to  the skin; or he has  been mowing,
in  the heat of summer, and  lies down to sleep upon the  damp
grass.   All these suppositions are derived from actual occurrences.
The perspiration is suddenly checked; and in the course of a few
hours  he  becomes univerally anasarcous. Sir  Thomas Watson
explains the sudden occurrence of  dropsy in such cases, by the
sudden check of  the exhalation of watfr from  the  skin and
kidneys, lungs and bowels.  " But supposing  the exhalation from 
Jones—Medical
49
one of these "surfaces to be much diminished, or to cease, without
a  corresponding increase of function in  the related organ, or in
any  excreting organ   communicating  with  the  exterior, then
dropsy, in some form or degree, is very apt to rise.  The aqueous

liquid  thus detained in  the  blood-vessels, seeks, and at  length

finds some unnatural and  inward vent, and is  poured forth into
the areolar tissue, or  into  the  cavities  bounded by  the serous
membranes."

  Dr. Charles  Murchison, in his " clinical lectures on  diseases of
the liver,  jaundice and  abdominal  dropsy,"  has recorded  the

following interesting case of what might be termed acute dropsy.
   Case XVI.—Symptoms of Colic folio wed by signs of Fluid in the

 Peritoneum.


  Edward J., aged 21, who had formerly been « printer, bat had been working for six weeks
 at a carver aud gilder's, was admitted into the Middlesex Hospital, under my care, on April
 12. 1S68. On Apiil 6, he had been suddenly seized with severe ptin in the  abdomen and
 retching  The pain had been constant tver since, but had been also liable to  some exacer-
 bations. The vomiting hid recurred daily, but had not been so violent as at first.   The
 bowels had acted on the 8th and 10th, afcer c storoil and  laudanum.  Shortly before his at-
 tack, the patient had baen suffering from gonorrhoea, and he stated that some years before
 he had a similar, though much less severe attack, of abdominal pain.
  On admission,  the patient, complained of constant paiu in the abdomen, with frequent
 acute exacerbations.  The pain was increased by any movement, and there was also consid-
 erab'e tenderness over the abdomen, most marked over the caecum.  The abdomen was dis-
 tended and tympanitic, and the breathing was entirely thoracic.  There was frequent retch-
 ing of scanty-b lious matter.  Th< re was a dark red (not blue) line along the margin of the
 gums.  The tongue was moist and o ily slightly furred, there was thirst, and the bowels had
 not been open for two days-   The pul*e was 84 ;  the skin was cool, and the  temperature un-
 der the Tongue 97°. There was no albumen in the tiriue.
  The patient was ordered a warm bath, warm fomentations to the belly, an enema of three
 pints of barky-water with four drachms  of tincture of assafootida, and a grain of opium every
 four hours.
  The enema brought away two copious motions, but with no relief to the pain. On  April
 13th, a third  of  a grain of extract of belladonna was ordered every tiireo hours, but
 next day tho pain, tenderness, and tension  of  the abdomen had increased  although the
 the pul-'e wa< only 72. and the temperature 97°.  He was again ordered a grain of opium
 every four hours  a draught of castor oil and laudanum and frequent enemata. He also con-
 tinued taking six grains of opium a day until April 17th, and then three grains until  April
 23d.  Under this  treatment  the bowels were freely moved, and the paroxysms of pain be-
 came less seveie; but  he still had occasional vomiting, the abdomen grew larger aud more
 tense, and on April 19th, there was unmistakable evidence of fluid in the peritoneum.  A
 thrill could be propagated fiom one s:de to the other, on tapping, and where the patient was
 supine there was dullness on either flank, which varied with his position  He still had oc-
 casional paroxysms of pain, but no ten erness of the abdomen.  Tho pulse, however, kept
 ste <iily at 72. and the temperature rarely exceeded 98°. The signs of fluid in the peritoneum
 with occasional slight paroxysm-i of pain continued until May 4th.  After this the abdomen
 gradually became smaller, and on May 18th it had resjaiiien. its normal size aud presented no
sign of fluid, and the patient loft the hospital free from pain.


   The researches of Andral, Becquerel  and Rodier, rendered it

probable that in these cases  of acute dropsy, there is oftimes, if

not always, in the early stages,  a congestion of the kidneys with

the appearance of albumen in the urine. 
50                    Clinical Memoranda.
  Andral, after noticing the fact that sometimes individuals, who
after exposure to some sudden cause of cold, are attacked a few
hours after with anasarca,  states that, after accounting for the
dropsy by supposing that the sudden  suppression of the cutane-
ous function of transpiration  rapidly  produced a superabundant
exhalation of serum into the areola  of the cellular tissue and the
serous cavities, he was led to conclude that this kind of dropsy
was dependent upon derangement of the kidneys.
  A young man, previously in  good health and  strongly con-
stituted, entered the hospital of La Charite' with considerable an-
asarca and commencing ascites. He related to Andral that, a few
days before, being abed and asleep, some of his comrades poured
upon him a pot of cold urine, while  he was in a state of perspira-
tion.   He got  up naked in  order to pursure  them, and was very
much chilled; he remained, said he, as though frozen.  From the
day following  this occurrence, he began to perceive a slight de-
gree of swelling, which  rapidly  augmented.  The  urine of this
patient was examined and found to  be albuminous.   Andral con-
cluded from this that the blood had  been deprived by the kidneys
of a  certain amount of its albumen,  aud in this way accounted
for the formation of the dropsy.  It is then upon the kidneys that
the  action of the cold had fallen.    This  dropsy was not,  more-
over, of long duration ; at the end  of a  fortnight, the cure was
complete.
  Becquerel and Eodier, in their pathological chemistry, have
given the results of the analysis of  the blood in eleven cases of
acute dropsy.
  The follovring is  the historical resumd, which these authors
give  to establish the  dependence of  acute dropsy upon  some
alteration of the  blood,  although this dependence  was  proved
merely by induction.
  " Nine of the patients were males, and two were females.  In all the disease set hi rapidly
under 1 he following circumstances.
  Iu one case it followed a sudden suppression of the catamonia from violent emotion • in  a
second, it occurred at the fifth month of pregnancy, bui without anv very appreciable cause-
in a third it followed an attack of scarlatina ; in four other cases it followed a lon»- exposure
to cold ; in another it resulted from sleeping on the ground in the open air durin^'the month
of June ; lastly, in three cases the cause was inappreciable. In two of these latter the na.
tients were suffering from a relapse of the disease.                       '   1
  Of these eleven patients, nine enteied the hospital before the fourth, or  after the eleventh
day of the disease.
  The primary phenomena were not the same in every case.  In six, dropsy was the only 
Jones—Medical
51
symptom; in two, it was accompanied by fever; in two others there was likewise a slight
anion t of fever, with vomiting and diarrhoea; while in another, there was vomiting coupled
w th an attack of jaundice.
  On the i duiir-siun of the patients into hosnital, the only marked symptom was general an-
asarca of varying intensity, from  slight but diffuse puffiness  of the integuments up  to a
c nsidi'iable infiltration of the sub-cutaneous cellular tissue.  The skin was, as a rule, some-
what pa er than usual.  The remaining organs, and even those which had i>eeti affected at
tho outset of the disease, were in a healthy condition.  The feverish FymptoiiiB had likewise
disappeart d.  In nine of these patients the urine piesented no tiace of albumen, either on
their entrance into, or i uring their whole stay in the hospital;  it was perfectly natural
moreover, both as re aids quantity and chemical composition.  In two ca es, however, the
following phenomena  weie observed : in one man, who was admitted on the  Iburth day of
tne di.-ea>e, a considerable amount of albumen was found in the urine on that  and  the  suc-
ceeding day : on the sixth and seventh day it had gradually diminished; on the eighth it
was barely discernible, and on the ninth day it had  entirely disappeared. The dropsy, how-
ever, was'not removed until the seventeenth day.   In the second case, admitted on the fifth
day of the disease, a small quantity of albumen was fouud on the sixth and seventh  day,
hot Hum' whatever  on the eighth.
  Of these eleven cases, nine were cured and two left the hospital relieved.  In none did the
disease last longer than  a month.
  An analysis of the blood was made in each of these cases and the mean results thus ob-
tained will be found in the subjoined  table :

                    ANALYSIS OF 10C0 GRAMMES OF BLOOD.
                                            Mem.      Maxim'a.     Minim'a.
        Specific gravity ..........-...........  1045 84       1053 3d        1037 55
        "Water................................   830 78         ......         ......
        Globules  ............................   104 58        134 88          7J.10
        Sol.d matters  of the serum............    6187         65 62         57.24
        Fibrin................................     3 67          4.10          1.25

                    ANALYSIS QF 1000 GRAMMES OF SERUM.
                                            Mean.      Maxim'a.     Minim'a.
        Specific gravity.......................  K22 61        1024.28        1020.05
        Water................................   928 47         ......         .....-
        Albumen..............................    58 52         63 J8          51-12
        Extractive matters and salts  ........   13.01          17.14          7.74

  The  qlobules are less liable to decrease than in cachectic dropsy; they nevertheless fell,
in one case to 70. and in another to 72.  In three cases they were about laJ per 1.0J ; in three
others  between 10. and 12-; and in live cases, between 1J0 and lib.
  The  fibrine underwent a marked diminution in two cases only, viz : between  1 and 2 per
10oo • in six cases it varied Horn 3 to  6, while in three others it rose above 3 per 10 )0.
  The albumen of the serum was always diminished, aud in  some instances this diminution
was considerable ; it ranged Horn 60 to 66 in lour cases, and from 55 to 60 in six others, while
in one case it fell ss low as 51 02
  It is almost needless to add, that the specific gravity of both the blood and serum  was
always found  to have fallen below the standard ot health.
  iMich then i* the history of acute dropsy.   We have now to interpret and  explain its at-
tendant phenomena.                        ,            ..    .,     •>  -   x,   i
  At first two prominent facts present themselves to our notice; the one being the dropsy,
and the other a modification of the blood, consisting  in a decrease of the albumen, and of
the specific gtavity of the ciiculatiug fluid itself.           _
  What is tiTen the correlation ot  these two facts ?  Upon which of the two does the other
depend  or aie they independent of each  other?  To answer such  questions, is  somewhat
nioie difficult th m might be a priori imagined.  If, in fact, we admit that the alteration  ot
the blood piecedes the dropsy, how are we to explain the  deciease  of the albumen m those
cases  where there has not exist, d (as in cachectic dropsy) any material appreciable cause,
to acconut for the impoverishment of the vital fluid ? This difficulty however is not insur-
mouutable. and the following simple explanation may perchance prove satis actoiy:
  Of the eleven cases quoted above, two were admitted before the seventh day ol the disease.
  Whit then did we find in these two cases?  An expiring albuminuria, it we may  be per-
mitted to use such an expression.  On admission, a certain amouut ot albumen  is found in
the urine us decrease is watched, and about the eighth day it is found to disappear ent.rely.
In such a esse, tne modification of the blood admits of easy explanation.
  It is evident  in tact, that the following sequence ol events took  place :  These two indi-
vidu ds whether under the influence  of cold oi  of some other cause, were attacked with a
ceruiin amount of con_es,ion of the  kidney.  This congestion was manifested  by the es-
CMtie , f albumen  along  with the urine, which lasted as long as the congestion itself;  viz.,
seven or eiVht days, and then ceased.  Under the influence of this  escape of the albumen,
the moooition ot that element naturally existing in the blood beca.ne diminished, the density
of tfc serum fell, and d.opsy was produced.  But the change in the  compos tion ot the blood
when  once effected, lasts tor  bonie time alter the disappearance  ot the  albumen from the 
52
Clinical Memoranda.
 urine, and as lone: as this change exists, so long will the dropsy likewise exist. Had these
 two patients not men seen until the eighth day of the disease, no albumen would have been
 found in the urine;  the diminished amount of that constituent existing in  the "'['j'". to-
 gether with the dropsy, could alone have been discovered, and their correlation would have
 been lost.
  In these two cases this solution of the problem  would appear simple and rational, nor do
 we think it can well be contested.  But will it hold good with  respect to the remaining nine
 cases ?  We think it will; aud wo admit the same, by induction it is true, but yet upon cer-
 tain plausible reasons, which are the following:
  1.  As these nine patients were not admitted into hospital until  after the seventh day of
 the disease, we may readily conceive the albumen to have disappeared from the  urine  pre-
 vious to admission.
  2.  The symptomatic expression of the disease was the same in every case  In several of
 them its onset was marked by  a combination  of phenomena, sufficiently characteristic of
 acute congestion of  the kidney 'active hvperaemia).
  3.  The modification of the blood was the same in each of the eleven cases.
  4.  The pregress and duiation of the disease were likewise identical in • ach.
  We may now, therefore, offer the following summary of our theoiy; for, however rational
 and sat sfactorv, it is still but a theory :
  Under the influence of some cause or other, congestion of the kidney is produced.  The
 congestiou is indicated, along with other symptomatic phenomena, by the escape of a certain
 amount of albumen  with the u ine ; this, ere long, diminishes the natural proportion of the
 albumen of the blood, and the latter condition in  its turn  gives rise to a greater or  less
 degree of dropsy.  We may here observe that, when this  decrease of the albumen takes
 place rapidly, dropsy is produced with gi eater  facility and with less diminution on the part
 of this constituent of the blood, than wlien it occuis in a chronic form.  But the congestion
 of the kidney is generilly ot much shorter duiation than the modification of the  blood  and
 its consecutive dropsy ; it disappears therefore long before these latter phenomena, and if
 the patients are not examined until a ceitain time after  the onset ot  the disease, they alone
 are observed, the escape of albumen with the urine having altogether cea-ed.
  If the theo'-y which we have thus propounded he the true one, it would seem advisable to
 designate the disease in question, as coi gestb n or  active hyp< rsemia of the kidney, rather
 than a« acute dropsy from decrease of the .dbumen of lhe blood.  We do not, however, deem
 ouiselves authorized to make such  a change, being unable,  as yet, to elevate oar hypothesis
 to the rank of a positive fact, at least in the majority of cases.


   These  investigations of Becquerel aud Rodier, conducted   in

 the spirit of Philosophic inquiry, are of great value, in establish-

 ing the connection of acute dropsy with  congestion of the kidneys.

 It would be more reasonable to suppose that the accompanying

 dropsical effusion was  as much the result of the non-elimination

 of the  elements of the  urine, and  the  retention  of  the  watery

 element,  as the  mere  loss  of  albumen.   I  have  witnessed  the

 supervention of acute  dropsy  in  patients  who  were exposed  to

cold, during convalescence from chicken pox,  measles and scar-

latina, within two days after the cause which produced congestion

of the  kidney, with  almost  complete cessation of its action.   In

such cases, the two or three ounces of urine excreted during the

twenty-four hours, although loaded with albumen, were not suffi-

cient in quantity to materially affect the  composition of the blood.

The most sudden case of  acute  dropsy, that  I  have  ever  wit-

nessed, was attended with almost complete suppressi 3n of urine, as

the result of exposure to cold during convalescence from variola ;

and uremic convulsions of the most  violent character supervened.

   The  retention of the urea, and water normally excreted  by the 
                       Jokes—Medical.                     53

 kidneys, appears to be connected with the dropsical effusion, even
 more iutimately than the loss of a small amount of albumen.
   The treatment of acute dropsy should  be based upon an ac-
 curate knowledge of the previous state of the patient, and the
 amount and composition of the urine.
   When the kidiieys are congested, and  the  urine is scant and
 leaded with albumen, and the patient suffers with fever, general
 uneasiness  and gastric derangement,  both  general  and  local
 bloodletting may be practiced with benefit.
   Leeches and cut-cups over the region  of the kidneys will prove
 beneficial in relieving the congestion.  After the albumen has
 disappeared from  the urine, and  in those cases in  which its
 presence has been never dett cted, blood-letting is not indicated.
   The diet should be light but nutritious, and composed largely
 of vegetable and farinaceous articles.
   Various measures may be instituted to procure  the removal of
 the effused fluid; as purgatives, hot air baths, diuretics and stimu-
 lating frictions.
   When the kidneys are congested, stimulating diuretics  should
 be avoided, and the saline diuretics should be employed.  The
 bitartrate of potassa (cream of tartar),  employed  in the propor-
 tion of one ounce dissolved,  or  rather suspended in  one piut  of
 the infusion of juniper  berries (jumped  fructus), may be ad-
 ministered during the twenty-four  hours.  If the gentle stimu-
 lant effect of the volatile oil and resin of the juniper berries be
 contra-indicated, the cream of tartar may be given suspended in
 one pint of water.   A wine glassful of this mixture may be taken
 every two or three hours.  After the relief of the kidneys, and
 the  establishment  of the excretion  of the urea  in its normal
 amount, good  diet, together with tonics, especially cinchona and
 the vegetable  bitters, may be employed to restore the blood to the
normal standard.
2.  • Dropsy arising from derangement or alterations of the  Blood,
    leading to  derangement of the Nutrition of the Tissues, with an
    increase of Secretion, or a diminution of Absorption.
  The prolonged action of the malarial poison, not unfrequently 
54
Clinical Memoranda.
induces such changes in the composition of the blood and such
derangements of the liver and spleen, as to lead to the effusion of
serous fluid into the areolar tissue and peritoneum.  The changes
of the blood induced by malarial fever,  appear to be the  chief
cause of the dropsical  effusions, although in  some cases this
symptom may be attributed to the  mechanical obstacle, afforded
by the enlarged spleen and liver.  Several well marked cases of
dropsy resulting from the prolonged action of the malarial poison
have been from time to time presented to the Medical  Class of
the University of Louisiana,  in which  no  albumen could be
detected in the urine, nor any diminution of  this secretion, nor
any very great enlargement of the liver and spleen.  Such cases
were uniformly  characterized by a  sallow, anaemic complexion,
and watery blood,  poor in solid constituents. The effects of the
malarial poison in altering the composition of the blood, are
shown in the  following table  embodying the results of my
investigations: 
CB£C

^ a era



p —• "
tc » »
<3hj
a   2.5
** 5i  ca •-»■ ."
B 1  3
go
SOTQ
CB »

3%
„ o
s GO S3
^3
S
w
Q
» r 3
fa
►O C
 2.r§
 w-3 S
■c-s a
.   » g
to.
O'
     piooo   o »- —•

b-lCOtOtO©**tO-1
Intel mittent Fever of
12  days' duration,  at
   time  of analysis.
    HI ale.
     i-"   tO -1
—J -1 *U _. CO Ol
■" — » c o o
       OS -1     tO to
     OMO   -J tO '-O
B*0COOKOOM
Intermittent Fever of
2  weeks  duration  at
time of analysis.  Male
     •"-•   tO -1
OS —I ' -   J- >b.
OOMMOaC
       -J -J     <-. tO
     ^ tC (O   C Cn O
i—'COoii—'MO-' Cn -J
Intermittent Fever of
6 week's duration.
Male.
       Cn Ci   •—' CO A.
     CKitO   O O O
u«h cn ic ^ o a <i
Remittent Fever of 16
days' duration at lime
of analysis. Male.
C5 -1 -1   u-  cn
tO — tO >-• CO O
       Oi C7i   >—» Co >£».
     Ci O C!   © tO CO

<8kCntOtOrf»->*^COC50i
CO in i— -4 :C CO IO CO ©
Remi'tent Fever of 10
days' duration at time
of analysis.   Male.
     —■   tO-1
M M CO " K Ol
■— OS CO O O O
     —   ro -i
GO GO OS —• CO Ol
© -4 © tO -J o
     >->   tO -1
■j oo o> " ;= -^
-J OS - © w 50
     i-"   tO-1
oo co cs   >*»• oi
© —1 OS ■—■ Cn tO
       OS -7     >—tO
     CS OS CO   O O OS
to* jsitk^-ltOtOCStO

00tO©*-Oi«P©CO*.
Remiitent & Typhoid
Fever of  11 days' du-
ration at  time of  an-
alysis.  Male.
       c- OS     to CO
     -J OtD   -J CO ©
tocccs--i©cocotoco
—i-aco«-"©-.ios>*^«o
►-•OiCOtOCS-JOiCiCO
       OS OS     to CO
     -1 © 00   —J CO —
©tooitotocoosco-J
boco-itcto>&-©'to-5
-.IGOOrf^Oi©©-!*
Remittent Fever  of 2
week's duration.
Male.
Congestive Fever.
Male.
       Cn OS     tO CO
     -J -J Oi   CO Oi >B»
(-"CTl^^CiS^GOCO
Congestive Fever.
Male-.
8 
56                   Clinical Memoranda,

  The effects of the malarial poison upon the blood, are rendered
manifest, by a  comparison  with the  following typical formula
of the constitution of the blood.
  Physiological limits of the variations of the constituents of the
blood,  as established by the researches of MM. Bequerel  and
Eodier:
                  In 1000 parts of Blood.

The water, may vary..................from  7G0.00 to  800 00.
  "  specific gravity may vary...........  "  1055.00 to 10U3.00.
  "  globules         '*   "  ..........  "   120.00 to  150.U0.
  "  fibrin            "   "  ..........  "     2.00 to    3.50.
  "  solid matters  of  serum may  vary  "    90.00 to  105.00.
  "  saline constituents         "   "    "     4.00 to   10.0o[

                  In 1000 parts of Serttm.
The spec. grav. of serum may vary......from 1027.00 to 1032.CC.
  "  water of seium may vary...........  "    8fc0.00 to 900.00.
  "  solid matters     "   "...........   "  100.00 to  l'JU.00.
  "  albumen may vary.................   «   70.00 to   90.00.

  The following is the typical formula of the constitution of the
Blood in health, adopted by MM. Becquerel and Rodier.

             Analysis of 1000 parts of Blood.
Specific gravity of blood..............................1060.00
Water................................................  781.00
Globules...............................................  135.00
Albumen............................................   70.00
Fibrin................................................    2.50
Fatty Matters, Extractive Matters, and free Salts......   10.00
Phospates..........................................    0.50
Iron.................................................    0.35

             Analysis of  1000 parts of Serum.
Specific gravity of serum.............................1023.00
Water.................................................90&00
Albumen............................................   80.00
Extractive  Matters and free Salts.....................   12.00
  The following results are established by this comparison :
  1.  In malarial fever the specific gravity of the blood and serum is
diminished.
  The specific gravity  of the blood ranges in this disease from
1030.5 to 1042.4,  and the  specific gravity of the serum from
1018. to 1023.6.
  In health, on the other hand, the specific gravity of the blood 
Jones—Medical
57
varies from 1055. to 1063., and the specific gravity of the serum
from 1027. to 1032.
  2.  In  malarial fever the colored blood-corpuscles are greatly di-
minished.
  In health the dried corpuscles may vary from 120. to 150. parts
in the J 000 of blood, and the moist blood-corpusles from 480. to
600.  In malarial fever, on the other hand,  the dried  colored
corpuscles range from 51.98 parts to 107.81; and the moist blood"
corpuscles from 207.92 to 323.63.
  The crreful  comparison  of these analyses of  malarial blood
with each other,  reveals the fact, that the extent  and rapidity of
the  diminution of the colored  corpuscles, corresponds  to the
severity and duration of the disease.  A short but violent attack
of congestive  or of  remittent  fever, in its  severer forms, will
accomplish as great a diminution of the colored blood-corpuscles,
as a long attack of intermittent fever, or the prolonged action of
the malarial poison.
  3.  In malarial fever,  the relation between the colored corpusles and
liquor sanguinis is deranged.
  Thus in healthy blood the relative proportions  of moist blood-
corpuscles in the 1000 parts and liquor  sanguini3 may vary  from
480.00 to 600.00 of the former,  and from 520.00 to 400.00 of the
latter; whilst in  malarial  fever, tho globules vary  from 207.92
to 323.63, and the liquor sanguinis from 792.08 to  676.37.
  4.  The Fibrin of Blood is diminished to a marked extent, in  some
cases.of malarial fever, and is altered in its properties  and in Us
relations to the other elements  of the blood, and to the blood-vessels.
  5.  The Organic matters of the Liquor Sanguinis, and especially the
Albumen, is diminished in malarial fever.
  Thus the solid matters of the serum may  vary  in health,  from
90.00 to 105.00: whilst  in malarial fever, they vary from 62.78 to
80.22 parts, in the 1000 parts of blood.
  It is  chiefly to this latter change, viz., the diminution of the
albumen  of the blood in malarial fever,  that the dropsical effu-
sions are to be traced.  The other changes of the blood, without
doubt, lead to congestions of the liver and spleen, and to  de-
rangements of the  capillary circulation and nutrition of the
organs and tissues, but a careful examination of those diseases 
58
Clinical Memoranda.
as anaemia, chorea, and pyaemia, in which the colored blood cor-
puscles are  greatly' diminished,  will show that this course alone
will not induce dropsy.   In the watery state of the blood induced
by  the action of paludal poison, comparatively slight obstructions
of the circulation in the spleen and liver might lead to dropsical
effusion.
  It would appear also, that from the derangement of nutrition
caused by the action of the malarial poison upon the blood and
nervous system, that certain effete products are not sufficiently
and properly eliminated, and then as in the case of urea, may be
active in the  production of dropsy.
  MM. Becquerel and Bodier have demonstrated that in that pe-
culiar condition  of the system called marsh cachexia, accompa-
nied by a  remarkable decoloration  of the skin,  and  not uufre-
quently by dropsy, and produced by the long influence of malaria,
there is the greatest decrease of both the albumen and the glo-
bules;  as  is  well  shown  by  the  following  analysis  of  marsh
cachexia.

ANALYSIS OF 1000 FARTS OF  BLOOD IN  MARSH CACHEXIA.
Specific Gravity.......................
Water..................................
Moii-t Globules........................
Solid Matters of Moist Globules-
Water of Moist Globules...........
Solid Matters of Serum ............
Fibrin....................................
*H as 83
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 378.88
  87.22
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   4.15
ANALYSIS OF 1000 PARTS OF SERUM  IN  MARSH CACHEXIA.
Specific Gravity ...............
Water .............................
Albumen..........................
Extractive Mattexs and Salts
1020.37
 936.40
  55.68
   7.92
1016.40
 953.29
  37.26
   945
1021.61
 930.08
  50.20
  13.72
1024.15
 926.75
  60.20
  13.05
1023.56
 922 98
  63 25
  13.77 
JoNES—ilfetKcaL
59
   The mean composition of the blood in marsh cachexia may be
 represented thus:
 Analysis of 1000 parts cf blood (mean composition of in five cases of
                       Marsh Cachexia.)
       Specifie gravity..........................1036 76.
       Water.................................. 962.38.
       Moist globules............................ 303 76.
       Dried residue ot globules...................   75.95.
       Water of globules......................... 22782.
       Solid matters of serum......................  57.79.
       Fibrin..................................   3.39.
           MEAN COMPOSITION OF 1000 PARTS SERUM.
       Specific gravity............................1021.22.
       Water.................................. 935.10.
       Albumen................................  53.32.
       Extractive matters and salts..............  11.58.
   The following interesting remarks, with reference to the cause
 of the dropsy, are made by MM. Becquerel and Rodier:
   " The dropry has been attributed to  the mechanical obstacle
 afforded by the enlarged condition of the  spleen, so  common in
 these cases.  We do not deny the possibility of such  a sequence;
 but it is certain that in many instances, we fail to discover such
 an amount of splenic enlargement, as would suffice to explain the
 occurrence of an increasing and general anarsarca.  In only one
 of the preceding analysis of  the blood, in marsh cachexia, did
 we notice a marked degree of splenic enlargement; it was, how-
 ever, insufficient to account for the serous infiltration."         *
   " It is in this disease, therefore, that we meet with the greatest
 decrease of both the albumen and globules.  It may be taken as
 the type of cachectic dropsy."
   " How,  now, are we to account for so  great a change in the
 composition of the blood 1  We are driven to admit a poisoned
 condition  of this fluid, produced either b\ the absorption of the
 marsh miasm,  or  by repeated attacks of  the  peculiar fever to
 which  this miasm gives rise."
  The indications in  the treatment of dropsy arising from the
action of the malarial  poison, are:
  1st.  The removal of the cause, giving rise to the phenomena 
CO
Clinical Memoranda.
of malarial fever, and causing a  simultaneous  decrease of the
globules and albumen, with congestion of the liver  and spleen.
The patient must be removed from the influence ot the paludal
poison.  In many cases, even after  the removal of the patients
to elevated, healthy non-miasmatic regions,  the attacks of ague
will  recur again and again with obstinacy.
  2d.  The prevention of the recurrence of the malarial paroxysms,
and  the removal, neutralization  or  elimination of the  cause.
This indication may be fulfilled  by the persistent use of cinchona,
in various fcrms, and especially sulphate of  quinia.  To prevent
the recurrence of the paroxysm, quinine should be given in doses
varying from five to ten grains every two or three hours, until
from twenty to thirty grains have been taken before the time of
the expected paroxysm.  In the intermission, and in fact through-
out the continuance of  the dropsy, the patient  should be kept
gently under the  influence of quinine, from two to four  grains
being  administered  three  times a day.   The iodide of quinia
(from one to three grains dissolved in a wineglass of water), has
proved highly  beneficial in my hands in such cases.  As the
blood is impoverished, good results are obtained by  giving iron
in combination  with the sulphate of quinia.
  3d.  The removal of the dropsical effusion.  This will best be
accomplished by  the judicious use of purgatives, diuretics, the
hot air bath, and stimulant frictions of every kind, as dry friction,
and aromatic, alcoholic and ammoniacal frictions.
  Purgatives judicially  used  not  only cause absorption of the
serous effusion, but they also diminish  the congestion of the
liver and spleen.  The blue pill (pilulse hydrargyri), in doses of
from five to ten grains, occasionally may be administered with
marked benefit.  The cream of tartar and juniper berry infusion
is one of the best diuretics in such  cases.
  In the employment  of purgatives  aud diuretics, great care
should be exercised not to exhaust  the patient, or to weaken and
derange the digestive function.
  If  possible, we should avoid impoverishing the  blood further
by the use of these remedies.
  In many cases, the free perspiration, induced by  the hot air
bath, will prove of essential benefit. 
Jones—Medical
61
  4th.   The  improvement of the  blood.   Nitrogenized food,
especially good beef-steak, if the digestive powers are sufficiently
strong, fresh milk, and soft boiled eggs, with a moderate quantity
of generous wine, will tend, not only to improve the digestive
powers, but also to furnish the materials for  healthy, rich blood.
  The digestive powers and the nervous  system may, in like
manner, be invigorated by the use of the vegetable  bitters, and
especially of gentian, and strychnine.  It  is best to administer
the strychnine in doses of one twentieth of a grain dissolved  in
water acidulated with citric acid.  In  many cases  it is found,
that the dropsical effusion diminishes, just as the blood recovers
its normal composition.
  Iron is almost universally indicated, by the marked decrease of
the  blood  globules, and  on  account of its valuable  effects  in
restoring the digestive function.  One of the best combinations
in such cases, is a pill composed of three grains of  precipitated
Iron (iron by  hydrogen), two  grains of sulphate of  quinia, and
one grain of the extract of rhubarb.   The extract of rhubarb is
used in proportions just  sufficient to  overcome the astringent
effect of the iron.  This pill may be  taken three times a day
and persevered in for weeks and months.  In this combination,
we likewise obtain the prophylactic action of sulphate of quinia-
  The cure of this form of dropsy is tedious and prolonged  in
most cases, and the iron and  bitter  tonics should be  used vtilh
perseverance.
  5.  Hygienic Measures. A healthy, well ventilated residence
in an elevated non-malarions region,  gentle but regular exercise
in open air, and the wearing  of warm clothing, as  flannel next
to the skin, are valuable adjuvants to treatment.
  Dropsy may also arise from the changes of the blood, induced
by insufficient and salt food (as in scurvy), by repeated haemor-
rhages (as the haemorrhoidal flux);  by chronic diarrhoea, and  by
the effects of the absorption of cancerous matter.
3.  Dropsy arising from derangement of the  Circulatory Apparatus,
     attended icith venous obstruction and congestisn, increased serous
     effusion from  the dktendcd blood vessels, and diminished  ab-
     sorption.
  Under this head may be classed Cardiac dropsy, resulting from 
62
Clinical Memoranda.
structural alterations of the heart and large blood-vessels ; and
Hepatic dropsy resulting from certain diseased states of the livery
and  sometimes accompanied by enlargement and induration of
the spleen.
Cardiac Dropsy, resulting from structural  alterations of the heart
    and large blood-vessels.
  In the  first  stages of heart disease, the constitution is as a
general rule unaffected, and apart from certain local phenomena
aud  physical  signs, aud slight dyspnoea and palpitation, the
general health appears good.
  Owing  to the continuous disturbance however slight, at first,
of the  circulation and respiration, the  dyspnoea aud palpitation
increase, the nutrition of the body is impaired, the general health
progressively deteriorates and a slight amount of oedema appears
in the lower extremities.
  As the  disease progresses there is not  only a progressive ag-
gravation  ot the affection of the heart,  but also, as a direct effect
of the disturbances of  the respiration  and circulation, a  great
increase of dyspnoea and dropsy.
  Iu the  last  stage  of cardiac disease  in which the  patient  is
doomed to speedy death, the countenance assumes a yellowish
white,  cachectic  appearance, and the dropsy  in many  cases
becomes generals
  Although cardiac dropsies appear in  most cases to be preceded
immediately by venous congestion, we  should not  refer the
dropsical effusion to this cause alone, for it appears to be referable,
to a  certain extent at least, to  the progressive alteration of the
blood and derangement  of nutrition caused by the disturbance  in
respiration and circulation.  The blood is not properly oxygenated,
the carbonic acid is not properly eliminated, and the organs and
tissues are not only supplied by an imperfectly elaborated blood,
and that too in an irregular manner, but the office of important
organs as  the kindneys and liver is in turn deranged.
  This symptom of cardiac disease is usually, therefore, of late
occurrence, making its  appearance almost invariably about the
ankles and feet, as slight'eedema, and by slow degrees ascending
towards the trunk, and ultimately involving the upper extremities 
Jones— Medical.
63
and face.  The anasarca  commencing in the feet and gradually
proceeding upwards, precedes the ascites, and even when the belly
becomes swollen, the swelling of the legs is large, out of all pro-
portion to the ascites.
  According to Dr. Walshe, dropsy, sequential to heart disease,
occurs in the following situations,  enumerated  in the order of
frequency with which  they  severally suffer; the subcutaneous
cellular tissue; the pulmonary parenchyma; the  peritoneal and
pleural sacs; the pericardium; the cerebral and spinal arachnoid
and sub-arachnoid spaces; the tunica vaginalis j  the joints, and
the eyeball, especially the aqueous chambers.  But in the last
three situations, dropsy is excessively rare.
  Dr.  Latham has justly  observed that the first appearance
of the  dropsy,  marks   an eventful period in the progress  of
cardiac disease.  It indicates that a new law takes effect in the cir-
culation, and gains the mastery of the law of health,  which has
hitherto been able to retain the watery  elements of the blood-
vessels, now the serum escapes and accumulates in the areolar
tissue of the body.
  The forms of valvular disease, as laid down by pathologists in
the order of the frequency in which dropsy is met with, are :  (1),
Considerable  contraction of the left auriculo-ventricular orifice ;
(2), Dilatation of the auriculo- ventricular orifice, with hypertrophy
and  dilatation of the  right ventricle; (3), A state of the mitral
valve and orifice permitting free regurgitation ; (4), Considerable
contraction of the aortic  orifice.   As  a general rule, cardiac
dropsy supervenes earlier, the earlier  that  venous congestion
ensues.  The  establishment of a varicose condition of the blood-
vessels in the  air-vesicles of the lungs, essentially aggravates the
dyspnoea.  When the dropsy is carried to great amount, erythema,
erysipelas, rnd even sloughing are prone to occur; the skin cracks,
the serous fluid oozes  more or less copiously.
  Dr. Walter  Hayle Walshe, in his valuable " Practical Treatise
on the Diseases of the Heart and  Great Vessels,v gives the  following
important observations upon the nature and causes of dropsy and
serous flax of cardiac origin:
      9 
64
Clinical  Memoranda.
  (a).  Systemic Form.
  Dilatation was formerly regarded as the condition of the heart mainly inducing the import-
ant class of dropsical  symptoms.  This  opinion, discountenanced by M. Brouillaud, who
sought to establish valvular obstruction as their sole efficient cause, was restored to favor
by Hope and M. Andral—the former of whom indeed went the length of teaching  that  pure
hypertrophy, also, was capable of generating dropsy.  Of late, Dr. Blakiston has brought
together a body of evidence calculated to show that the systemic vessels  do not become
loaded in cases of dilatation, unless there be co-existent tricuspid regurgitation,  still  more
rec. ntly Dr. H. Douglas has defended tho original thesis of our forefathers.  It becomes ne-
cessary for me here to express an opinion on this " vexed question''  of the mechanism of
cardiac dropsy ; let me commence by throwing into a series of  propositions  such inferences
as flow directly from facts that have fallen under my own notice.
  t.  Mitral regurgitation or obstruction, or aortic regurgitation or obstruction, may sever-
ally exist, and, for a  lengthened period, without  systemic  dropsy  supervening.   2. Mitral
regurgitation and aortic regurgitation may c -exist for years, and yet no dropsy occur.
3.  Both of  these propositions hold good,  whether  notable hypertrophy do,  or do not,  exist
behind the obstruction.  4.  Simple  hypertrophy of the left ventricle may reach the highest
point without systemic congestive  effects of kind arising.  Dr. Hope, as  is well known,
maintained vhe'reverse, holding that pure hypertrophy, if prot  acted, will produce general
dropsy ; but he gives no cases demonstrating the facts, and the motives of his belief are, as
far as he shows totally speculative.   And <i priori views are not so completely in his favor as
he appears to imagine j when  he talks of the 'increased force of circulation surmounting
the natural tonic power of  the capillaries," he forgets that that very tonic power miy have
increased pari pasm with,  and  in  conse'quence  of, the growth of the hypertrophy.  The
question is one of observation ; and I have stated what I have actually seen  in persons who
had not been reduced by treatment  to a state of ansemia.  5. Dilated  hypertrophy, even of
the left ventricle may last for years without any such effect, provided the dilation be not in
notable excess.  6. The heart may be in a state of advanced tatty metamorphosis, the pulse
feeble and infrequent, the encephalic and respiratory functions  exhibit the siugular perver-
sions attending a high degree of the disease, the entire organism betray functional languor
and inactivity, and yet ever, the praetibial integuments fail to,pit in the least under  pres-
sure.  7. Or the heart may be soft and flaccid and the pulse persistent, frequent, feeble, and
irregular in force and rhythm, and yet no systemic congestions occur.  8. The natural  rela-
tionship of width of the arterial orifices, and also of the auriculo-ventricular  orifices, may be
materially perverted, without the least systemic dropsy arising, until the closing days of
life.  This is seen, for instance, in cyanotic cases where the  aorta and pulmonary artery are
transposed in 'origin,'the relationship of the great veins to the  two sides being normal.
Similar evidence is often afforded by cases of aneurism of the arch of the aorta with an ori-
fice more or less widely dilated, so as to exceed that of the pulmonary to variable amounts.
9-  Tricuspid regurgitation where the right ventiicle is in a state of dilated  hypertrophy, as
shown during life, by swollen and pulsatile jugular veins, which fill from below, and as shown
after death by actual examination, does, not necessarily produce dropsy. Besides if tricuspid
regurgitation  sufficed unassisted,  on mechanical principles to produce systemic dropsy,
why snould not constriction of the pulmonary orifice, so frequent in cyanosis,  habitually
engender it.
  These propositions are, I believe,  incontrovertible; they are the mere general expression
of facts which  are perpetually occurring.  I cannot, then, see how the conclusion is  to be
avoided, that something beyond and in  addition  to any one, or  any group, of the cardiac
conditions referred to, is required in order, as matter of "necessity, to entail  the occurrence
of dropsy.   I can scarcely suppose the unwarranted assumption that, were life sufficiently
prolonged, these conditions would of themselves suffice for the  purpose, would  be seiiously
urged in rejoinder.  And again, the existence of some acting cause beyond, and independent
of, the heart, is farther shown by the facts: that there is no direct relationship between the
amount, of heart disease'and of dropsy ; that dropsy comes on suddenly sometimes from ex-
traneous causes, the state of the heart remaining,  as tar as ascertainable,  in precisely its
previous condition ; and that dropsy diminishes and increases,  comes and goes, either  spon-
taneously or through the influence of treatment, while the organic changes in the heart  re-
main permanent and unmodified.
  We must not, however, run  into the opposite and equally erroneous extreme of wholly ig-
noring the direct influence  of organic changes of the heart and its orifices.  Two cardiac
affections are, as matter of experience, frequently associated with systemic dropsy—namely.
dilatation and tricuspid regurgitation.  And it is certainly so rare for either of these states
to exist for any length of time without the supervention of such dropsy, that any hypothesis,
explanatory ot cardiac dropsy, must look  to these states  as forming important  links in the
chain of causes-
  A share in the direct mechanism  of systemic  dropsy  being thus conceded to  structural
change in the heart, the question next arises what is the nature of the influence, indepen-
dent of that organ, which completes the causation.  Local conditions in the heart, we admit,
establish a difficulty  in the systemic ciiculation ; what  influence  actually  and directly
leads to the dropsical exosmosis ?
  This influence seems a compound of conditions, favorable to  transudation of the serosity
of the blood, in that fluid itself, ia the walls of the capillaries and venous radieles,  and ia
the receiving tissues.                                          ' 
Jones—Medical
65
  First, at concerns the blood, the influence of an impoverished state of that fluid is too well
known to be for a moment contestible.  Experiments on animals prove that if the veins be
more or less loaded with water, they  yield this in the form of dropsical  effusion   The
oedema, and sometimes extensive anasarca, of spansemia; the slight oedema  attending the
hypnosis of protracted convalescence from various acute  diseases;  the various dropsies of
uremia—are all illustrations in point. Obviously  morbid states of the blood, when of the
proper kind of themselves alone suffice for  the' production of dropsy ;  look at the sudden
anasarca of acute Blight's disease, or of an  acute  recrudescence in the chronic affection,
while the heart, liver and lungs, may be texturally sound.  Secondly, it is readily conceiv-
able that, the variable densiiy of texture of the walls of the vessels may promote or restrain
the piocess of filtration.  Thirdly, cases occasionally present themselves,  in  which diopsy
supervening from diseased heart, fails to affect  portions of the body, noted, under ordinary
circumstances, as the earliest and readiest sufferers—for instance the lower extremities.  I
have observed this where the legs  had been the seat of erysipelas and subcutaneous inflam-
mation prior to the occurrence of the cardiac dropsy:  the chronic anatomical changes in
the cellular tissue in such a  case possibly acts as a barrier to its reception of oerosity from
the vessels.
  It may, no doubt, be argued d priori that dilatation of the heart, occurring as a primitive
disease through simple weakness, or following actual structural alteration of the texture of
the organ, will occasionally prove the efficient cause of dropsy, even admitting the necessity
of blood  change just contended for.   It may be urged  that when the heart is so affected,
the necessary vis a tergo in the circulation is wanting, and capillary stagnation must ensue—
and that this very stagnation, becoming habitual, may modify the qualities of the  blood,
and impair the nutrition of the walls of  the vessels through the  strain they suffer. But
plausible though  this argument  be, I believe, as matter of experience,  that the necessary
change in the composition of the blood is meanwhile really worked out by other and more
effective agencies.
  Long since, Lower i-howed that local  dropsy  might be produced by ligature of veins; and
the occurrence of  serous effusion from  local obstruction of vessels "f that class is clinically
well known.   But here are instances of sudden and limited oostruction ;  they are evidently
not logically comparable witlf cases of  slow and centric obstruction. And even where the
difficulty in the way of the  returning blood is purely local, it does not  necessarily  follow
that transudation shall occur from the communicating venous radicles,  although  the evi-
dences of changed condition of these vessels be structurally obvious. Thus in case of aortic
aneurism, pressing one or both innominate veins, the capillaries of the base of the neck may
dilate  in such manner as to produce notable general swelling at the spot, yet not a particle
of cedenia be discernible."
  (b)  Visceral and Intra-Serous Form.
  Pulmonary oedema is chiefly connected with disense, constrictive or regurgitant,  of the
 orifice, sometimes with dilatation of the left ventiicle, very rarely with hypertrophy of the
ri"ht.  Ascites arises especially from general dilatation of the heart and tricuspid regurgi-
tation ; and these are the conditions mainly observed, as antecedents to all the other varieties
of dropsy enumerated."
  B.—Cardiac Flux.
  (a)  The intestines become the seat of serous flux in some rare instances of certain forms
of heart disease.   Watery diarrhoea thus, ii duced may be wholly spontaneous, or the original
excitant of the discharge may have been  some  hydrogogue purgative, the influence of which
holdBon.     *     *      *
  (b)  I believe that in some of those case, where vomiting forms so obstinate a symptom of
chronic heart-disease, the immediate cause of  the nausea  is the pi esence of an irritating
watery secretion from the gastric surface.  It  is  never very copious.
  (c)  Watery flux from the kidneys, though on the whole not very rare, is uncertain in its
occurrence, doubtful in its mechanism, and cannot be said to belong to any particular cardiac
aff ction.  '  For  my  own  part  I have  seen   passing  attacks of hydruria  more fre-
quently  in connection with different forms of dynamic disturbance than with any specific
organic disease.      *      *     Here the rationale is the same as in the case of hysterical
diuresis ; and so long as the immediate mechanism of the latter continues in its present ob-
scurity,  we must remain in ignorance of that of the former.
  Albuminuria occurs every now and then in cases  of cardiac disease, especially of dilata-
 tion and tricuspid insufficiency, the tendency  of which is to congest the viscera-  The cor-
tical and tubular substances remain taxturally sound.  The character of this form of albu-
 minous  flux  are as  follows.-  it is a  passing phenomenon,  sometimes  disappearing spon-
taneously sometimes yielding to treatment; the albumen is always small in amount; the
 specific'"a'avity of the'fluid never falls very low,  its color remains unaffected and  its smell
 wholly tree from that whev-like odor to which I  long since drew attention as notably signifi-
cant of Bright's disease.  A few casts  of the latter occasionally appear."


    The researches of pathological  chemists have shown that in the

 early  stage of organic heart disease, marked  merely by the local 
66
Clinical  Memoranda.
phenomena, a few physical signs, and a slight  amount  of  dysp-
noea and palpitation, the proportion  of water increases, and the
specific gravity of the blood consequently diminishes; the  glob-
ules decrease somewhat, their mean being represented  by  125;
the fibrin remains unchanged; and lastly, the albumen contained
in 1000 parts of serum undergoes a trifling diminution, propor-
tionate to that of the globules, its mean being represented by the
figures 71.05.
 "As  the  disease progresses', the physical signs become  more
clearly defined, the local symptoms more marked, and the general
health begins to fail, and the  constitution  to evince  signs  of
deterioration, and the  face .becomes ansemic  and the lower ex-
tremities slightly cedematous, the specific gravity of the  blood
and serum becomes lower, the proportion of water increases,
the globules undergo still further diminution,  their mean  being
represented by 117; the fibrin augments in  many  cases; and
lastly, the albumen decreases like  the globules, its mean pro-
portion in  1000  parts  of serum being 66.21.   The dropsy  is in-
dicated at its onset  by a decrease of the albumen of the blood.
  When the disease has reached an advanced stage, with severe
palpitation and  dyspnoea,  considerable  serous infiltration, in-
vades the pleural and peritoneal cavities  as  well  as  the sub-
cutaneous cellular tissue.  Under these  circumstances  the blood
for the most part,  undergoes great modifications, of which the
following  is a general outline.
  The amount of water is greatly increased, whilst the specific
gravity and solid matters of both the blood  and  serum are pro-
portionally diminished.  The blood globules and the albumen, and
especially the latter element, undergo very considerable decrease.
The decrease of  the albumen of the serum is consecutive to the
dropsy, only taking place when the latter becomes well marked.
The decrease of the  albumen has been referred to the impoverish-
ment  which the blood undergoes by reason of  the loss  of  serum
constituting the dropsy.  Becquerel and Rodier, very justly con-
cluded from their analysis of the blood  in cardiac dropsy, that,
when once the blood has become impoverished by the occurrence 
Jones—Medical.
67
of mechanical dropsy, it is  probable that infiltration  proceeds
with  increased rapidity  and that  the serum,  even more  watery
than heretofore,  escapes with  greater facility  under the  influence
of two  causes acting in  the same direction, viz., the impediment
to the circulation, and the diminution of  the solid  matters of the
serum.

   The following  cases of cardiac  dropsy, have been selected from
those observed  in  our  wards in  the Charity Hospital,  by  the
students of the  Medical  Department  of the  University of Lou-
isiana. :
    CASE XVII.—Cardiac  Dropsy of Heart: Hypertrophy; First

 stages of Cirrhosis of Liver.


    In  this  case  the students  were  enabled to watch the gradual

 progress of the disease to a fatal issue, and to observe the gradual

 aggravation of the heart  symptoms and the origin and increase

 of the general anasarca.

   James Duncan, age 30 years; height five feet, nine inches; weight 135 pounds •  dark hair
 blue eyes,  dark complexion ; native of Ireland ; six years a seaman and fifteen years a boat-
 man on the Mississippi river. Twelve years ago had several attacks of chills and fever • again
 six years ago, ana finally during the fall of 1868.
   Eighteen months ago, the patient says that he was  working in the hot sun,  and drank
 large quantities of cold ice water, when he was attacked suddenly with an affection of the
 heart, which lasted several days ; six months afterwards was attacked in a similar manner
 and spit up blood.
   Habits intemperate at times ; previous to the late civil war, drank regularly but not to in-
 toxication ; entered the Southern service and drank but little during the war.  Since the
 war used alcoholic stimulants freely to relieve the pain in the region of the heart.  At first
 the stimulants gave comfort and he consumed  large quantities,  even to intoxication-
 Shortly, however, before entering the hospital, the stimulants appeared to  aggravate the
 disease and the patient gave up steady drink.  Suffered severely the week before entering
 the hospital.
   Admitted into the Charity Uosbital, w?rd 18, bed 267; March 9th, 1869.  At this time the
 patient was suffering with great pain in the  region of the heart, soreness and pain in the
 epigastric  region, and along the abdomen in  the  legion of the liver, extending  on either
 side to  the hypochondriac regions. Bowels irregular  and constipated.  Appetite pretty
 good, patient indisposed to exertion, but not confined to bed.
  Treatment, consists in the administration, three times a day, of ten drops  of Tincture of
 Digitalis and the same quantity of the Tincture of the Sesqui Chloride of Iron.
  April 5th, 1869.—Patent takes gentle exercise during the day, walking around the ward
 and hail; but suffers debility from muscular exertion; came under my treatmeut at this
 time, and the foUowing results of physical exploration weie then recorded :
  Auscultation and percussion revealed enlargement  and dilatation of the heart; the dull
 space over the region of the heart being at least twice as large as in health.  The beat of the
 heart is lower down and more to the right than normal; and the impulse as communicated to
 the hand placed upon the wall of the thorax, is different from that of health, giving the im-
 pression of the impulse of a large soft quivering bag, against the thoracic walls.  The space
 of the walls of the thorax against which tl'.e apex of the heart is propelled appears to be at
 least three times the ordinary size of health.   The first sound of the heart is entirely altered
 being converted into a loud blowing sound, much more distinct upon the left side, and over
 the region of the  left auriculo-ventricular  valve,  near  the junction of the cartilage
 of the fourth left rib with the sternum.  This  loud cardiac  murmur was heard at tEe
 apex of  the heart, and along its  body,  becoming most distinct over the  region of the
 auriculo-ventricular valves, in the middle  of the sternum, in a line with the articulation of
the cartilages of the fourth ribs with the sternum, and gradually diminishing towards the 
68
Clinical  Memoranda.
base, and becoming quite indistinct over the position  of the semilunar valves  of the aorta
and pulmonary arteries, near the junction of the third ribs with the sternum.  At the apex
of the heart the second sound was heard with difficulty. At the base of the heart or rather
about the region of the arch of the aorta and the arch of the pulmonary artery, above the
line  joining the cartilages of the third ribs with the sternum, the first sound was heard with
difficulty, or rather .'t became indistinct.  The second sound of the heart was loud, sharp and
nietalic,  with a slijrht roughness prolonged in the direction of the arch of the aorta.  Some
dullness upon percussion over  region of lungs.  No physical siffns of either tuberculosis or
pneumonia, or of pleurisy weie detected.   The congestion of the lungs was referred to
mitral regurgitation.   The veins of the  neck (external jugulars) gave a distinct  venous
pulse.
  The liver was enlarged, and tender to the touch.  Slight effusion into the abdominal cavity
and oedema of face and extremities, especially marked in the feet and ankles.  Complexion
sallow, wax-like, with slightly jaundiced hue.  The yellow jaundiced hue was especially dis-
tinct in the eyes.  TJrine scanty,  high colored, high'specific gravity, and loaded with biliary
acids.  The urine contained no albumen or urinary casts.
  Bowels irregular, most generally constipated.  Appetite poor; tongue coated with whitish
colored fur.  Pulse feeble, 80 per minute; respiration 22; temperature  under axilla in the
morning 99° F.  Sp. gr. of urine 1023.
  The diagnosis established by this examination was
  Enlargement and Dilatation of Heart.
  Regurgitation of Blood from  Auriculo-Ventricular openings.
  Roughness in the Aorta, beyond  the Semilunar Valves.
  Congestion  of the  Lungs  and  Venous Pulse, in consequence of  Regurgitation  of Blood
through both Left and Right Auriculo-Ventricular openings.
  Absence of Active Inflammation or Tubercles from Lungs.
  Cirrhosis of the Liver in the  early stage in which the organ is increased in size.
  The patient was treated with small  doses of Calomel and Sulphate of Quinia, with occa-
sional  saline purgatives,  with no  perceptible  benefit.  The heart trouble  increased, the
spitting ot blood liecame quite common, and  the oedema of the extremities and  dropsical
effusion steadily increased.  Tincture  of Wild Jessamine (Gelseminum Sempervirens) was
also  effectually tried, as well as Tincture of Digitalis, but without any perceptible  beneficial
effect, and in  fact the latter remedy appeared to do harm rather than good, by its depressing
effects upon the action  of the heart, and its debilitating effects upon the nervous system.
  IS'itro-Muriatic Acid  administered internally, and also in the form of foot-bath,  appeared
to afford more relief.
  The failure of strength appeared to be quite gradual, and the patient finally became much
swollen, the effusion in the abdominal cavity  increased, the venous congestion became more
marked,  with distinct pulsations of the jugular veins and blue lips; the difficulty  of respi-
ration became so great and the action of the heart so irregular, that the patient could not
rest at night and was compelled to sit up in bed.  The forces failed progressively  and he
died  on the 15th of June.  The following is  a tabular  statement of the more important
symptoms: 
w H O o «« fl	p p q P o W	P CO P P P	O M H <! P CO p p	-4 «h O o a CS m e H	STATE OF INTELLECT, TONGUE, BOWELS, APPETITE AND COMPLEXION.	CHARACTER OF URINE.	REMARKS UPON GENERAL SYMPTOMS.
April 6 .. 7 .. 8 9 .. 10 .. 11 .. 12 .. 13 .. 14 June 8 .. 9 .. 10 .. 11	9 A.M. 9 A.M. 9 A.M. 9 A.M. 9 A.M. 9 A. M. 9 A.M. 9 A. M. 9 A.M. 9 A.M. 9 A.M. 9 A.M. 9 A.M.	92 93 98 88 86 86 87 87 88 110 112 110	22 22 26 22 22 22 22 22 21 26 26 20	99° 99° 100° 99° 98°. 5 99° 99° 99° 99° 100°.5 99° 100°.5 100°.5	Intellect clear; bowels constipa-ted ; no appetite; dark and jaundiced complexion. Condition same. White coating on tongue; action on bowels. General symptoms same; feels better. Appetite better. Tongue coated. Improving. Rowels constipated. Rowels opened. 6ame condition. Jaundice ; constipation of bowels. Tongue coated. Bowels constipated. Jaundice. White of eyes yellow. Two small stools. Tongue coated ; patient feeble and depressed; pulse weak and thready.	Scanty, high color. Sp.gr. 1025. Same character. Sp. g. 1023. Scant, high color. Sp. gr. 1025. Sp. gr. 1025. Amount of urine f. oz. xv. Sp. gt. 1025. F. oi. xxvii. Sp. gr. 1015-F. oz. xxx. Sp. gr. 1015. F. oz. xxx. Sp, gr. 1015. F. oz. xxvi. Sp. gr. 1015. F. oz. xvi. Sp. gr, 1030. Only f. oz. iv collected ; high col-ored and loaded with bilo. Urine high colored, scanty and loaded with bilo. No albumen or casts. Urine scant, high colored and loaded with bile.	Patient complained of great soreness and tender-ness in abdomen, especially in region of liver. Still complains of soreness ; vomiting, no appetite, some fever iu the evening. Patient says that he feels better, with less abdom-inal pain than yesterday. A little more comfortable. Feels a great deal better with almost total ab-sence of pain in abdomen aud epigastric re-gions. Continues the same. Purgatives administered. Bowels opened by Comp. Cathartic Pills. Not so well as yesterday. Breathing oppressed. Has been spitting blood for several days. At times great oppression in breathing. Nausea and spitting of blood ; soreness over re-gion of liver. Ascites. Anasirca of extremi-ties greatly increased. Cannot lie down ia bed. Great oppression of breathing. Spits blood. Great congestion of veins of neck. Purple lips and fingers. Great oppression in respiration. Exhausted and feeble. Loud, dis-tinct bellows sound taking the place of the first sound of the heart. Roughness in second sound. Great exhaustion and dyspnoea.
 
70
Clinical Memoranda.
  The forces progressively failed, although  the patient was able to converse when propped
up in bed, almost, up to the last moment of life, and died suddenly at five A. M., June  15th.
  The Post Mortem Examination was performed six hours  after death.
  -Exterior.—Surface of a yellow jaundiced hue and with dark mottling of blood in the de-
pendant portions. Abdomen and lower extremities considerably swollen from serous effu-
sion.
  When  the thorax was opened, the lungs did  not collapse to any marked extent.  The
lungs were greatly congested with blood.  The marks of the haemorrhages were visible in
various portions of the lungs.  The effusions of blood had transformed the pulmonary tissue
into a dark, liver-like, hard substance.
  The lungs contained no tubercles, were not softened, and gave no evidence of pulmonic or
pleuritic inflammation.
  Heart.—The pericardium was adherent to the sternum  upon the anterior aspect.
  The heart as it lay in its natural  position, presented an enormous size, and was distended
in all its cavities with black fluid blood.
  The heart contained at least one pint of black fluid blood, and it appeared as if the patient
had died from the want of power in the walls of the heart to contract upon the blood distend-
ing its cavities.
  The left auricle and ventricle were enormously dilated; the right  auricle and ventricle
were also dilated, but not to so great an extent.   There was an appearance of partial fatty
degeneration in  some portions of the heart, and the  muscular structures generally of the
heart were softer than normal.
  The auriculo-ventricular, and aortic and pulmonary valves, were not thickened nor altered
in structure, with the exception of some insufficiency of the mitral valve.  The auriculo-
ventricular openings, however, were so much alterea, in being greatly increased in  size,
that the  valves were insufficient.
  The length of the heart after being placed in alcohol, and after considerable contraction,
was six and a half inches, the breadth five inches, and the circumference eleven and a half
inches.
  The walls of the aorta and pulmonary artery, beyond the semi-lunar valves, were rough-
ened by calcareous and osseous deposits.  These  deposits accounted for the rough sound
succeeding or rather flowing from the first sound.
  Liver, cirrhosed enlarged, with some fatty degeneration. Surface of  liver presented a yel-
lowish bronzed mottled color.
  Microscopical examination, revealed increase of fibrous tissue, and oil globules, together
with numerous fragments of hasmatin.  The masses of haematin  scattered through the tex-
tures of  the liver, gave the  dark mottled bronzed appearance, and were most probably de
posited during the previous attacks of malarial fever.
  Kidneys, congested, but normal in structure.


    In the preceding case,  the dilatation  of the heart appeared to

have been due  in  a manner to  the same  causes  which   induced

softening and fatty degeneration  of  the muscular fibres of this

organ and of the cells of the liver.


    In the following case the symptoms  of heart disease, although

severe, have been relieved partially or mitigated by treatment.

  Case XVIIL—Daniel Dunn, aged 46 years ; height five feet six inches; weight 176 lbs, in
healih; large well developed chest and limbs, large head and intelligent countenance ; dark
hair, dark blue eyes and dark complexion ;  native of Ireland ; occupation fireman on steam-
ship'. Has no hereditary tendencies, and has always led an active life; served in the South-
ern army during the  recent war, and was wounded five times ; left  leg fractured by Minie
ball; flesh  wound  of posterior portion of upper third of thigh, flesh wound of right hip,
another wound on the instep, and still another on the anterior part of  the thigh, two inches
below Poupart's ligament.  Had repeated attacks of intermittent fever, dnring 1857, '58, and
'59 and was affected with sun-stroke on the 4th of July, 1863.
  During the summer of 1868, suffered with  pain in the region of his  heart, attended with
anasarca, pain in the head, loss of muscular power, and difficulty of breathing.  Admitted
into Charity Hospital, October 19th, 1868.  At the time of his admission was suffering with
anasarca, cephalalgia, muscular debility, and irregular and imperfect action of the heart.
  The treatment consisted of tonics, nutrition, diet, and  the  free use  of diuretics.  Under
this treatment his general condition improved.
  At the time this patient came under my treatment in March, 1869, his complexion was
sallow, anasmic, and of a yellow, wax-like hue.  Temperature  normal;  pulse 76; respiration
20. Lower extremities oedematous. Some cedema about  face and upper extremities. Urin-
ary secretion abundant.  Patient complains of pain in his head, and of weakness upon any
unusuai exertion.  Action of heart abnormal, a murmur being heard with the  first sound,
having its maximum  intensity at the position of cardiac impulse.  The anasarca has been 
Jones—Medical
71
greatly reduced by the persistent use of diuretics and especially by the cream of tartar and
juniper berry intusion and mixture.  Tincture ot bark, and preparations of iion, and espe-
cially the tincture of the sesquichlonde, appear to have been most beieficial in maintaining
the strength of the patient.  The tallowing observations give a correct view of some ot the
leading symptoms in this case.  April 7th, 9, a. m., lespiration. 20; temperature  of axilla
98° ; tongue clean, bowels regular, complexion sallow, anaemic, urine abundant  oedema of
extremities and efface ; spirits good, assists in nursing the patients.  April 8th, 9 a. m., pulse
86; lespiiation 22;  temperature  of axilla 98°5,  sp. gi. of mine 1020. April 9th, pulse 92,
respiration 21, temperature of axilla 99°5;  urine abunndant, one  hundred and forty ounces
(140 ozs.) being passed timing the las tweLtj-four hours; sp  gi  1010. a he mine ^as
carefully tested upon this occasion, as it h d > een upon others, for giape sugar and  albu-
men, but no traces of tuese substances were detected.  April 10th, 9 a. m., lulf-e 9* ; lespi-
rational; temperature of axilla 99°: urine excreted duing t wenty-four hours 100 f. ozs , sp-
g . 101U ;  no grape sug^i noi aibnmen.  April  11th, 9 a.  M.; pulse t-8: respiration  22- tem.
perature of axilla 98°5 ; amount of urine U0 f. ozs,; sp. gr. 1010.  April 12th;  9 a. m.; pulse
88;  respiration 22; temperature  of axilla  98°5;  amount of urine K0 f. ozs.; sp. gr. 1010.
April 13th, 9 a. m.; pulse 88;  respiration 20; temperature of axilla  98°5;  amount, of urine
110 f ozs : sp. gr. lolO.   April  14th; respiration  20; temperature of axilla 98°5; amount
of urine ltO f. ozs.; sp. gr. 1010.


   At the time  of the entrance  of this patient  into the  hospital,

the anasarca was very great and troublesome,  but it yielded and

was held in abeyance by the action of diuretics.

   Neither albumen nor  grape sugar  were detected in the  urine.

   The  dropsy in  this case appeared to be the  result of the cardiac

disease,  and the ansemic state  of  the blood.
   Case  XIX.—Dilatation  of  Heart;  General Anasarca;  Death.


  Hannah Clark, colored woman ; age 40.  Entered ward 34, bed 517, Charity Hospital, Sep-
tember 19th, 1669.  Patient  lies on  her  back utterly prostrated, with apparent  com-
plete muscular and nervous exhaustion.  Universal  anasarca; abdomen,  and extremities,
and  head swollen from dropsical effusion.  Action of heart very feeble; impulse of heart
can scarcely be felt.   Gieat dullness upon percussion over region of heart; and  the area of
dullness at  least four times as great as that usual  in the healthy thorax.  Dullness upon
percussion  over both lungs; dullness most marked over the lower dependent portions of
lungs.  The dullness is so great over  the lower portions of the thorax as  to indicate pleu-
ritic effusion.  Upon auscultation, ihe sounds of the  heart are indistinct and feeble   Diag-
nosis :  dilatation of both sides of the heart,  and generaal dropsy as the result of cardiac dis-
ease.
  The patient is evidently in extremis. Oppression of  hreathing so great that the t atient
is unable to articulate w 'th a ny force,  and it i difficult to understand her broken sentences.
  Patieat died September 21-t, two days after her admission into the ward.
  Autopsy twelve hours after Death.
  Exterio<\  -Trunk  abdomen and extremities greatly  swollen.  Areola tissue everywhere
infiltrated with serous flui <.  On opening the ca ity of the thorax, a large amount of serous
fluid filied the pleura, and occupied a 1-ugo portion of  the space usually filleu by the lungs.
'J he right lung was compressed into a  mas-, not, larger man a man's hand,  and preseneu a
hepaiized appearance, and apparently had lost trie power of  dilatation,  ihe lct'G lung was
also compressed into a comparatively small space, but was readily dilatable when removed
from the pieural cavity.  '1 he heart was enormousiy enlarged, mt asuring seven and three-
tenths indues in lengtn, aud fifteen and a half iucne's in Circumference, as it  lay in the thorax
with the au icles and vent icb-s i  mensely distended  with bl*ck blood. The blood was par-
tially i ovulated, and the c oagula were eadily divisible into two portii ns  the one or inary
blood aod formed p st-mortem, aud the other lidht jellow fibrihou ,and formed ante-mortem.
The fibrinous cl. ts were  to a great extent, stripped  of co ored corpuscles, and adhered
closely to the valves and chordae tendmae.   The wails of the heart were thin and not hyper-
trophied
  The edges of the mitral valve were thickened and from the deposits of calcareous or osseous
matter; or  rather fro.n toe deposit of fibrin in some preceding attack of rheumatic endocar-
ditis, which had been gradually transformed  into an inorganic hard mass
  Spleen, liver and kidneys healthy in  appearance. Intestinal canal also normal in appear-
ance.   Some small loose tibriuous clots floated in the serous fluid of the pleura and perito-
neum; and a small pateh of fibrinous exudation was observed ou the surface of the descend"
ijig colon, in the lumbar region.

       10 
72
Clinical Memoranda.
   The  origin of the cardiac  disease and the supervening dropsy
appears to have been the deposit  of fibrinous matter  upon the
auriculo  ventricular  valves in some former  attack  of rheuma-
tism, thus causing auriculo-ventricular regurgitation.
   Case XX.—Dilatation of Cavities of Heart;  Universal Dropsy ;

Death.


  John Wilson ; negro man ;  aged 57; stout, well-built man; native of Virginia. Admitted
 to Charity Hospital, waid No. 32. September 2d, 1868.
  Patient says that he has always enjoyed good health up to December, 1868, when he was
 seized suddenly with palpitation of heart, and great difficulty of breathing.  Has been ad-
 mitted several- times into the Charity Hospital, since this date, suffering With palpitation of
 the heart and dyspnoea.  As  soon as some slight improvement took place, under rest and
 diuretics and tonics, the patient would ask to be discharged.
  At the present time, September 2d, the patient suffers with great dyspnoea,  pain in the
 region of the heart, dry hacking cough, general anasarca, which however is less in the right
 arm and hand.
  The apex beat of the heart is just below the nipple; space of percussion dullness over
 region of the heart greatly enlarged. First sound of heart prolonged and attended with a
 distinct regurgitant murmur.  Second sound normal.  Diagnosis—1'ilatation of both  sides
 of the heart, with auriculo-ventricular regurgitation. General dropsy, and dyspnoea  conse-
 quent upon heart  disease.  No albumen or bile was found in  the urine.  Diuretics and
 tonics were administered, with only temporary benefit, however,  as the anasarca increased
 as well as the oppression of breathing ; the lower extremities became immensely distended;
the patient was unable to lie down and finally died twelve days after his admission, on the
 14th of September.
  The post mortem examination revealed a similar condition to that described in the preced-
ing case JS'o. XIX.   Universal anasarca,—liver  and kidneys and intestinal canal healthy.
Heart gieatly dilated and distended with black blood.  The dimensions  of the  organ  were
fully equal to those given in the preceding case. '  The mitral valve was thickened with
osseous deposit-
  The auricles and ventricles were greatly  dilated, and the auricular ventricular opening so
much enlarged as to lender the valves insufficient, and to allow regurgitation of the blood,
during the contraction of the ventricles.

   The following case illustrates the fact  that  we may  have   de-

cided  evidence  of insufficiency  of  the  aortic  valves,   without

dropsical effusion.


   Case XXI.—Articular Rheumatism, with derangement of Second

Sound of Heart.

  Wm, Rogers) seaman; aged 21  years; stout, we'l formed man; admitted into Charity
Hospital, wa.d No. 11, bed  154,  January  20th,  1870,  suffering with chionic rheumatism,
affecting chiefly the upper extremities.  Patient states that seven  years previeus to the
p>esent attack, he was confined to his bed six or eight weeks by rheumatism, which affected
chiefly the upper extremilies.  The attack  was brought on by exposure. Two years after-
wards he had a second attack which was confined to the parts and joints of the lower ex-
tremities ; and at this time he  suffered severe pain in the left side, which  his attending
physician pronounced to be due to pleuritis, with  palpitation  of the heart.  The present at-
tack came on in November, 1869, with pain in the  wrists, joints and  hands, and finally
affected the shoulder joints.   On percussion  the heart appears to be hypei trophied ;  and
upon auscultation the second sound is entirely  altered, being converted into  a prolonged,
blowing sound, heard loudest at the base of  the  heart over the aortic and pulmonary valves,
and is transmitted up as high as the point of  bifurcation of the common carotid artery!
The sound is loud and distinct.  The patient was placed on a mixture of Wine of Colchicum,
and !-olution  of Iodide of Potassium,  so compounded that  eight diops of the Wine of
Colchicum and five grains of the Iodide of Potassium should be administered three times a
day.   Iodine was also used locally and the parts covered with cotton and oil silk.  Under
this treatment the patient steadily improved, and was discharged from the ward on the 26th
of February, 1870.


   It is worthy of note in this  connection, that the most extensive 
Jones—Medical
73
aneurism  may exist, without the production of any dropsical
effusion.   If the aneurism presses upon one or more of the large
veins, it may, by its mere mechanical pressure, cause such a con-
gestion  as to  lead to oedema of those parts from  whence  the
obstructed vein should remove the blood.
  It is also worthy of note that in the cases of aneurism, which I
have examined in the Charity Hospital, there was most generally
more or less fatty degeneration of the arterial  coats, in various
portions of the circulatory system.
  Case  XXII.  Aneurism of Internal Iliac.
  Thus in the case of the large aneurism  of the internal iliac,
which filled the entire pelvic fossa on  the left side, measuring
eleven inches in the  longest diameter,  and six-and-a-half inches
in the short diameter; the heart is partially degenerated into fat
and the entire aorta is dilated, with thickened,  degenerated,
roughened walls.
  Case XXIII.—Aneurism of Descending Aorta, Absence of (Edema-
Great Emaciation—Death.
  The body of this man,  aged sixty,  after death,  presented no
marks of dropiscal  effusion, and was  greatly  emaciated.   The
descending aorta was dilated into a large aneurism having an
hour-glass contraction in the middle.  The long diameter of the
aneurismal tumor was six and one-half inches and the transverse
diameter four inches.   The vertebral column  had  been eroded
and absorbed upon  its anterior  surface, by the pressure of the
tumor, and adhesions  had  formed  between  the  walls of the
aneurism  and the diaphragm.  No dropsical effusion  was  dis-
covered in the areolar tissue and serous cavities after death,  and
none had  been observed during his residence during the past
three months.

  Case XXIV.—Aneurism of Ascending Aorta ; sudden rupture
of Aneurysmal Sack within the Pericardium ; Hemorrhage—Death.
Absence of dropsical effusion.
  A young woman entered the Charity Hospital, complaining of
pain in the region of the heart; the general health appeared to 
74                   Clinical Memoranda.
be good—complexion clear and  limbs round  and firm.  This
patient  died  suddenly a short time after  entering the hospital.
When the cavity of the thorax was opened, the pericardium was
found to be filled with blood; the amount of which was about
one pint.  No blood was effused exterior to the pericardium, and
there were no marks of dropsical effusion in any of the serous
cavitie?, nor of cedema in any of the extremities.   Death in this
case appeared to have resulted from the sudden compression of
the heart, by the blood effused into the pericardium, rather than
from the amount of blood lost.  As is well known that portion of
the aorta which arises from the left ventricle, behiud the sternum,
opposite the third intercostal space, and passes from left to right,
the ascending portion of the arch, coming to  the  right of the
sternum, between the cartilages of the second and  third ribs, is
within  the pericardial sac.  The  ascending aorta together with
that portion of the arch from which the carotid, innominate and
subclavian arteries are given off, was enlarged or dilated to more
than twice the normal diameter, aud a diverticulum or pouch
from the aneurysmal dilatation was sent off, downwards  from the
arch of  the aorta, and rested against the  auricle.   The rupture
took place at tha  most dependent portion of this division or
diverticulum from the dilated aorta, just where it rested upon the
auricle.
  In the case of aneurism of the  femoral  artery operated on by
Dr. Warren Stone Jr., and which terminated fatally from haemor-
rhage and pyaemia,  I found the artery for some distance above
the seat of the aneurism in a state of fatty degeneration.   We can
see in such a case, the cause of failure in the operation of ligation
of the artery for aneurism.  The ligatures cut through the softened
and  degenerated arterial coats, and haemorrhage occurred ; com-
pression had been previously  tried without success.   It is
probable that in such cases, the results of compression would be
rendered unsatisfactory from the degeneration of the coats of the
artery.
  In the three following cases, no dropsy and no tendency to it
was at any time observed. 
Jones— Medical.
75
    Case  XXV.—Aneurism  of Arch  of Aorta, involving  also  the

 ascending Aorta ; absence of Dropsical Swelling ; Death.

   Michael McCann ; male ;  age 35 years ; height 5 feet 6 inches ; weight  120 pounds ; dark
 brown hair, grey eyes; dark florid complexion ; sharp features ;  native of Ireland ; has been
 twenty years in New Orleans ; occupation, day laborer ; had syphilis ten years ago, which
 the patient says affected him for several  months; had yellow fever fifteen years ago; and
 chills and fever in the summer months of 1868.
   Admitted into the Charity Hospital November 14, 1868, suffering with pain in right arm,
 extending up along the side of the neck and head, and attended with difficulty of deglutition.
 Patient says that he suffered with pain in the right elbow joint, in August,  1868, which
 lasted three months, and then shifted to the light shoulder joint, and from thence passed
 to the head, with which he still suffers.  Before coming to the hospital, was  treated with
 local applications and liniments, without any perceptible benefit  For four or five weeks
 after entering the hospital, the patient could not lie down by day nor by night, on account of
 the great oppression of breathing, and a most troublesome cong'h, and sensation  of  choking
 in the recumbent posture.  He lost flesh, his weight being reduced from 155 in health to 12J
 pounds  The treatment has consisted chiefly of Anodyne, subcutaneous injections oi Morphia
 and Atropia, at night;  Iodide of Potassium as an alterative, and Tincture of Sesqui-chloride
 of Iron as a tonic.  The pains are relieved by the subcutaneons injection of Morphia and
 Atropia, and the patient is unable to sleep without them.
   April 3d, 1869: condition of the patient much the same as when he entered  the hospital.
 Constant cough, and constriction  about the throat   The patient coughs and clears  his
 throat in'a peculiar manner, as if a tumor  was pressing upon the bronchial tubes   General
 appearance favorable; patient is not emaciated  or  swollen.  !-kin dry and warm, tonaue
 reddish upon surface.   Suffers with pain in head and neck and upper part of right side  of
 thorax   Pulse strong, but differs in character and intensity in the two arms; 70 per minute ;
 apex beat of heart, visible one inch below its natural position   Pulsation very marked and
 forcible over the upper portion of the sternum, producing a loud impulse against the walls
 of the chest, over the intercostals of the first and second  ribs, immediately to the right of
 the sternum, whee the sounds are loudest.  There is also flatness on percussion  over the
 intra-clavicular region, on right side of chest, where the sounds of the heait are heard with
 the greatest intensity.  Temperature of axilla variable, ranging from 98°5 to 1(0°5 F.  The
 respiration varies from 18 to 22. and is natural with the exception of some prolongation of
 expiration and inspiration  and a peculiar sound  as if the bronchial tube was pressed by a
 tumor.  The constant cough, and peculiar clearing of the throat, in like manner indicates
 the presence of a tumor pressing upon tho wind pipe.  There is also difficulty and pain in
 deglutition.
   These symptoms led to the conclusion, that this patient was suffering with an aneurism of
 the aorta, involving the ascending portion, the arch, and probably also the upper portion of the
 descending aorta.
   April 6ih —The heart is beating tumnltuously; the apex sound being much more distinct
 than  the sound made at the intercostals of the first and second ribs. Tne pulse in the right
 arm is weaker than in  the left.  When the patient raises the right arm and attemps to grasp
 the bed-post as high up as the arm can reach, standing with his back to the bed, and throw-
 ing the hand a little backwards, as well as upwards, ne experiences numbness, also a ten-
 dency to faint.
   May 6th.—There appears to have been a gradual change in the position of the supposed
 aneuiismal tumor in the chest; careful and piolonged examination revealing a more tumul-
 tuous ana powerful impulse against the supra-clavicular region of the left side.  The sub-
 clavian artery of the left side appears to have suffered dilatation, as it is of great size, and
 the column of blood is thrown with great power and a marked thrill through its  dilated
 walls, with every impulse of the  left ventricle.  On  the other hand it is remarkable, that
 the carotid artei'y on this the lett side, can  scarcely be felt, being  exceedingly small in out-
 line and feeble in beat  In fact it is almost impossible to teel the beat of the carotid, with-
 out the most persistent and careful examination.  As the carotid and subclavian are given
 off separately from the arch of the aorta, on the left side, we are forced to one of three con-
 elu*-ions : either the carotid  on the left 6ide has been partially occluded, by fibrinous matter
 deposited along the walls of the aneurism, or the tumor presses upon it in' some manner, so
 as to diminish its column of blood; or the aneurism does not extend much beyond the junc-
 tion of the left subclavian.  The tbird supposition is excluded by the previous history of the
 case   It would appear-that  this tumor was slowly shifting its position to the left of the ver-
 tebral column.  It is well known, that the soft parts become incorporated with  the aneuris-
 mal tumor, and even the vertebras are absorbed by the constant pre sure, as was seen in the
 case of the aneurism of the descending aorta, previously described.  The. diagnosis of aneur-
 ism of the arch of the aorta, appears by these signs, ana especially by the movable nature of
 the tumor, to be still further confirmed.
  May 3.)th—Under nutritious diet, and moderate purgation, and the persistent use of Iodide
 ofPtassium,  alternating with the Tincture of the Sesqui-chloride of iron,  the condition of
this patient has s 'mewhat improved ; at least he has certainly " held his own."
  Patient does not suffer any pain of consequence—heart is not so forcible in its action—the
left radial pulse is still stronger than the right, whilst the beat of the right carotid ia much 
76                          Clinical Memoranda.
 more powerful than that of the left, which can scarcely be felt.  Dullness upon percnssion,
 with bronchophony extending from the leit border of the sternum, to the middle of right
 clavicle ther.ce downwards, to midway between clavicle an ■ nipple thence inwards to left
 border of sternum, thenca upwards, to starting point, making  an area, of marked dullness
 and bronchophony of about four inches in diameter.
  June  9th—Patient is suffering more than usual pain,  in  head; and neck and supra-
 clavicular spaces have a full swollen aopearance.  The patient also suffers pain in the middle
 and upper portions of the  thorax, in the region of the aneurismal tumor; he complains of a
 smothering sensation in the throat.
  June 21st.—Condition of the patient good, complexion that of health ; appetite good.  Im-
 pulse of heart quick and powerful, two and a half inches below left nipple.  The apex of the
 hearr. acts as it it  was thrust directly forwards against the walls of the thorax, making a
 defined beat.  The beat of the heart gives the impression ol a tumor above, which  forces the
 heart downwards, orrather fioin which the organ recoils.
  Left supra-clavicular region prominent  a powerful  pulsation synchronous with the con-
 tracti n of ventricles of heart,  being evident to the eye. and also to the touch, above the
 middle of the clavicle.  Left carotid artery can scarcely be felt in its beat.  The first sound
 of the heart is heard  at the apex, mingling with tie powerful blow against the walls of the
 tho'rax ; the second sound is not distinct, and there appears to be a third sound, which may
 be  rlue to the pulsation  of the aneurism, together with some clicking,  thrilling rushing
 sounds of low intensity. Marked dnlluess in bith supra- lavicular regions along the borders
 of the sternum, and over t e  sternum, for two inches below the nipple.   Distinct metallic
 click or thrill over upper portion of sternum.
  The air is drawn in and expelled from the bronchial tubes, with difficulty, as if the wind-
 pipe was compressed. Difficulty of deglutition continues, solid  food appears to be arrested
 about midway in the oesophagus, or rather at the upper t ird of the sternum.
  This patient continued  under my  treatment until the first of November, 1869, when a
 change occu'red in ihe wards, and lie  passed  into  the hands of Professor Bemiss.  Up to
 this time, the patient had maintained apparently  a stationary position ; the most marked
 symptom for the worse was the stridulous breathing and sense of suffocation.
  The patient continued much in the  snme condition, with a gradual aggravation of the dis.
 turbance of respirafon. and finally died on the 10th of April, 187J.  We are informed by
 Professor Bemiss that up to the time of death there was no dropsical effusion.
  A post-mortem examination was held by Dr. Bemiss, and  he kindly presented the  heart
 and aneurismal tumor to my pathological collection.
  The heart was enlarged, and dilated, and fatty degenerated and flabby.  All the cavities
 were dilated,  but  the  dilatation was  greatest in the  left ventricle.   The  arch of the
 aorta was  dilated  into a  large aneurismal  tumor, thirteen inches in circumference, and
 contained a large laminated fibrinous  mass, eleven and a half inohes in ciicumference   Por-
 tions of this fibrinous clot were ev dontly of recent  formation, aud contained coagulated
 blood  The ascending aorta was gieatly dilated, the dilatation commencing at the junction
 of the aorta with the heart, and gradually increased upwards to the aneurismal tumor.  The
 diameter of the ascending aorta, just before it passes out of the pericardium, was  three
 inches  The pericardium was thickened.  The semilunar valves of the  aorta,  as well as
 those of the pulmonary artery, and the tricuspid and semilunar valves, appeared to be nor.
 mal in structure.
  The result of the post mortem confirmed  the diagnosis,  twelve  months   before  death, viz i
Aneurism  of arch of aorta.
  The wind pipe was compressed into  a flattened ribbon-like tube, and the mucous membrane
presented a thickened and highly congested  appearance.   The  aneurismal  tumor  pressed
upon the lower portion of the wind pipe and upon the bifurcation of the bronchial tubes.
   Case XXVI.—Aneurism of Arch of Aorta;  great oppression of

respiration ; absence of Dropsical  Swelling ; Death.


  William Willoughby ;  aged 36; height 5 feet 3 inches ; weight 147 in health ;  auburn hair,
gray eyes ; fair complexion ;  native of Canada ; seaman by occupation.   At eleven  yeirs of
age. suffered with chills and fever, which continued  seven years :  had yellow fever in 1858 ;
had two falls on ship-board, when intoxicated ; these falls were from considerable height^
but no ill effects were noticed.   About five months before entering the hospital, was in  the
habit of using his shoulders in pressing up heavy weights and after strainin ■-. felt pains in
the i egion of the heart;  about  a month afterwards began to suffer with pains across  the
thorax, in right arm, and on side of neck and face.
  Admitted to Charity Hospital February 3d. 1869, suffering with pains in the thorax, right
arm, and in side of neck  and  face, and after remaining in ward 21 for one month, a tumor or
swelling with a livid surface appeared, extending from four to six  inches  across the thorax
in a line with the second rib; this remained for several days, and then slowly subsided  At
the time of his admission the patient weighed only 125 pounds.  He suffered with  great op-
pression and difficulty of breathing, and was unable to sleep at night in the recumbent pos- 
Jones—Medical
77
 ture.  The  treatment consisted of subcutaneous injections of Sulphate ol Morphia and
 Atropia.  Rest at night could be procured  only  by these injections.  The effects of the
 Atropia were almost immediately manifest, in the rapid dilatation of the pupils of both
 eyes.

  April 1st.—The patient came under my treatment and observation at this time.   Says that
 he does not sutler so much pain.  General appearance that of health,  with clear florid com-
 plexion ; no oedema or dropsical effusion in any part of the body ; his countenance, however,
 wears an anxious, and at times distressed and oppressed look;  weight 125 pounds , appetite
 fair; bowels regular ; skin soft and natural; tongue clean; pulse 88; suffers with cough and
 oppression in breathing.  Apex of heart displaced, two inches below, and to the  left of the
 nipple ; action of heart strong ; pulsations very marked  over  the sternum,  and  visible  at
 apex.  Great difficulty in the deglutition of solid food, from the pressure of the aneurismal
 tumor upon the oesophagus ; with a sensation as if the passage of the food was interrupted
 about the centre of the sternum.  Respiration 19 per minute,  and embarrassed with cough
 when lying upon back.  The cough and clearing of the throat is peculiar in its  chaiacter,
 giving the impression ot great constriction of the wind pipe and  the bronchial  tubes, and
 the sounds  are heard as is they proceedeu directly laom the upper third of the sternum.
 Pulse  feebler in the light than in the left arm.
  Diagnosis.—Aneurism of Arch of Aorta.
  April 2oth.—Condition same, with increased cough.
  May 12th.—Complains of pain in side of neck and head, and over the sternum, difficulty in
 respiration very marked and amounting to decided dyspucea, especially when attempting to
 assume the erect position.  The least particle of phlegm in the  irachea,  gives much trouble
 and distress until  removed.  Cleais  his throat in a peculiar manner as it the bronchial
 tubes  were compiessed.  Gre.it difficulty in the deglutition of food'
  Impulse not so marked over sternum, as if the tumor was embedding itself in the poster-
 ior wails of the thorax, and against the vertebral column.
  'May *5th.—Pain not so great, but general appearance less favorable.  Hypodermic i jec-
 tion of .Morphine and Atropia administered last evening, and the patient is this uiorniug in
 a nervous state ; pulse 96, temperature of axilla lol°75 ; pulse in right arm very ind stinct.
  May 31st.—-Bronchial rales, over both lungs ; rales and vocal resonance more marked over
 right lung;  these physical signs appeared to be clearly referable to the pressure of the aneu-
 rismal tumor upon the trachea and bronchial tubes.
  The  sternum appears to be more prominent upon the right side; apex of heart still further
 displaced to left oi nipple; sounds at this point apparently normal, though with less force
 than befoie; and the sound heard over the base ; viz., the second.
  The  bronchial rales are unattended  with  much expectoration,  and it appears, as if the
 mucus is with great dimculty expectorated, through the compiessed bronch al tubes.
  Juue 10th.—i^ymptonis greatly aggravated j great difficulty of deglutition: great oppression
 in bieatiung, wiih prolonged weezing inspiiation and expiiation, as it the air passed through
 the compressed bioi.chial tubes auu trachea with git at  dimculty.  Tne patient although
 oppressed, distressed and weak, still moves about the waid and hospital.
   When the ear is placed against the walls of the chest, the sounds of th ' voice and oi respi-
 ration appear to issue directly out over the space of at least Ave inches in dia ..et  r, as it the
 sonorous vibrations  w«.it transmitted dnectiy through a tumor.  Percussion revealed dull-
 ness over the sternum, and o\er  the greater portion ot the clav.cular and iufra-olav,cular
 spaces. The form of the tumor and lto pos tiou n,ay be made out with great clearness,  by
 combining  peicussion a d auscultation.  The  diagnosis is especially aided by causing the
 patitnt to 6peak when the ear is appi ed todinereui portions oi ine moiax  In. position  of
 the tuiuoi ii.ay be uiiiue out oy  ambulation and peicussion  on the back as well as upon the
 front of ihe chest.
  When the patient coughs, the sounds are transmitted, almost like peals of distant thunder,
 to the ear, applied over the walls ol the chest, just above the tumor.   The louud bronchial
 rales, heard  most distinctly, over all the  upper  portion  ol the lungs, appeared  to be due
 soleiy to the prtssure exerted by tne tumor.
  The patient is evidently near his end, and at this examination the opinion was  expressed
 that his lite would terminate suddenly from suffocation in the .ourse ot a few days.
  During the night of the 13th of June,  the patient was  eized with great dimculty of respi-
 ration, became black in the la e, strugg ed violently for breath, and died suddenly from the
 eile^ts of ihe compiession of the bronchial tubes or arrtst of respiiatiou.
  This patient haa friends, who  carried off his body, before a post-mortem examination could
be made.  This was greatly to be regretted.


   It  was clearly  shown  in  the  preceding  cases also,  that  the

most  extensive  aneurisms  are  not  necessarily  attended  with

dropsy. 
78
Clinical Memoranda.
  Case  XXVII.—Aneurism of Ascending Aorta  and Arch of
Aorta; Dilatation of left Ventricle:  Sudden Death; Absence of Drop-
sical Effusion or (Edema.
  Mooney, age 56, native of Ireland, tall,  well-formed man, en-
tered the  Charity Hospital, ward  16, bed  150, January 16th,
1870.  Has been in this hospital several times  before.
  At the  time  of my examination, January  18th, the patient
presented well developed limbs.   Suffered with great oppression
in breathing, loss of  rest, and almost complete prostration after
making any effort.  I attempted to examine this patient, but  he
suddenly became greatly oppressed, his lips and hands  turned
blue, and the patient appeared to be dying.
  The results of this imperfect examination, was, dullness upon
percussion, over and around the space normally occupied by the
heart, for an  area, the diameter of which  was at least seven
inches transversely, and eight inches laterally;  the apex  beat
of the heart was at least two inches below its normal position;
great oppression in breathing,  inspiration and  expiration pro-
longed,  with a wheezing sound, as if the air was passing through
a greatly  constricted  trachea.  It was  necessary to prop  the
patient  up  in the sitting posture before an open window.  The
symptoms of enlargement of the heart and aneurism of the aorta
were well marked.  This patient dhd suddenly next morning.
  The post-mortem was performed eight hours  after death.
  The exterior was full and without marks of oedema.
  When the cavity of the chest was opened, the heart was found
to be enlarged, with all the cavities distended to  their utmost
capacity, with dark fluid blood.   The ascending aorta was greatly
dilated, the dilatation commencing at the heart, and increasing
rapidly  upwards, and just after  emerging from the pericardium,
the arch of the aorta expanded into a large aneurismal sack, six
inches in diameter.  The arteries given off from the arch of the
aorta were  greatly dilated, and the innominate  artery, was, at its
junction vith the aneurismal tumor, as  large as a healthy aorta.
The pericardium was adherent  to the  heart, this  adhesion  ap-
peared to have been of long standing, and was probably coincident
with the changes in the semilunar valves.  The heart  measured 
Jones—Medical
79
in its longest diameter,  seven inches, and in its  short diameter
six inches.  The semilunar valves of the aorta were  thickened,
adherent at certain points and insufficient.  The  aortic regurgi-
tatiou accounts for the great dilatation of the left ventricle.   As
far as we could learn, this patient  had suffered  with deranged
action of the heart and  oppression of breathing for more than
six months, and he referred the  first distressing symptoms, to
the lifting of a great weight.
  We shall consider in the next place, briefly the treatment of
cardiac dropsy.
  Treatment of Cardiac Dropsy.
  When dropsy  depends  upon  serious organic  lesions of  the
heart and large blood-vessels, treatment should  be  regarded as
chiefly palliative;  the physician may relieve certain symptoms of
the most  grave and distressing character, and  relieve intense
suffering and thus prolong life, for a considerable length of time;
but the cure of the disease, is  in many cases out of  the question,
as it is impossible either by drugs, diet or mechanical means, to
restore the  enlarged, dilated,  degenerated heart  and insufficient
valves, to the normal state.
   Cardiac dropsy  supervenes in most cases, after the forces have
been depressed, and  the blood rendered  watery,  venesection
therefore  as well as drastic purgatives should be  used with great
caution.  Local blood-letting  (cut cups over  the region of the
heart and kidneys) may accomplish good results by  relieving
congestion and promoting tree diuresis.
   It is well known that diminished fullness of the  vascular system
promotes the absorption of serous effusions ; when therefore ob-
struction  to the circulation of the blood through the  heart, co-
exists with pulmonary congestion and anasarca,  and at the same
time, the general vigor is as yet unimpaired, the  abstraction of a
moderate  quantity of blood, affords relief to  the  over-loaded
blood-vessels, aud congested  lungs, and facilitates the action of
hydragogue remedies.
   Bitartrate of Potassa, the Compound Jalap  Powder, Gamboge
and Elaterium, are peculiarly valuable,  from their  certainty of
action as hydragogue purgatives.
        11 
80
Clinical Memoranda.
  From one ounce to one  ounce and a half of the bitartrate of
potassa, in eight  ounces of water,  taken in two  doses at an
interval of two or three hours,  forms one of the most effective
and safe purgatives.
  The Extract of Elaterium may be adminished in doses of from
one-sixth  to  one-half of a  grain.  Caution, however, must be
employed  in  the use of the Extract of Elaterium,  on account of
its intense activity, and occasionally depressing effects.  A bolus
of the following  composition has been  recommended and em-
ployed with success by  various physicians:   fjL. Pulveris Jalapa,
Pulveris Ehei.,  Pulveris Seammouii, aa, gr. v;  Elaterii,  gr. ss;
Bitartratis Potassse; Sulphatis Potassae, aa,  3ss; Syrupi Zinge-
beris; quantum sufficet utfiat bolus.  It is an  observation of  long
standing,  that in the  exhibition of remedies,  more decided  and
beneficial  effects may be obtained by combining several  analogous
remedies  in small quantities, than by giving a single one  in a
large dose.
  In  cardiac, as in other forms of dropsy, the urine  is  almost
always scanty, and the progress of the effusion frequently bears
a direct relation to its diminution; the attention therefore should
be strongly directed to  the secretory  function of the kidneys, as
affording  the most probable channel for the relief of the disease.
  Although sometimes uncertain in their action, diuretics, upon
the whole prove  most  effective in the control, moderation  and
even complete removal of dropsical  effusions.
  As far as my experience extends, the Bitartrate  of Potassa, or
Cream of  Tartar,  is the  best diuretic, and I have relieved many
cases  of dropsy by this remedy alone.  When used  as  a  diuretic
from half  an ounce to one ounce and a half, should be suspended
in a pint of water, and the  mixture should be tRken in winegluss-
ful doses,  every two or three hours, so that  the whole  may be
administered during the twenty-four hours.  The bottle containing
the mixture should be  always  most  carefully agitated,  as the
cream of tartar is almost insoluble, and falls to the bottom of the
vessel upon standing.  When the digestion is impaired, or should
dyspeptic  symptoms be  induced by the cream  ot tartar, we should
employ as a vehicle for the salt, an infusion of juniper berries, or 
Jones—Medical
81
wild carrot seed, and some aromatic, cardamom, fennel or ginger
may be added.
  It would be foreign to our purpose to enter into any recapitula-
tion of the remarks made at the bedside with reference to the
various diuretics, aud  we shall simply name  those  of the most
undoubted efficiency ; as :
  Acetate, Nitrate and Citrate of Potassa; Acetate of Ammonia ;
Iodide and  Bromide  of Potassium; Nitric Ether;  Squills; Di-
gitalis; Veratrum ; Colchicum ; Tobacco ; Decotion of Scoparium
and of Chimaphila.
  Squill as an active diuretic has enjoyed a high reputation with
the profession, and it appears to be peculiarly useful in dropsy of
the  chest, with  scauty,  high-colored  and uncoagulable urine,
which deposits a sediment on  standing.  It should be  used at
short intervals aud in  such  doses as to produce nausea, and the
patient should be subsequently kept just within  the nauseating
point.  In cases which demand the mercurial influence, the squill
may be advantageousely  combined with calomel.  Small do^es
of Blue Pill, occasionally at bedtime, will frequently promote the
action of diuretics.
  Diaphoretics are much less efficient then diuretics and cathar-
tics ; beneficial results, however, may be obtained by  the free
diuresis excited by the vapor or hot air bath.
  When drugs fail to control the dropsy, mechanical means be-
come necessary for  controlling its influence;  such as  tapping,
puncture  with  a sharp lancet  and acupuncture.  Owing to the
danger of the supervention of  erysipelas, incisions should be
made with great caution,  and whenever practicable,  puncturing
with the needle should  be preferred, the point of  the needle
should merely penetrate the true skin, the punctures should vary
in  number from twenty to  fifty or sixty, according to  the  part
or the extent of the effusion, and they  should be at least half an
inch asunder.
   When the blood is  anaemic, Iron and the bitter tonics, and
nutritious diet should be  employed.
   Experience has established the fact, that no advantage arises
from the  denial of water to  dropsical patients. 
82
Clinical Memoranda.
  In some cases attended with great debility, spirituous liquors,
in  moderate amount, are indicated;  hard cider and gin,  are
amongst the best forms of alcoholic stimulants.
  Of course, the results  of treatment  will depend, in a  great
measure, upon the extent and character of the organic lesions.
  Hepatic Dropsy, arising from some  obstruction to the circulation
of the blood through Hhe Liver.
  The distinguishing character of dropsy,  from diseases of  the
liver or portal vein, as laid down by  systematic writers, are:
  1st.   In  uncomplicated  portal  obstruction,  the dropsy com-
mences in the abdomen, and the legs are only affected secondarily
and in consequence of the pressure of the ascitic  fluid on the in*
ferior vena cava.  When the affection of the liver is complicated
with heart disease, the ascites may be preceded by dropsy of  the
legs.
  In cardiac disease, on the other hand, anasarca commencing
in  the  feet and gradually proceeding upwards, precedes  the
ascites; and even when the belly becomes swollen, the swelling
of the legs is out of all proportion to  the ascites.
  2d.  No signs of dropsy in the face, arms or upper part of  the
trunk, are observed in dropsy  arising from  obstruction of  the
portal  system;  whilst in that form of the disease which is
dependent upon structural alterations  of the kidneys, oedema of
the face aud arms is a very common symptom even in the early
stages.
  3d.  Dyspnoea, never precedes the hepatic dropsy, although it
may  accompany  the serous effusion  when  great; from  the
pressure of the  fluid interfering with  the action of the diaphragm
and abdominal musoles : in cardiac dropsy on the other hand,
the dyspnoea precedes the ascites, and is  distressing out of all
proportion to its extent.  In cardiac  dropsy, from the congestion
of the lungs aud imperfect aeration and circulation of the blood,
there is more or  less lividity  of the lips,  face and extremities,
whilst this symptom is not characteristic of uncomplicated portal
obstruction.
  4th.   If there be no concurrent disease of the kidneys, albumen
is absent from the  urine, except in  those cases,  in  which  the 
Jones— Medical.
83
ascites itself, when extensive, may, in consequence of the pressure
of the fluid on the renal vein, lead to the appearance of albumen
in the urine.  The albumen,  however, disappears upon the with-
drawal  of the  pressure,  as in  the operation  of paracentesis.
The absence of puffiness  of the face,  or pitting of the upper
extremities, and of granular, fibrinous and oil casts from the urine,
will still further distinguish hepatic dropsy, from that dependent
upon alteration and degeneration of the kidneys.
   5th.  The ascites occasioned  by portal obstruction, is still
further distinguished, by enlargement of the spleen, enlargement
and tortuosity of the superficial veins of  the  abdomen,  haemor-
rhoids,   gastro-euteritis and  haemorrhages from the  stomach
and bowels.  Enlargement of  the superficial  veins  of the
abdomen,  however, is  not  in  all cases  a certain  indication,
as the same appearance is sometimes observed in cardiac dropsy
and in  ren'al  dropsy,  as the result of  the pressure  of a  large
quantity of ascitic fluid upon tho inferior vena cava; but in such
cases, there will be usually also a varicose state  of the  veins  of.
the legs.
  It is important that we  should consider briefly  those morbid
conditions of the liver, which give rise to  dropsical effusions,  in
connection with  those diseased states of this organ, which seldom
or never gives rise to this symptom.
  In waxy, lardaceous or amyloid degeneration, the liver under-
goes greater enlargement than from any other*disease, excepting,
perhaps, cancer;  the  enlargement being  often so great as  to fill
up  a large portion of the abdominal cavity.  The enlargement
being uuiform in every direction, the form of the organ is not
essentially altered, the outer surface is smooth, and the  lower
margin  more rounded than  natural, regular and  free  from  all
indentations.  In rare cases,  this  change may  co-exist  with
cirrhosis, or with syphilitic gummy tumors, and then the organ
may present a nodulated surface, and this complication  may be
attended with ascites.
  In like manner when  accompanied with waxy  degeneration  of
the kidneys, dropsy may result from the derangement of the
excretory function of these organs. 
84
Clinical Memoranda.
  In those cases of waxy deposit of the liver,  which have come
und'r the observation of the students of the Medical Department
of the University of Louisiana, the statements of pathologists has
been verified,  that there is but little tendency to obstruction of
the portal circulation; and consequently ascites, and enlargement
of the subcutaneous veins of the abdominal walls, are not common
phenomena it its clincal history.  The absence of ascites in waxy
liver, has  been accounted for by  the fact, that the branches
of  the hepatice artery, and not  of  the portal vein, are im-
plicated in the disease.   In  some rare cases of waxy liver,
ascites  results from the pressure of enlarged waxy lymphatic
glands in the  fissure of the liver, upon the  trunk of  the portal
vein.
  In fatty liver, the enlargement is  due to the accumulation of
oil, as has been well shown in the post-mortem examinations, and
in the specimens  of fatty  liver mounted in alcohol.* In fatty
liver, as in the waxy disease, the enlargement is uniform in every
direction, and without tumors or nodules upon the surface,  and
the natural form of the liver is but little altered; there is no
ascites or enlargement of the superficial veins of the abdomen,
the secretion of bile is not arrested or impeded, and jaundice is
not a symptom, and as in waxy liver, throughout  the progress of
the disease, pain is absent. This degeneration of the liver is often ac-
companied by similar changes in other organs, and more especially
the heart and kidneys.  Fatty degeneration of the heart is  evi-
deuced by the feeble cardiac impulse, faint cardiac sounds, slow
or quick, feeble and irregular radial pulse, attacks of vertigo,
syncope or pseudo-apoplexy, and dyspnoea on slight exertion.
When fatty degeneration of the liver, is attended by fatty de-
generation of the  kidnqy, there will be a tendency  to general
anasarca; the urine is diminished in quantity, oftimes turbid,
and contains albumen and casts of the  tubuli uriniferi,  contain-
ing oil globules.
  In simple hypertrophy of the liver, attended  by an increased
size of the lobules, aud by an increased size or number of the
secreting cells, without any alteration of structure, the enlarge-
ment is uniform, aud rarely great, and  is not  attended by  any
prominent symptoms nor by dropsical effusion. 
Jones—Medical.
85
   Whilst the enlargement may be very great in hydatid tumor
of the liver,  ascites, oedema of the lower  extremities, enlarge-
ment of superficial veins of the abdomen, jnd haemorrhoids are
not distinguishing characters; and as the hydatid  tumor rarely
interferes with the functions of the kidneys, those of the urine so
common in waxy  and fatty enlargements,  are absent; in rare
cases however, the kidneys also may be the  seat of hydatids, and
dropsy may arise from this cause, or from the pressure of the hy-
datid tumors upon the portal trunk;  or from the bursting of
the cyst, or through the supervention off>eritonitis.
  Ascites rarely results from mere congestion of the liver, unless
this depend  on mechanical  obstruction of the circulation in the
heart aud lungs.
  In  the venous engorgement of the  liver resulting from me-
chanical obstruction of the cardiac circulation from valvular
disease of the heart, the primary enlargement of the liver  gives
place after a  time to an opposite condition of contraction, atrophy
of the central portion of the lobules, being induced by the pressure
of the constantly  distended veins.   The congestion of the liver
dependent upon cardiac disease, induces a form of granular  liver
very  different from true cirrhosis, where the atrophy commences
at the circumference of the lobules.
  The diseases of the liver which most commonly give rise to
portal obstruction, with ascites, are,  according to those patho-
logists who  have had the most extensive  opportunities of ob-
servation : 1. Cirrhosis and other forms of chronic atrophy of
the liver; 2,  cancer of the liver; 3, peri-hepatitis; 4, thrombosis,
or obstruction of the trunk of the portal vein.
  We  shall  confine our  observations to   the  first  and  most
common cause of portal obstruction and ascites; viz., cirrhosis of
the liver.
  Cirrhosis of the liver is most common in those countries, where
the drinking  of alcoholic stimulauts prevails, and the disease can
almost always be traced to the abuse of strong spirits; and hence
the name gin drinker's liver.
  Most observers have noted in the early stages of true cirrhosis,
a temporary  congestion and enlargement of the liver, apparently
caused by the irritant effects of the alcoholic stimulants* 
86                   Clinical Memoranda.
  The lobules  of  the  liver have been described  by Malpighi,
Kiernan, Miiller, Leidy and others, as isolated from each  other,
and each invested with a layer of areolar  or  fibrous tissue.  In
the pig, in which  these lobules  were first noticed, and in the
Polar bear according to Miiller, and in the Octodon Cummingii,
according to Hyrtl, the lobules are invested by fibrous tissue, but
in the liver  of the human subject, and in that of the  vertibrate
animals generally, the  lobules are not separated from each other
by a fibrous partition, and there is no areolar  or fibrous tissue or
prolongation of Glisson'i capsule  between them  or in their in-
terior.  Vogel,  Henle,  Bowman,  and Beale have failed to  detect
any fibrous tissue in  the interlobular fissures of the normal
human liver.
  In cirrhosis  of  the  liver,  on  the other hand, there  is a re-
markable development  of fibrous tissue in the parenchyma  of the
liver; and the individual, secreting segments become prominent
or even form isolated lobules.  The  increase of fibrous tissue in
the cirrhosed liver, may  be manifest to the eye,-and  especially
when slices of the organ are subjected to the action of a stream of
water, and gently washed between  the fingers.  The character
of the fibrous tissue may be determined by microscopical examina-
tion.  Cirrhosis of the  liver is of slow development aud progress.
The whole structure of the liver is not  pervaded with fibrous
tissue  in  a few days.  It is reasonable  to  conclude with Dr.
Budd, that the  remarkable changes  in cirrhosis, are mainly the
consequence of  adhesive inflammation in the areolar tissue about
the  small twigs  of the portal veij, and in the areolar tissue  of the
portal  canals, by which serous fluid and  coagulable lymph are
poured out.
  In this stage the liver may be  enlarged.  The serous part of
the  effusion is next absorbed, the lymph contracts, becomes con-
verted into dense fibrous  tissue, which divides the lobular sub-
stance of  the liver into  well defined masses, and gives  great
density and  toughness  to the  organ.   Finally, this fibrous  tissue
compresses the  small twigs of the portal vein and the small gall
ducts, and thus impeding  the escape of the bile and the flow of
blood induces great atrophy of the original hepatic tissue, and 
Jones—Medical
87
causes, by a deprivation of the blood and the admixture of this
dirty white fibrous tissue, marked changes  in the color of the
liver.
  In cirrhosis, the normal, dull, reddish brown color of the liver
is altered to a bright canary yellow, sometimes to a brownish or
greenish, and occasionally to a reddish color.  A section of the
liver, upon a general view, presents the grayish and yellow color
of impure beeswax.
  Owing to the contraction of the organ in the latter stages, the
outer surface presents a  granular or nodulated character, which
has given rise to the  designation, " hob nail liver.n  The yellow
color of the organ is also due to the large amount of yellow pig-
ment contained in the secreting cells, and hence the term cir-
rhosis.   The capsule is also sometimes ^thickened and adherent
to the surrounding parts.
  In the firm tenaceous granular liver, resulting from  the con-
gestion caused by obstructed cardiac circulation, and which has
frequently been mistaken for cirrhosis, the depressions  however
correspond to the centre of the lobules, whereas in true  cirrhosis
they are at the circumference.
  Ascites, resulting from portal obstruction, is met with oftener
in cirrhosis than in any other disease of the  liver.  The fluid in
the peritoneum, is a clear yellow  serum,  rich  in albumen, and
without any blood or inflammatory products.  In consequence of
the congestion and distention of the veins  that return the blood
from the intestines and  peritoneum, the  serous portion of the
blood transudes through  the walls  of  the  vessels into  the peri-
toneal cavity, and when once ascites appears, it persists  and
gradually increases; and when the amount of the effused fluid is
large, it may compress the inferior vena cava and iliac veins,and thus
produce secondary oedema of the legs, but  it is a peculiarity of
dropsy from  uncomplicated portal  obstruction,  that the ascites
precedes and  preponderates over  drospy elsewhere.  A large
accumulation of fluid in the peritoneum  may also interfere with
the action of the diaphragm, and cause embarrassment of respira-
tion, but it is distinguished from the  ascites caused by cardiac
disease  by the fact that  the dyspnoea follows and never precedes
      12 
88
Clinical  Memoranda,
the  ascites.    Pressure  exerted  on  the  renal  veins  by a large

quantity  of fluid  in  the peritoneum,  may  also  embarrass  the

action of the kidneys, and lead to the appearance of albumen in the

urine, independently  of any disease of those  organs, the albumen

disappearing from the  urine,  after  the removal of  the pressure

by the operation of paracentisis.

   The  following  cases  will illustrate the characters of dropsy

resulting from portal obstruction.


   Case XXVIII.—Dropsy resulting from obstruction of the portal

circulation in  Cirrhosis of the Liver.


   This  case illustrates  in a  striking manner, the  effects of  ob-

struction of the portal circulation, in the production of ascites,

and of serous effusion  into  the cellular tissue of the lower  ex-

tremities.

  S. McL---, native of Rapides Parish, Louisiana; lately a resident of Catahoula Parish;
has been engaged in farming during the past two years; age 35; height 6 feet; blue eyes,
dark hair, dark complexion, thin beard ;  no hereditary tendencies; up to the present attack
has enjoyed good health with the exception of occasional attacks of chills and fever. Patient
says that he has used ardent spirits in moderation, and never to excess, except upon one
occasion when he had an index finger shot off.
  Patient states, that three months since, was seized with violent abdominal pains, extend-
ing from the umbilicus to the pubis,  and attended with griping.  A few days afterwards
was seized with violent vomiting and ejected a large quantity of blood  ("an ordinary blue
bucket full"); the vomiting and loss of blood was attended with great exhaustion ;  four days
afterwards, there was a repetition of this attack, attended with vomiting of blood.
  Two weeks afterwards, an increase in the size of the abdomen was observed, attended with
swelling of the lower extremities. Purgatives an!d diuretics, were administered; the patient
remembers that Eleterium was used which appeared to be productive of no beneficial effects.
Three weeks since his lower extremities began to ulcerate, and the ulcerations involved the
subcutaneous areola tissue, and ragged indolent ulcers appeared.
  This patient was admitted into the Charity Hospital, Ward 19, bed 284, on the 13th of April,
1869, in an exhausted restless state ; abdomen greatly distended ; lower extremities oedema-
tous ind ulcerated.  Auscultation and percussion revealed no  disease of the heart and lungs .
  The lungs and diaphragm were forced upwards by the effusion in the cavity of the abdomen
the heart also appeared to be pressed upwards and forwards.
  The sounds of the heart were unusually distinct,  and abiupt and sharply defined but no
enlargement, dilatation,  degeneration or valvular disease, could be discovered. The lungs
were resonant; the respiration was more frequent than usual, from the abdominal pressure,
but there were no signs of obstruction in the pulmonary circulation; no pleuritic effusion,
and no tubercular  deposit.
  The abdomen was enormously distended with dropsical effusion, and the veins of the ab-
dominal parietes were enlarged and filled with blue dark blood, and presented a distinct ar-
borescent appearance upon  the  abdominal parites. The lower extremities were  greatly
swollen,  and the legs ulcerated, with thickened, indurated discolored integument.   The
general complexion was sallow and anaemic. The urine was scant, high-colored, and loaded
with biliary acids.  The swelling was circumscribed by the superior wall of the abdominal
cavity, and in fact, by the diaphragm.  All above this was of the normal appearance, an d the
face  and arms and thorax were thin and wasted, almost skeleton-like, whilst all below the
diaphragm was swollen and infiltrated with serous fluid.
   The sullow, jaundiced lue;  the presence of the constituents of bile in the urine; the limitation
of the swelling to the abdominal cavity and lower extremities ; the absence of all organic disease
of the heart and lungs; the absence of albumen and of fibrinous easts from the urine; the ab-
dominal dropsy,  and the congestion of the  venous  system of the abdomen and lower extremities,
all sustained the diagnosis, that this was a case of Cirrhosis of  the Livek, in the latter stage of
contraction, unattended by disease of the heart, lungs or kidnegs.
   The bowels were opened with two Compound  Cathartic Pills, and the  patient was placed
 upon the diuretic mixture composed of Cream of Tartar oz.  i, Juniper  Berry Tea (Juniper
 Berries oz. i, boiling water f. oz. xvi; after  cooling  strain) f. oz. xvi; to be taken in wine-
 glassful doses during the twenty-four hours. 
Jones—Medical
89
   The ulcerated extremities were treated with a stimulant and antiseptic ointment, composed
 of Carbolic Acid drachms i ; Tincture of Iodine f drachms i; Simple Cerate oz. ii  Mix; and
 apply lightly to ulcerated legs ; and.cover the ulcerations with English lint coated with Simple
 Cerate.  Simple, but nutritious diet was directed.  One sixth  of a grain of Morphine was
 ordered at bed time, with directions to repeat in three hours, if necesiary.
   April 15th.—Temperature of axilla 97° ;  it is of importance to note that the temperature
 is below rather than above the normal point.   This depression appears to be due to the ob-
 struction in the portal circulation, caused by the cirrhosis and contraction of the liver, and
 also to the interference of the circulation aud respiration from the abdominal pressure.
   This observation, as well as others, confirmed the accuracy of the diagnosis, as to the  ab-
 sence of tuberculosis, and also confirmed the view that the affection of the liver was of long
 standing  and in the stage of contraction.
   Only eight ounces of urine were collected during the twenty-four hours;  specific gravity
 1030; high colored, loaded with biliary acids ; upon standing  let fall a copious deposit  of
 urates, which disappeared when the urine was heated, and yielded a large crop of crystals
 (lozenge-shaped j ot uric acid.
   The diminution in the amount of urine appears to be dn« in a manner to the pressure  of
 the fluid distending the abdomen,  and also to the small amount of nourishment taken, the
 anaemic state of the blood, and  the depletion of the serous or albuminoid elements of the
 blood.
   April 16th,—During the night the patient was aroused about 1 o'clock A. M., with violent
 retching  aud vomiting, and ejected a greenish black mater in sufficient amount  to fill an
 ordinary wash basin.  This  afforded some relief, but the patient was considerably depressed.
 In two hours the nausea returned, and the patient vomited a similar amount  The m tter
 was so  disagreeable in its odor, that vomiting was excited in his nurse, whilst removing the
 matter from the ward.
   Twenty-two ounces of urine were collected. Sp. gr. 1030; high  colored; bowels free.
 Appetite  poor.
   April 17th.—The nausea, with occasional efforts at vomiting, continuing, the Bitartrate of
 Potassa and Infusion of Juniper  Berrie-t were discontinued,  No appetite,  Bowels free.
 Seven and a half fluid ounces of urine  collected; high colored and loaded with biliary acids
 and urates   Ulcerations of the lower extremities improving under the use  of the Carbolic
 Acid ointment.   Patient restless and unhappy.  It has been necessary to administer Mor-
 phine each evening to produce rest.  Tincture  of Cinchona of Gentian aud  of Rhubarb,  in
 proportion of  two parts of the former to one of the latter, have been given, properly diluted,
 in wineglassfnl doses, as a tonic and gentle laxative.
   April 18th.—Symptoms the same; the distention of the abdomen has progressively in-
 creased.  Only four fluid ounces of urine collected during twenty four hours.
   April 19th—No change; distention of the abdomen so great as to embarrass in  the most
 disti essiug manner the action of the heart and lungs.
   It was determined to  tap the patient upon the  following morning.  Sixteen and a half
 ounces of urine were collected; upon careful testing  no  albumen was discovered; urine
 high colored and loaded with urates and bibary acids ; sp. gr. 1030.
   April 20th.—At my request, Dr. Warren Stone, Jr., performed the operation of  para-
 centesis, midway between the anterior  superior spinous process of ileum and  umbilicus;
 three and a half gallons of serous fluid were drawn off, which presented alight golden yellow
 color.  Specific gravity of serous  fluid 1009, and upon the application of heat, the coagu-
 lated albumen filled about one-fifth of the  test-tube.  The patient expressed great relief.
 Percussion revealed no enlargement of the liver, but an actual diminution in the volume of
 this organ.  After the application of the bandage around the abdomen, the patient was put
 on stimulants and nutritious diet.
   Seventeen ounces of urine collected, high colored, loaded with urates and biliary acids;
 free from albumen;  sp. gr.  1027.
   April iist.—Condition of the patient apparently improved by the tapping; appetite good ;
 swelling rapidly subsiding from the lower extremities, and ulcers  healing.  Twenty-four
 fluid ounces of urine collected ; high colored ; sp. gr. 1027; no albumen.
   April 22.—Patient perspiring freely; previously the skin has been dry and harsh. Serous
 fluid gradually accumulating in the abdomen.  Appetite good, spirits cheerful, bowels regu-
 lar.  Urine presented similar character.
   The patient was placed upon a gentle course of mercury, one  grain  every four hours, and
 on the  27th his gums were  slightly touched; the  abdominal swelling,  however, went  on
 steadily increasing.  The patient continued to lose strength,  and the accumulation of
 serous fluid in the abdominal cavity continued until the distention was as great as before the
 first tapping,  bedsores  'e^an to form on the 29th, and a persistent diarrhoea set in, which
 was not arrested by astringents.
   The patient became delirious on the night  of the  30fch, and lay in a semi-comatose state,
 aud passed his urine and excrements in bed ; and gradually sank by almost  imperceptible
 stages, lying for two days in a state which could with difficulty be distinguished from actual
 death, aud finally died at 4 o'clock p. M.,  May 3d
  The post-mortem, performed twelve hours after death, revealed the following points :
  Upper extremities, head,  neck  and thorax, greatly emaciated, merely the skeleton with
 the skin stretched over; abdominal cavity and lower  extremities greatly swollen and dis-
 tended. The abdominal cavity contained near four  gallons of serous fluid.
  The lungs were healthy ; without tubercles, or adhesions, or any marks of Inflammatory
 change
  The heart was normal in size, with no lesions of  the valves ; the pericardium, however,
was adherent,  and this adhesion of the serous membrane of the heart, throughout its entire
extent, accounted for the more distinct sounds of the heart. 
90
Clinical  Memoranda.
  The liver was greatly contracted, hardened, and of a slate color ; and the spleen also was
enlarged and haidened, and of a similar color with the liver. The kidneys were congested
but healthy.  No  derangement beyond congestion of the bloodvessels was discovered m the
kidneys.                                                  .     .
  The liver was cirrhosed, hardened and greatly diminished in size : the weight  being  only
twenty-four ounces ; the length ten inches, an< breadth four and a half inches, and greatest
thickness two and a half inches.  The liver had lost the appearance of divisions into lobules
upon the exterior, and resembled an elongated flattened spleen.
  The color of the liver was slate on the exterior, and a mottled olive  gieen yellow and
bronze within.                                                       ,
  The peculiar color of the liver appeared to be the result of the previous attacks of malarial
fever, and the slow action of the  malarial poison. • Under the microscope, the fibrous tis ue
was found to be greatly increased, and the dark masses of altered ha?matin were scattered
throughout the structures,  giving to the organ,  its peculiar malarial hue.  'Ihe liver cut
like leather and was firm and hard.
  The spleen was enlarged and indurated and had lost the natural splenic mud.  Weight of
spleen : nine ounces ; length, six inches ; breadth, three and a half inches ; thickness, one
inch, spleen cirrhosed like the liver, and cut like leather.  Contained numerous masses of
haBmatin and altered blood corpuscles.
   This then  was a case of undoubted induration  and contraction
of the liver, unaccompanied  by disease cf the heart or kidneys;
but attended with the marks of pre-existing malarial disease.
   The  relations  of the action of  the malarial poison, to  the
induration and contraction of the liver, are of the most  important
character, and demand  farther investigation.
   The question is, whether the effects of the malarial poison were
merely concurrent  with, or subsequent to,  the establishment of
the cirrhosis, or  whether  they  caused the peculiar state which
lead to the throwing out of fibrous  matter, and the subsequent
contraction and induration of the organ.
   This case, resembles the chronic atrophy of Frerich, or the  red
atrophy  of  Kokitansky;  in which there  is  no nodulation  or
granulation of the outer surface, and not necessarily any thicken-
ing or adhesions ot  the  capsule.   The liver  affected with  the
chronic  atrophy  of Frerich,  like  that of  the  case now under
consideration, presents a  dark-brown, or bluish-red color, firm
consistence and  homogeneous appearance,  with little or no in-
dication  of  a division  into  lobules;  the  secreting cells  being
smaller  than  natural  and  loaded  with  dark-brown  pigment
granules.  In like  manner, the atrophy of the organ is  general,
and as  in the  present case  it  has been known to weigh only
twenty-four  ounces.  But the most important anatomical charac-
ter of chronic  atrophy,  is said to be, the destruction of  the
ramifications of the portal vein, the branches of  which terminate
in club-shaped extremities, so that the organ cannot be minutely
injected  from the portal vein. 
Jones—Medical.                         91
  Pathologists  describe this  comparatively rare form of  liver

disease,  as  being occasionally  seen  in connection with  simple

and cancerous ulcerations of the stomach and intestines, or  with

a deposit of blood pigment in the minute vessels of the  liver,  in

the bodies of persons, who have suffered long or often from inter-

mittent or remittent fevers.

  It is well known that both the liver and  spleen are congested

during the cold stages of intermittent and  remittent fever,  and

during the action  of the malarial poison, either in its most active

manifestation, or in  the state of chronic malarial poisoning, the

colored blood corpuscles are destroyed in large numbers both  in

the liver and  spleen.

  It is reasonable therefore to refer the induration and atrophy

of  the  liver  in this  case, in  its first origin,  to  the action  of

malaria.

  Case  XXIX.  Dropsy resulting from  Cirrhosis of the Liver and

Cardiac  disease.

  This  case of  the  stout seamen, William Woods, who  died in

ward Xo. IS, a few days after coming under my treatment, presents

several points of interest, and the dropsical effusion in the cavity

of  the  abdomen,  and into  the cellular tissue  of  the face, and

upper  and lower extremities, were due to  both cardiac  disease

and cirrhosis  of the  liver.   The following outline of this case will

serve for comparative deductions.

  William Woods; aged 47; dark hair, dark complexion; in health a large powerful, stout,
athletic man; ship carpenter by trade; has been  sick about two years ; says that  his
disease commenced whilst working in the water; has always  used ardent spirits daily in
large, or rather, pretty free quantities.
  Entered the Charity Hospital November 9th, 1868.  At that time the abdomen  was much
distended with serous effusion, and it has been necessary to tap the abdomen upon several
occasions ; and several gallons of water have been drawn off.
  When this patient came under my treatment in the month of March, 18G9, the complexion
was of a wax-like, unhealthy jaundiced hue ; the features of the face were swollen and livid
from venous congestion;  the abdomen was distended with dropsical effusion, and the ex-
tremities were cedematous.  Patient feeble, but able to sit up, and  walk about a little.
Great obstruction of venous circulation; veins of neck distended with black blood. Lips
livid, Arteries in all  parts of the body, where they  could be carefully examined, greatly
enlarged and toituous, with a powerful beat.  The column of blood is sent out with great
force from the heart, giving  a powerful beat to the arteries, which appeared to be universally
enlarged and degenerated.  This degeneration of the arterial system is still farther shown
by the arcus senilis. Great oppression in breathing. At times the restlessness and oppression
very great.  Patient  caDnot lie down with comfort, but requires to be propped up in bed.
Percussion and auscultation revealed dullness in the lower dependent portions of the lungs,
and greater flatness over the chest than in health;  there were no symptoms of pneumonia
or pleurisy or of phthisic, and the dullness was referred wholly to  the  obstruction of  the
circulation.  Heart greatly enlarged, with a powerful beat.   The dullness upon percussion
extends from the junction of the second rib with the sternum, to the lower edge of  the
seventh rib, and even beyond the right border of the sternum.  The region of dullness, in-
dicating the position of the enlarged heart,  is eight inches in the longitudinal and about six
inches in the lateral or transverse diameter.
  The first sound of the heart is entirely altered to a low bellows sound, terminating ab-
ruptly by the powerful closure of the pulmonary and aortic valves. Both  sounds of the 
92
Clinical  Memoranda.
heart are merged into one—a powerful, low, blowing sound, with a sharp, loud termination :
thus tu-u-chuck.  The sounds of the heart resemble those made by an ordinary steam tug.
The sounds of the heart are heard with great distinctness along the track of the large
arteries, and especially of the carotids.
  .Abdomen greatly distended  with serous effusion. Liver apparently diminished in size
and hardened.
  Derangement of the liver is  evidenced aside from the ascites, by the yellow jaundiced hue
of the complexion,  and the great amount of bile in the  urine.  Oedema  of extremities.
Bowels constipated.  Appetite poor.   No marked febrile phenomena.  Patient dull and
lethargic, but calm and sensible.
  The diagnosis of this case was:
  Hypertrophy and Dilatation of Heart.
  Universal Degeneration and Dilatation of Arterial System.
  Great Enlargement of Aorta.
  Cirrhosis of Liver.
  The dropsical effusion was referred directly to these causes.
  The patient continued to grow worse; treatment was  only palliative, and he died on the
27th of March, 1869.
  The Post-mortem Examination, performed six hours after death, revealed enormous hyper-
trophy of the heart; this organ was eight inches in the longest diameter, and six and a half
inches in transverse diameter,  after being emptied of the dark venous blood which distended
its cavities, and after being preserved in alcohol.  During life, when distended with blood,
its dimensions were much greater  All the cavities of the hearc, but more especially the
left ventricle, were dilated, and the^auriculo-ventricular openings were greatly dilated.  No
thickening of the auriculo-ventricular valves  was observed.
  The valves of the aorta and pulmonary arteries were somewhat enlarged and perhaps de-
generated, but no deficiency or adhesions or calcaneus degeneration were observed.
  Aorta and pulmonary artery; but  especially the former, degenerated, roughened and di-
lated.  The dilatation of the aorta amounted in the ascending portion and arch almost to an
aneurism. The arteries were universally dilated aud  degenerated in their structure, and
appeared in a great measure to have lost their elasticity.   Microscopical examination showed
that this dilatation  and loss of elasticity was due  to the conversion of the unstriped mus-
cular fibres into fat.  The liver presented a rough hob-nail appearance upon its exterior; it
was contracted, diminished in size ; the capsule was greatly thickened, and could be pealed
off, and the structures were cirrhosed.
  Kidneys congested, but healty in structure—no degeneration or alteration of secretory
textures.
  Spleen somewhat enlarged-
  This liver, as in all the other patients who had been exposed to the malarious climate  of
the Mississippi valley, presented a darker color than usual in cirrhosis, and  also  gave evi-
dence in the dark granular masses of the preceding distruction of the colored blood cor-
puscles.


  The dropsy  in  the preceding  case  was  clearly referable  to

cirrhosis of the liver,  and cardiac disease.

  We will consider briefly in the next place :

  The Treatment of Hepatic Dropsy.

  The treatment of dropsy arising from  portal obstruction, must

depend not only upon the cause of  this  condition, but  also upon

the various  complications, as  cardiac and   renal  disease.   The

preceding cases illustrate in a clear  manner, the fact, that dropsy

may be referred in  the same case, to several  causes, as  cirrhosis

of the liver, and cardiac  disease;  it is therefore absolutely essen-

tial that the physician, should, as far as possible, clearly recognize

in each case the cause  or prominent cause of the dropsical effusion.

It would be foreign to our purpose,  to discuss the mode of  treat-

ment applicable to  all the diseases  of the  liver, which  may give

rise to ascites; and our effort will be to indicate briefly the  mode

of treatment of that form of dropsy illustrated by the preceding

cases, viz., ascites arising from cirrhosis  of ihe liver. 
Jones—Medical.
93
   Cirrhosis of the liver is at the outset obscure and insidious,
 and is slow in its progress, often extending over several years,
 the physician therefore rarely has an opportunity of treating the
 disease at its commencement.  When, however,  the existence of
 the disease is indicated  by the symptoms of disordered digestion,
 loss of appetite, flatulence, irregular action of the  bowels,  pain
 after food, dull pain, with slight tenderness in  the right  hypo-
 chondrium, and slight enlargement of the liver, occurring in a
 person addicted to spirit drinking, attention  should  at once be
 directed to the habits and diet of the patients.  Alcoholic stimu-
 lants, and rich, indigestible,  stimulating food  and condiments,
 should  be interdicted,  and  the patient confined  to  spare, but
 nutritious diet, consisting of such articles as  milk,  eggs,  and
 farinaceous substances,  with a moderate allowance  of  meat  and
 fish.  In  order to avoid  the occurrence of delirium tremens,
 it will be necessary in some cases in which the  habit of taking
 large quantities of alcoholic stimulants has been fully established,
 to reduce the amount  gradually.   The bowels should be kept
 freely open,  by saline purgatives,  and occasional doses of blue
 mass and calomel, and  the general health preserved  by regular
 exercise in the open air.
   If the pain and uneasiness, in  the region  of the  liver, is well
 marked, sinapisms, leeches, dry  cups and cut cups may be  used
 over the affected organ,  with  benefit.
   If the liver  still remains enlarged, after the subsidence of pain,
 the alterative effects  of Iodine—ether locally,  in  the form of
 the tincture or ointment, over the region of the liver,  or internally,
 in the form of the Iodides of Potassium and Iron,.or of Lugol's
 Solution should be carefully  tried.   If these measures fail in re-
 ducing the  liver, recourse may be had to the mineral acids,
 the Hydrochloric, Nitric and Xitro-muriatic Acid, internally, and
 to the Xitro-muriatic acid bath*.
   When the stage of contraction of the liver sets in,  as evidenced
 by diminution of the area of  hepatic  dullness, jaundice  and

 * The Nitro-muriatic Acid Bath is prepared by adding two ounces of strong Hydrochloric
 Acid, and one ounce of strong Nitric Aoid to two gallons of water, at 98° F.  Deep, glazed
 earthen or wooden vessels should be used, and the feet and legs are immersed in the bath'
 whilst the thighs and right side are sponged with the acid solution.  The patient should re-
main in the bath from half an hour to one hour. The bath thus prepared should be renewed
at least every third or fourth day. 
94
Clinical Memoranda.
ascites, there appears to be  no known treatment, which will
restore the liver to its normal condition, or remove the obstruction
to the portal circulation.   In this stage the  efforts  of the  phy-
sican are directed chiefly  to the  relief of  symptoms,  and the
support of the patient's strength, in order that life may  be pro-
longed to its farthest limit.
  The  diet  should be nutritions but  not stimulant, alcoholic
stimulants should be entirely prohibited, or used only in  cases of
emergency and with great caution;  the digestion should  be im-
proved by such tonics as Quinine, Gentian, Xitro-muriatic Acid and
Strychnia; and the bowels should be kept open, whenever sluggish,
by mild purgatives.
  The  ascites should be treated by diuretics and purgatives.  A
pill composed of half a grain of powdered digitalis, one grain
and a half of powdered squill and two grains of blue pill, has been
administered with benefit in  cases of ascites,  dependent upon
hepatic disease, two or three times daily.
  The diuretics and purgatives  previously recommended in the
treatment of cardiac disease may be  employed.  As a rule, how-
ever, the ascites slowly increases, and sooner or later it is neces-
sary to resort to the operation  of paracentisis; this should  be
delayed,  as  long  as possible, for notwithstanding the temporary
relief afforded, and the increased action of the kidneys, the fluid
usually collects again rapidly, and the patient is exhausted  by
the great drain of albumen from the blood,

  L—Dropsy arising jrom derangement or lesion of those organs
    which regulate the amount of the blood, as well as its constitution,
    by regulating the amount of the watery element, and by the elimina-
    tion of excrementitious material
  The  kidneys  not only regulate the amount of  the watery ele-
ment of  the blood, but they also • eliminate certain noxious sub-
stances, resulting from the metamorphosis of the tissues,  aud the
chemical  changes involved in  the  generation  of the  physical
forces; any arrest or alteration  or suppression of the action of
these important organs, must, therefore, be  followed  by an ac-
cumulation of the watery element,  and certain excrementitious 
Jones—Medical.
95
matters in the blood, derangement in the processes of absorption
and exhalation, and disturbance of the sympathetic and cerebro-
spinal nervous system.
   It has been estimated upon reliable data, that the amount of
water taken by an adult, in twenty-four hours, is, on an average,
from one-half a fluid ounce to six-tenths or  seven-tenths of an
ounce for each pound avoir, of body weight; a mau weighing 140
pound , will therefore take about seventy to ninety fluid ounces
daily, and in ordiuary diet about twenty  to thirty ounces of this
are taken in the so-called  solid food, and the remainder is drank
as liquid of some kind.
   But the amount taken  varies within wide limits in  different
circumstances, and from individual peculiarities; some men take
only sixty ounces—ethers as much as one hundred and twenty,
or even more; more water is consumed in a dry than in a moist
climate, and during great exertion than during a period of rest.
The mean amount of water, excreted through the kidneys by
different male adults, varies from  thirty five to eighty-one fluid
ounces a day.  The variations  in the  amount of water  excreted
by the kidneys, will depend upon the varying quantity introduced
into the system, and upon the varying quantity eliminated by the
skin, lungs and bowels.
  It  results  from  the preceding  calculation, that the kidneys
alune, eliminate during the year, in adult men, on  an  average,
from  eight hundred to eighteen hundred pounds of water.  This
great'and continuous circulation  of  water through the living
being is essential to the existence  of  life; and the performance
of the various functions.   Thus during  the development  of
heat, and ot the forces which work the animal machine,  a portion
of matter is chemically  altered,  decomposed and broken up
into simpler forms; if these matters, as urea, uric acid  and car-
bonic acid, and urate of ammonia, be  not coutinuously removed,
ill-health aud finally death will result.  To accomplish the con-
tinuous removal of the various useless and noxious substances,
there is first, the  almost  universal solvent water; second,  the
circulatory apparatus,  in  which these substances are  received
and by which they are distributed; third special organs as thelungs
and kidneys, which separate these  matters from the blood, and
        13 
96
Clinical Memoranda.
cast them  out of the circle  of living molecules.   We are thus
enabled to  understand the reason, why general dropsy so rapidly
and so surely supervenes,  when  the function of the kidneys is
arrested or materially impaired.
  An additional cause of dropsy is also known to exist in certain
diseases of the kidneys: viz., the constant loss of albumen by
transudation through the capillaries and excretory tubes of these
organs, and the consequent derangement of the composition  of
the blood.
  The diseases  of the kidneys, which  are almost universally
attended with dropsy, are :
  Congestion  and acute inflammation of the kidneys, occurring
as a sequel to scarlatina;
  Acute nephritis caused by exposure to cold or wet;
  Acute Bright's Disease (" croupous nephritis.") The course of
this disease is always acute, aud terminates either in recovery or
death in most cases within  a few days.  It is a frequent com-
plication of scarlatina.   Postmortem examination  shows  the
kidneys to  be  congested, enlarged,  with the urinary tubes filled
up and occluded with an extravasation consisting of a coagulatiug
exudation,  containing epithelial cells and blood-corpuscles.
  Chronic Bright's Disease  (" parenchymatous nephritis.")  The
predisposing causes  of Blight's disease,  are  cold; incautious
exhibition of certain irritating diuretics, as cubebs,  copabia and
oil  of turpentine;  the abuse of  ardent spirits;  the alcohol
eliminated  with  the urine acting locally  upon the  structures of
the kidneys, the disease appearing almost  as frequently among
hard  driukers, as cirrhosis of  the liver; tedious  suppuration,
accompanying caries and necrosis of the  bones; the conditions
of dyscrasia, occasioned by gout, rachitis,  scrofula and  malarial
cachexia.
  In  the so called large  white  kidney, the cortex is pale and
bypertrophied, and the uriniferous tubes crammed with  grauul; r
epithelium. The large white kidney, is often merely an advanced
stage of acute nephritis, but it may also be developed  indepen-
dently, as the result of chronic inflammation.
  In  the fatty  kidney, the organ is large and  pale, and the
secreting cells loaded with oil;  and the observations of patho- 
Jones—Medical
97
logists render it probable, that this stage is preceded by the
stage of exudation, characteristic of the large white kidney.
  On the other hand, in the two common forms of chronic kidney
disease, characterized by the contracted,  granular, or  gouty
kidney, and the waxy or amvloid kidney, anasarca rarely shows
itself, except shortly before the fatal termination.
  Dropsy arising from renal  disease, has the following  distin-
guishing characters.
  The anasarca of the subcutaneous areolar  tissue,  is general
from the first, and most generally noticed first in the face; fluid
is also always almost effused into the pleural,  pericardium and
peritoneum.  The urine is  scant, turbid or smoky,  containing
large quantities of albumen and sometimes blood ;  also renal epi-
thelium and casts  of the uriniferous  tubes,  varying  in their
character, according to the particular disease of the kidney.  The
couutenance is swollen, heavy aud pale, with a peculiar  wax-like
appearance.  There is a  tendency to  nervous disturbances, con-
vulsions, loss of memory, restlessness, delirium and coma.  The
digestion  is deranged, with dry tongue, foetid breath, and ob-
stinate vomiting.
  In  the  production of the anasarca, which  accompanies and
forms a prominent symptom in certain  diseases of the kidney,
several causes are in operation.
  1st.  In the acute affections, w hen dropsy conies on rapidly in a
few hours, and is almost the first indication of the disease, this
symptom is most probably produced by the retention in the blood-
vessel  system  of the  water urea  and  salts  which  should be
eliminated iu the  form of urine. The anasarca comes on before
any great amouut of albumen has been thrown off from the blood
by the kidneys; the blood is still rich in this constituent, aud
the change in the blood results rather from a relative increase in
the watery element and the  retention of those  noxious com-
pounds as  urea,  which  should  be  continuously eliminated.
The circulation of the blood through the capillaries, depends not
alone upon the continuous action of the heart, but also upon the
relations of the blood to the  capillaries and to the organs and
tissues through which it circulates; whatever therefore alters
the constitution of the blood,  deranges the capillary circulation, 
98
Clinical Memoranda.
by deranging the chemical affinities of the blood and tissues, and
by deranging the action of those portions of the nervous system
which preside over and regulate the amount and character of the
capillary circulation.  If water be injected into the blood-vessel
system of living  animals  to an extent greater than that which
may be readily and rapidly overcome by the kidneys, congestions
of important organs,  and  serous transudations will  speedily
result.  Whether the view be held  that urea, as urea acts  as a
poison, or it be  maintained that the  poisonous effects resulting
from the injection or retention of this substance in the blood,  be
due to certain changes of chemical  constitution  in the urea,  in
consequence of which it is converted into a more active substance,
viz., carbonate of ammonia;  the cause of the anasarca is  with
equal justice traced in part, at least, to the paralyzing or deleterious
influence of certain excrementitious matters  upon the nervous
system, heart, smaller arteries and capillaries.
  2.  In chronic Bright's  Disease, in addition to the retention to
a great extent of the watery  element,  and the consequent dis-
tention and relaxation  of  the swollen  aiterial  branches  and
capillaries, and the retention of the poisonous urinous exerements,
there is a continuous and great loss of albumen, which results in
the production of a thin poisoned  blood ; and  the consequent
derangement of  the nutrition circulation and functions of the
organs and  tissues.  The  researches  of Gregory,  Bostock, Clnis-
tison, Andral aud Gavarret, Becquerel  anl Rodier, have shown
clearly,  that a diminished  proportion  of albumen, and a  con-
sequent  decrease in the density  of the serum, constitute the
leading changes of  the blood iu Bright's Disease, and from which
may be deduced, in  part at least, the pathogenesis of the dropsy
developed  under such circumstances.   Ihe  diminution of the
albumen, as well as the extent of the dropsy, bear a relationship
to the duration of the disease, being  much  less in acute, than in
chronic Bright's  Disease.  The diminution of the proportion of
albumen in  the blood, is scarcely perceptible in the acute stage,
before the fourth day.   A great change takes  place in the blood,
in chronic Bright's  Disease; its meau density falling from  1060.
to 1045.6; the globules fall likewise, whilst the fibrin is some-
what increased;  the serum  likewise undepgoes a considerable 
Jones —Medical.
99
change,  the mean specific gravity being represented by 1021;  and
the albumen  being so much diminished,  that its  mean  is  re-
presented by  55.

   These propositions were discussed at length in  the  lectures by
the bedside;  it  would be impossible to record this  discussion  at
the present time,  aud we  will  conclude  this  subject,  with the
following cases  illustrating in a  striking manner,  the  production
of dropsy by kidney disease.
   Case  XXX.    Dropsy  resulting  from  BrigMs  Disease  of  the

 Kidneys.

  Frederick Mayer ; aged 30 years; height 5 feet 7 inches ; weight 160 pounds: light sandy
 colored hair ; blue eye  lair  omplexion ; nativt of Sweden ;  1m borer by occupation; has
 generally enjoyed good health, wiih the exception of chills and fever, in the last two years.
  Admitted March 21st, 1869, to Charity  Hospital, ward 29;  bed 422; oedema of the lower
 extremities; scrotum and penis greatly distended with serous effusion ; some effusion in
 abdominal cavity ;  face puffed;  complexion sallow and wax-like; action of heart somewhat
 irregular, with a slight niuru,ur in the first sound ; slight cough attended with pain, referred
 to the precordial region ; cough m st troublesome during the night;  very slight expectora-
 tion ; percussion sounds over lungs duller than in health, indicating cede'ma of thoseorgans,
 with some pleuritic effusion.  Patient has a large and well formed  chest and there are no
 symptoms of tubeiculo.-is.  No enlargement of the heart was detected, and the cardiac mur-
 mur was referred chit-fly to the anasmic state of the blood.  Bowels regular,   'the  diagnosis
 that this was a case of Bkioht's DiskasE, was still further confirmed by an exa niuatiou of
 the urine.  Heat and nitric acid showed the presence of albumen in ihe urine aud  casts of
 the urinary tubes of the kidneys weredetei t d in moderate abundance i,n lei t e miurosi ope.
  The bowels were opened freely with Compound Cathartic Pills, and the atlempt was made
 to excite and increase the action of the kidneys, by the Cream  of Tarta'1 and Juniper Berry
 mixture previously desciibed. The patient was directed to shake  up the  Cream of Tartar
 before using, so that the entire amount of one ounce, in a pint of the Infusion  of Juniper
 Berries should  be  taken during each twenty-bur hours.  Under this treatment the urine
 increased in amount, the p .lse became regular; the tongue cleaned; the bowels were moved
 regularly every day; and the patient became more active aud cheerful, and there was  a
 marked diminution of the anasarca
  April 3d.—Amount of urine passed f. ozs. lxiv; color pale ;  albumen abundant; numerous
 casts of tubuli uriniferi; the casts contained numerous oil globules, with degenerated cells
 and gianular matter
  April 3d.—Amount of urine passed f ozs. lxxvi ; pale yellow;  sp. gr.  1013;  upon  applica-
 tion of heat, the albumen, alter  coagulation, filled one-fifth of the test-tube
  April 4 h.—Pulse 7ti; respiration 20; tongue clean, appetite good ; bowels regular; sallow,
 unhealthy wax-like complexion.  Amount of urine passed, fozs. lxxvi; sp. gr 1013, amber
 coloied;  contains casts of tubuli uriniferi and  albumen   Under the  use of the Cream of
 Tartar and Juniper Berry tea the swelling is slowly diminishing, and the general condition
 of the patient improving.
  April 5th.—Con inues to improve slowly; the diuretics still keep up a full flow of urine,
 seventy-five fluid ounces having been passed  during the  last  twen y-four hours; amber-
 colored, and containing granular casts of  the tubuli uriniferi and albumen.
  April (ith.—Amount of urine passed during twenty four hours, f ozs  Ixxv; sp gr.  1013;
 careful microscopical examination shows the presence of numerous small oil globules in the
 excretory cells of the cast-off  tubuli uriniferi.
  April 7th —The amount of urine has slightly decreased, seventy  fluid ounces having been
 discharged during the past twenty-four hours;  but with this slight dec ease, there is an ele-
 vation of the specific gravity to  1016; so that the whole amount of aolid matter eliminated is
 probably greater than when the  urine  was somewhat more abundant, with a specific gravity
 of 1013
  Tue patient under the persistent use of diuretics and gentle purgatives, and simple but
 nutritious diet,  slowly improved, aud left the hospital at the end of April; the swelling had
 not entirely disappeared, but the patient  left ot his own accord,
  My attention was again called to this  patient in the month of August, 18H9; he had re-
 turned to the hospital ii. a most distrensing condition, with general anasarca, and the abdo-
 men enormously distended with dropsical effusion.  The scrotum was so greatly distended
 that the skin b\rst, and from  the cracks the serous fluid issued.
  The patient was not then under my treatment, and I Was nut informed what measures
were instituted for his relief, beyond'the free use of  squill and calomel. The patient died
about the middle of September; no post-mortem was held as his friends claimed the body. 
100                        Clinical Memoranda.
   Case  XXXI.—Dropsy  resulting from  BrigMs Disease  of the

Kidney.

  John Shone.  The patient gave the following history:  Was admitted to Charity Hospital
in lf58,with what he terms swamp fever, and was discharged 'n one week, after "/hich time,
was attacked  with dropsy, aud then  entered the Marine Hospital, where he remained three
weeks.  The dropsy was relieved, and he enjoyed good heal'h for the space of two years ;
at the end of which time he began to be afflicted with periodic headaches and vomiting.
  Entered the Charity Hospital, on the fiist of February, 1869, and was treated to'- Albn-
minuiia, and left of his own accord, on the  16th, and returned again on  the 5th of March.
The patient appears to have been benefitted by a mixture compound of Tinctuie of Sesqui-
Chloride of Iron,  Digitalis  and   Nux Vomica   Purgation  is  said  to have given  the
gieatest relief to the pain in the head and vomiting.
  Came under my treatment in ward 18, bed 264, on the 20th March 1869. Age 36; height
five feet eig t and  a half inches; weight in health one hundred and eighty-five pounds, at
the pn-sent time one hundred and sevont -two pounds; has a large and well proportioned
frame ; color of hair red aud sandy  eyes blue ; complexion  in health floiid ; native of Ger-
many ; seaman : has no hereditary tendencies as far as known.
  Complexion sallow, and of a waxen hue; bowe's constipated except,  when moved by pur-
gatives; skin soft and moist; tongue led around the edge and tip;  pulse i egular ; impulse
of hear regular, but a murmur is heard over the region of the  aortic valves  synchronous
with systolic impulse of tho heait;  respiration  natural;  temperature of axilla 98°5 P.
The features are full, swollen and cedematous, and the cheeks hang in a dead flabby manner,
and the expression of the countenance is heavy, though not disagreeable, and there  is no
expression of  pain or distress. The cellular tissue generally of  the body, and especially of
the lower extremities,  is cedematous and pits  when pressed, and the pits formed by  the
pressure of the fingers remain for a gteat length of time. The ur nary  secretion is abundant
and contains both albumeu and casts. The patient suffers, periodically  about every seven
days, with attacks of severe headache and vomiting.  The  patient was placed upon  the
Cream of Taitar mixture as a diuretic, and the bowels kept open by the compound Jalap
powder mixed in molasses
  April 7tn,—In much the same state.
  May l.th.—Has been tro bled with dyspncea at night, during the past week, and in addi-
tion to the  Cream of . artar mixture, has been put on a tonic composed of Huxham's Tinc-
ture of Bark and Tincture of Gentian.  The tonic has  improved his  appetite and reduced
the amount of urine.                                                  _
   May lath. -Tincture of Sesqui-Chloride of Iron,  in mcderate doses, substituted for  the
Tinctuie of Bark and Gentian.
   May 24th.—Suffering with beaduche and difficulty of breathing ; urine have increased in
quantity, since  the Tincture of Bark and Gentian has been omitted   The amount of albumen
in the u*ine has decreased during the last month, averaging from one-seventh to one-tenth
of the bulk of the urine, when coagulated and allowed to settle in the test tube.
   May 3-).—'I he condition of the patient mu h the same; his spells of  vomiting have  not
recurred so frequently ;  suffers with considerable dyspnoea during the spells of headache and
vomiting.  The amount  of albume  has decreased  somewhat, ranging  f^oni  one eighth to
one-twelfth in moist volume. The paiient  is  still taking the iufusion of Juniper Berries
and Cream of Tartar, together with the lincture of Muriate of Iron.
  Juno 10th.—suffer,ng with pain in  head  and dyspncea.  Urine passed in last four days
contained more albumen, averaging about one-sixtli in most volume,  and  the amount of
urine ranting from fifty to sixty-five fluid ounces.
  June 22d.—Patient suffering greatly with d  spnn-a; pale, anasmic; action of heart tumul-
tuous; great difficulty in filling the  lungs; the  left lung is dull upon percussi-n, from the
diaphragm or borders of the ribs upwards, to the nipple, between the fourth  and fifth ribs.
Upou careful examination of the patient in the sitting and recumbent posture, it is evident
that a considerable amount of fluid has been effused into the pleural cavity of the left lung,
compressing and embarrassing its  action.  Right lung more re-onant than left,  but there is
evidently some effusion upon this side also.  Dullness upon percussion, over region o' heart,
greater than normal. Action of heart irregular, and sounds indistinct;  blowing sound with
the first sound, whilst the second sound  is prolonged   Sotous effusion in abdominal cavity,
with tenderness in epigastric and hypocondriac regions
  The following table will present in a.condensed form some of  the chief symptoms; 
Jones—Medical
101
	<B	08	© C eS	CHARACTERS OF URINE.				
DATE.				Jtm'iin				REMARKS.
			£ 5 K		Sp.Gr.	Color.	Albumen.	
	a,	M	EH*"*5	ounces.				
April 1st, 1869, 9 a. M	72	18	F. 98 5	68	1010	reddish	1-6	
" 2d,	72	18	98.5	110	1010	yellow	i	In bed and suffering
" 3d, 1869, 5 p. M.	72	18	99 5	110	1010	amber	i	with headache.
" 4th, 1869, 9 a. M.	7U	18	98.	15i>	KIO	pale	i	Headache.
" 5th,	70	18	99 5	45	ltl4	yellow	1-3	
" 6th,	80		99.	72	U13		1 7	
" 7th,	82		99.2	75	K12		ft	
" 8th,	82		98.5	*5	1 12		i	
" 8th, 1869, 6 P. m.	86		IOj 5	10J	11)10		ft	
" 9th, 1869, 9 a. M	83		ltO	10J	1010		i	
" 10,	88	22.	99 5	83	1010		i	
" 12-13..........	88			80	li 10		ft 1-7	During night head-ache.
" 14th, 9 a. M.....	90		99.	85	1010			
" 15 and 16.......	90		99.	75-8fc	lolO		i	
" 17-2J...........	R0		99-100	65	It 10		ft	
" 21st, 9 a. M.....	91		99.2	50	1(14		1-3	On 20th headache
" 22d, "	96		100.7	60	1010		1-7	aud vomiting.
" 24-25, 9 A. M....	»i		10 .5	6J	1010		J	Do do
" 26th, "	82		HO 5	80	109		ft	Do do
" 27-Maylst.....	80		1 0 5	100	10i9		ft	Headache.
May 2d-9ih..........	8->		100	7J	1010		1-7	
" 11-15..........	82		99.0-10	35-75	1010		1-7 1-10	Headache and dysp-
" lr-24...........	82		99	40 0	1010		1-81-12	noea.
" 25-30..........	8J		99.	35-<i5	101.-1012		1-81-12	
June 6ih............	80		99 5	40-65	1012		1-81-12	
  In conjunction with  Dr. B. A. Pope, this t atient, together with several  other  cases of
 Bright's Disease,  under my  tier tment were subjected to a careful examination with the
 ophthalmoscope ; the characteristic alterations of the retina indicative of Bright's Disease,
 were discovered, all hough they were absent in  other cases of this disease ; thus  showing
 that the ophthalmoscope i-i incapable of indicating the disease  n all cases.
  This pat.eut left the ward for another on the 22d oi June, and passed  from my care ai d
 treatment.
  I was informed  that after  the transfer, the diuretics and purgatives  were discontinued,
 and thedlop^y rap dly  iuci eased, and the patient died about the middle  of July.
  In this case," the  dropsical effusion was restrained within certain limits by the judicious
 use ot  diuretics and purgatives, and as soon as they were discontinued  death speedily en-
 sued.


   Case XXXII.—Dropsy  Resulting from  Bright's Disease of Kid-

 ney.

  Charles Daley; age 60, height 5 feet 5 inches ; weight in health 140 lbs;  left le<r shorter
 than light, fioni having had compound fra fine of both tibia and fibula : the patella i« now
 quite prominent;  black hair,  hazel eye,  florid complexion in health ;  native of  Ireland ;
 laborer; no constitutional te  dencies as far as  could b<» gathered from statements coocern-
 ing the health and  di-eases of his relatives; has n^ver had syphilis or scrofula; has been in
 th" habit of drinking whisky  freely, at times to excess, for f >rty years j  has enjoy d pretty
 good health, wi'h the exception  of a spell of chin aim fever about fi e years ago.
  Wa« admitted to the Charity Hospital on the 15th March, 1869,  ward 29. bed 4£9, with gen-
 eral anasarca and with albuminous urine.  The anasarca appears to have  c me on gradually
  Complexion sallow and "fa waxy appearance.  Features swollen   Trunk  and extremities
 cedematous; pr» ssure causes pits which disappear verv s'owly.   Appetite and spirits very
 good, but  muscular and neivous forces depressed. Diagnosis, Bright's Disease of the kid-
 nevs.
  The patient was  placed upon the Cream of Tartar and Juniper Berry tea. Tincture of the
 Se-qoi-cliloride of Iron, and nutritious diet, aud the bowels were kept gently open by saline
 purgatives.
  * at ch 30th—Patient appears  to be  improving; the  amomt  of urine has increased; the
 complexion is somewhat clearer and the anasarca has disappeared to a considerable extent.
 Weight at the present time about one hun  red  and twenty pounds   Patient cheerful, with
 a good expression of eyes,  but is very weak and confined to bed  most of  the time.  Bowels
jegular; skin softer and more moist.  Tongue natural.  Urine  loaded with  albumen and
casts.
  The following table will exhibit some of the more prominent symptoms; 
102
Clinical  Memoranda.
DATE.
April 1st, 1869, 9 A, M
  --2d,  --
  - -  3d.
  --  3d,
  '--  4th,
  -•  5th,
  - -  6th,
  - -  7th,
  "-  8th,
  --  9th,
   - l'th.
5 p. ]
9 a.;
6 p. :
9 a.:
7518
7518
75; 18
7518
9825
98 26
S fl IS
P.c3 A.M
503:5"

ho.Ho
  .. 98  Sallow.
  ..98  Wa*y
83°5 97 5 features
99 5
98
97 5
97.5
 1005
 98 5
.98 5
swollen
o-S;
ulSg8

E"ZM~
Confin-
ed to
bed.
Lies  on
back.
CHARACTERS OF URINE.
52
34
30
3J
32
40
38
35
35
tTtS
1008
1010
K10
1010
1010
1.10
1 08
1010

ioiu
1(25
Pale.
Yellow
 eB

*JOq
Albumen.
Casts of Tubu-
li Uriniferi.
J albumen.
i   "•
i   ••
i   -
1-6   -
1-6  "-
1-3   -
5-6  -•
  April 10th.—Lungs dull upon percussion; and there is a decided increase of heat, every
day towards night.  The ui inary secretion progies ively decreai-ed, and with this decrease",
the swelling increased in the cellular tissue ami abdominal cavity,
  On the 12th of April, the patient got oat of bed,  and pass -d  a portion of the day on the
gallery, in the rear of the ward.  The day was damp, rainy aud cold.  From this exposure
the patient con racted a severe bronchitis, which seemed  o  prostrate him greatly, and he
gradually grew worse, and died on the 5th of May.  Death was preceded by convulsions and
coma.
  The post-mortem examination revealed adhesions of the liver, stomach, heart and lungs to
their respective  erous cavities a  d  membranes; the liver was congested; spleen normal;
lungs contained mihaiy tubercles; kidneys in a state of fatty degeneration.
Dropsy resulting  from   Bright's Disease of
   Case  XXXIII.

Kidney.

  John  Crowley;  seaman; native of Pennsylvania; age 27 ; no hereditary tendencies can
be traced ; had syphilis twelve years ago, the disease is said to have yielded readily to treat-
ment, suit! disappeai-d in three weeks ; well made, mu-cularman, with full well developed
chest; blue eyes ; light yellow hair • during his sea-faring life has been in the habit of uMng
strong alcoholic stimulants freely ;  during a portion of his life has acted as fi'emau on board
steamship, and whilst performing his duty, weuld frequently beexp sed to sudden changes
of temperature and to wet and cold, and  af. such time* would indulge freely in alcoholic
stimulants  Enjoyed good health  up to the l»st twelve months, wheu he was shipwrecked,
and remained in the water some nine hours, and contracted a severe c.dd. from the effects of
which the patient has suffered in the wav of a slight cough, up to the present time
  Hntered Charity Hospital, ward No. 13  bed 199,  ■ ecember  8th,  1869   Features ol face
swollen; slight serous effusion in abdominal cavity ; lower ex  remit'es cedematous, pitting
on pr ssure; scrotum swollen; comple>ion has a s How, wax-like appearance;  urine albu-
minous, and under the microscope loaded with casts of the tubuli nrin feri   Upon ausculta-
tion, subenpitant rales are heard in  the anterior  portion of  the right  lung,  retem-d to
chronic irtitation of  the bronchial  tubes; no  signs of tubercular de ositweie  discovered.
The heart sounds are not altogether normal, and the soft, murmur was referred to the au-
setnic cc dition of the blood.  Li> or slightly enlarged   Excretion  of kidneys  augmented;
the amount of urine passed daily ra ging f om  eighty-eight to one hundred and eleven  fluid
ounces  f  low specific gravity, ranging from 1008 toll 09.   Fatient says that during the last
three weeks, he has been easily fatigued, and  during the last twelve months has suffered
with pain  in his back in the region  of the kidneys, but has been following his usual occupa-
tion to within  the last month   Temperature of axilla  98°8 F.; pulse 72; respiration  18.
Amount of urine passed during the last 24 hours 88 f oz. ; sp. gr.  10 9. When the urine was
subjected  to the action of heat and  nitric acH; the   oist coagulated albumen filled one-fifth
of the test-tube.   The patient was  placed upon the Cream of Tartar and Juniper Berry tea,
Tincture of Sesqui-chloride of Iron and simple but nutritions dief
  December 18th.- The apex beat  of the heart is m  st foic ble to the left of nipple ;  percus-
sion also render* it probable that  the left ventricle is hypertrophied to some extent.  Aus-
cultation over region of heart  reveals a soft murmur, heard loudest over base of the heart,
during second sound; it is also heard at  apex with loss of murmur over body of heart, the
sound  being transmitted along arch of aorta, but not from apex towards spinal  column,
The veins of the upper portion  of the chest are somewhat enlarged and congested. Patient suf-
fers with cou;>h and oppression of brpaihing.after exertion  The lespiration  is prolonged with
considerable ronchus. with a  few sibilant rales.  Ihe lungs  are duller upon percussion than
in health,  and there is come effusion in both pleura  The dullness upon percussion appears
to be due in part, also especially in  the infra-clavicular and clavicular regions, to cedetna of
the pulmonary tissue   The cardiac murmur  is piobably due not only to the anaemic state
of the  blood, but also to fatty or calcareous degeneration  of the aortic valves, perniittim' 
Jones—Medical.                           103
 some regurgitation of blood into the left ventricle.  The urine contains albumen in abun-
 dance, with casts of the tubuli uriniferi.  The amount of urine passed during the twenty-
 four houis. has ranged from  sixty to one hundred fluid ounces.  The temperature of the
 axilla ranged in the morning from 99° to 1 0° F., and in the evening from 99°5 to 101°.
  Under the use of the Diuretics and gentle purgatives, the anasarca has slowly diminished
 and the patient appears to lie more comfortable,  'lhere are time  however, when  the nerv-
 ous system is much dis urbed ; (headache, restlessness and dilatation of the  pupils,, appa-
 rently from the retention of the constituents of the urine.
  Dec. 2Jth—In addition to the preceding treatment, the warm bath,  at bed-time ; and the
 st<  am bath (prepared by heatins- a brick and  pouring water  over it  while under the bed-
 clothes), were ordered ;'and as atonic and gentle stimulaut, a tablespoonful  of Huxham's
 Tincture of Bark, three times a dav, one hour before each meal.
  Dec. 21st —In order still further'to act upon the skin and kidneys, Syrup of Squills and
 Syrup of Ipecac were ordered in doses just sufficient to it due* nausea, but not vomiting.
  Dec. 31st—During  the past tweuty-f'Ur hours, has been affected with vomiting; pupils
 greatly dilated, with dull pain in head, lethargy of intellect and imperfect vision.  At times
 one pupil is dilated and the other contracted
  January 3d —Vomiting and dilatation of pupils continue.
  January 10th.—Patient feels much better than he did a week ago,  has ceased to vomit and
 the pupils are not dilated
  Jauuaiy 13th—Condition appears to be improved, the cederoa has almost  entirely disap-
 peared ;  the lungs also are much less dull upon percussion.  The same treatment  has been
 continued up to the present rime.
  Januai v 24th.— Patient has not been doing so well during the past fiv« days.  The cream
 of  tartar'mixture has disagreed with his  sto nach, and it has been necessary to intermit the
 diuretic. Pupils dilated.   05 lema of extremities increasing   The  cessation of the diuretic
 medicine has been attended with a  marked  diminution of  urine, only twenty-nine fluid
 ounces,  of low  sp  gr. (10,0), were excreted during the past twenty-four hours.  Tne amount
 of  albumen in the urine has also increased, and it now reaches one-fourth of the volume in
 the test-tube, when heat is applied. The bowels were opened by ten grains of the Extract
 of  Khubat b, and on the following morning the patient appeared to be less lethargic and more
 cheerlul, and the pupils were not so widely dilated.                      _  _
  January 26th.—Patient rested badly during the night; complains  of pain in  the lower
 part  of  the abdomen ; pupils of eyes greatly dilated ; nervous and restless, oppression in
 breathing: stomach very irritable, obstinate vomiting whenever the cream of tartar mix-
 ture  is administered. Four grains of the Iodide of Potassium  were  substituted, three times

  January 28th.—Patient rested badly and  was disturbed by frightful dreams.  Pupils still
 more dilated • stomach irritaiile.   Oedema increasing.
  January 29th.—Rest imperfect and troubled; pupils dilated; patient feels very  weak and

  February 1st.-Cough and oppression of breathing increasing ; patient weak and depressed
 anH nervous ; can retain but little upon his stomach from the nausea and vomiting.  It is
 impossible to administer sufficient medicine to act upon the kidney which secretes not one-
 half the former amount of urine.  The urine is not onlv diminished in amount, but it is ot
 low sp  <*r (1010i and loaded with albumen  and casts.  It is evident that the constituents of
 the urine are but partially eliminated  The warm bath and the hot air bath fulfil the office
' of  the Diuretic Mi\ture but imperfectly.                                    ,
  Febinary 8th.  The condition  of the patient has continued steadily to  grow worse, the
 nervous svmptoms increasing and the anasarca in like manner augmenting.  Patient very
 weak unable to get out of bed. and passes his urine in small quantities and involuntarily.
 The  patient lies in a dull, lethargic state, with pupils widely dilated ; as if under the influ-
 ence of some powerful narcotic poison.  Urine scant, and loaded with albumen and urinary

   February 9th.—Continues to grow worse, and more feeble; is not  able to move in bed with-
 out sufferiniT great pain has been vomiting almost incessantly during the past twenty-four
 hours, the fluid ejected resembles milk.  Urinary excretion suppressed, bowels constipated,
 constant hiccough.                                    .      ,      ,         .    .  .
   February 10th.—Vomiting continues, but; the matters  ejected  have changed color being
 green instead of white.  Pupils greatly dilated, muscles of extremities trembling, intellect
 dull  and le-hargic when aroused appears to be under the influence  of some powerful poison.
 The  slighest touch npoi the surface causes  pain.  The patient continued in this  state with
 voniitin"- and hiccough and suppression of urine, and died February 11th.
   The following table presents the changes of the pulse, respiration, and temperature and.
 the amounts of urine.
14 
Pulse,  Resniration  and Temperature,  and. amounts and Sp. Gr. in  Urine  in  Case of John Crowley—Bright's Disease.
				a.	CHAKACTER OF URINE.							o	CHARACTER OF URINE		
	O .		fl _o	fl . "S.2					O .		fl _o	S			
						<u									
Date.	M >>		a		'o.S t «	c		Date.	t- t» fl <3		(3	03 J5	*- 2 E •	CD ■ fl	
	fi5	6 "fl	S-i '£,	p/H g«a Ho	Am't Urine 1 24 hou | in f oi		Albumen and Urinary Casts.		w°	<6	t4 '3. XI	p-'S £<3		Sp Or of Uri	Albumen.
1869.							Albumen.	1870.							Albumin.
Dec.	9 a. m.	72	18	98 8	88	10C9	1-5 Urinary Casts.	Jan. 7.	9 a. m.			99.5	50		1-4 Cnsts.
S .7 p. m		73	18	HI 4			_^ fc.	8.	9 a m.	72		99 6	58		1-4 do.
1'. 9 a. m.		73	18	09 4	88	10C9	1-5 do	10.	9 a. m.	72		99 5	67		1-4 do.
It i7 p. m.		73	18	99 4				13	9 a m.	81		96.5	58		1-2 do.
11 ,9 a. in		70	17	99 4	88	iocg	1-6 do.	24.	9 a. m.	01	17	100.	29	ioio	1-4 oo.
11 |7 p. Til •		91	18	98 8				24	6 p in.	74	18	100.			
12 !9a. m		75	20	99 4	iii	iocs	1-6 do	25.	9 am.	62	15	100.	31	iocs	1-4 do.
12	7 p. m	88	20	100 2				25.	6 p. m-	90	20	101.			
13.	9 a. m.	76	19	98.5	103	iocs	1-6 do	26.	9 a m	80	18	99.	37	ioio	1-3 do.
\'<	9 a. m	72	17	100.	65		1-4 do		6 p. m.	64	18	99.			
17.	7 p. in.			100.8		iocs		27	9 a m.	72	19	99.	36	ioio	1-3 do.
18.	B. 111.	72	17	99	100		1-4 do	27	6 pm.	84	19	100.			
18.	7 p. in.	72	17	100.8		iocs		28	9 a. in.	90	21	inn.	40	ioio	1-2 do.
20	9 a. in.	80	17	99.4	75		1-4 do	28	p m.	80	19	100.			
20 7 p. in.				100 5		iocs		29	9 am.	75	18	100.	34	ioio	1-2 do.
21 9 a. m.				99 5	75		1-3 do	29	6 p. m.	80	19	loo.			
21 |7 p. in-				1(0.		iocs		30	9 am.	84	20	100.	26	ioio	1-2 do.
22. ,9 a. m.				99.5	68		1-2 do	31.	9 a. m.	90	22	100.	30	1'10	1-2 do.
22	7 p. m.			99 7		iocs		Feb. 1	9 a. ir.	84	23	99.	29	1010	1-2 do.
23	9 H. 111.			99.	65		1-2 do		6 p. in.	80	19	lot.			
23	7 p. m.			99 8		iros		2	a m.	84	23	99.	30	ioio	1-2 do.
27	9 a. m.			99.	70		1-2 do	2	5 p. m.	84	21	100.			
27	7 p. m.	166	20	100.		iocs		3	9 a. m.	84	22	99.	30	ioio	1-2 do.
28	9 a. in.			ICO.	50		1-2 do	3	3 p. m.	80	2)	100.			
28	7 p. m.	90		100.		10 08		4.	) a m.	90	22	99.	36	ioio	1-2 do.
29 9 a. m.				100.5	50		2-3 do	4.	5 p. ni.	90	24	99.			
29 17 p. m.		95		99 9		1008		5.	) a m.	90	24	100.	32	ioio	1-2 do.
30. 9 a. m.				101.	42		2-3 do	5.	7 p. m.	90	23	101.			
30. 7 p. m.		90		101.		iocs		6.	9 a xn.	84	22	101.	34	1008	1-2 do.
31 J9 a. in.				101.	32		2-3 do	6	7 p. m.	85	22	100.			
31. 7 p.m.		90		101.		1008		7.	9 a m.	90	24	1'2.	34	ioio	1-2 do.
1870.								7.	6 p. in.	100	23	100.			
Jan. 3	9 a.m.				33	1008	2-3 do	8.	9a. m.	115	30	104.	..		
3.	7 p. in.	90		99.2				8-	6 p. m.	98	22	101		__	
4.	9 a. in.				23	iocs	1-2 do	9	9 a. in	H2	23	99.			
4	7 p. i. .	83		992				9	6 p. m.	1<2	26	105.		__	
5	9 a. m				38		1-2 do	10.	9 a. m.	84	23	99.	..	__	
5	7 p. m. } a. m.	Bj		99 5				10	7 p m.	86	24	1(0.			
6					38		1-2 do	11	9 a. in.	96	28				
6.	7 p. TO.	78		99 5				11	6 p. m.	90	26				
 
Jones—Medical.
105
  A number of other cases of Bright's Disease have been under
observation during our medical service in the Charity  Hospital,
and careful post-mortem examinations were made in the presence of
the Medical Class;  and it was observed that the degeneration of
the kidneys was frequently associated  with fatty degeneration
of the liver, heart  and  arteries.  These  diseases occur most
commonly in the ill-fed and ill-conditioned laborers and drunkards,
who consume the  alcoholic stimulants undiluted, and to a great
extent substitute  them  for  more  substantial food.  Fatty de-
generation, cirrhosis of  the liver  and Bright's Disease of the
kidney, appear  therefore to  depend in a measure  upon similar
causes.
  It is also worthy of note, that the temperature in this class of
diseases, does not rise to the height that it does in phthisis and
idiopathic  fevers;  but still  the temperature of  the trunk is
elevated above  that of  health,  and  is Also subject to  morbid
perturbations.
  The truth of this observation might be illustrated by numerous
observations upon various diseases, recorded under our direction,
but these must be deferred for the present.
  We will  conclude these observation on the different  causes of
dropsy, with some general observations on  the

 Treatment of Dropsy arising from BrigMs Disease of the Kidneys.
  There are so many minute yet important modifications, depend-
ing upon constitutional peculiarities, habits of life, aud special con-
ditions of age, climate, and inherited  or acquired  constitutions,
that it is  difficult  to  describe in detail, the treatment of any
disease;  and the attempt is especially difficult in diseases of the
kidney.  We shall therefore attempt nothing more, than the in-
dication of those general principles of treatmeut which should be
kept  at  all times clearly in view.  The  student  should ever
remember,  that no description however minute, will relieve him of
the duty of studying each case careiully by the  bed-side, and of
adapting his remedial agents and measures to the  causes of the
disease, and the symptoms and the natural or acquired constitu-
tion of each patient.
  Iu chronic disease of the kidneys, it is almost always necessary 
106
Clinical Memoranda.
to continue the plan of treatment persistently for  a'length of
time; and without general principles, only disappointment  will
result from the frequent change of remedies.  In this  class of
diseases, it is especially necessary that  we  should not only
remove the  secondary effects  of the diseased action, but  also
correct, as far as possible, the morbid action of distant organs,
and relieve the kidneys as far as possible, by the supplementary
function imposed upon them.  The supplementary actions of the
skin and gastro-intestinal membrane, are of the most important
character,  and the physician should be  careful lest convulsions
and coma, and even death may follow the sudden and injudicious
arrest of the vomiting and diarrhoea, by  which the constituents
of the urine are eliminated and cast out of the system.  It should
be borne in mind also that the effusions in diseases of the kidneys,
are not simple in their character as in cardiac and hepatic dropsy,
but they contain urea and other constituents of the urine; and
the very act of effusion  may be a process  of purification of the
blood.  Hence even bandages to the lower extremities should be
applied with caution or wholly abandoned, as tending to throw
the effusion upon important internal organs; and for the same
reason, the recumbent position should not be retained too long,
and the patient should  take moderate exercise, as by this means
the internal organs, and especially the kidneys, are relieved, to a
certain extent, from the dropsical  effusion.
L  As the  skin and even the lungs may act as supplementary
organs to  the kidneys,  special  attention should be paid to the
clothing and  to  the surrounding temperature and hygrometric
condition of the atmosphere.
   The amount and character of the urinary  secretion  may also
be geratly influenced  by diet.  It is  well established that an
exclusive diet of meat greatly increases the nitrogenized elements
(urea  and  uric acid  etc.)  of  the  urine,  whilst  an exclusive
farinaceous diet greatly diminishes these  constituents  of the
urinary  excretion.  The importance of  attention to  the diet  is
placed in a clear light, when the  relations of  the retained urea
to the nervous  phenomena  and convulsions  characteristic  of
 Bright's Disease are considered.
   Alcoholic stimulants, and  stimulating  diuretics not only in- 
Jcxnes —Medical.
107
duce  the  disease,  but when persisted in, they aggravate the
symptoms  aud accelerate^ its progress.   Alcoholic  stimulants
should be  withdrawn at the earliest possible moment.
  In  the  acute form of  Bright's  Disease  dependent upon the
action of cold or the poison oi scarlet fever, the bowels should be
kept freely open by saline purgatives, and the congestion of the
kidneys relieved as far as possible, by cut cups and leeches over
the region of the kidneys, and the function of the skin should bo
freely excited by  the warm bath, hot air bath, vapor bath, and
warm clothing.  As purgatives, the compound jalap powder, or
epsom salts, or a combination of  carbonate  of magnesia and
epsom salts  (magnes. carb.  gr. vi; magnes. sulph.  3i to 3iss;
aqufje  menth. pip. f.  ^iss;  mix; administer  every  four or  six
hours), may be employed.  As a general rule, mercurials should
be avoided in both acute and chronic Bright's Disease.
  The diet should be  of the severest antiphlogistic character,
composed chiefly of farinaceous  substances; for in the acute form,
the blood is  not  sufficiently deteriorated to  demand rich nitro-
genized food, and but little diet is  wanted.
  Stimulating  diuretics  are contra indicated,  and in order to
excite the action  of  the kidneys, and to promote also  the ab-
sorption of the dropsical effusion, such, diuretics as the Acetate
of Ammonia, and Bitartrate and Tartrate of Potassa, and the
Seltzer and Vichy waters may be employed.
  When convulsions  and coma supervene in consequence of the
retention  of the urea iu the blood, local depletion by leeches and
cupping to the temples, and in  some cases general blood-letting,
and blisters to the shaven scalp, are in conjunction with the hot
bath, and  brisk purgation with  elaterium and brisk hydragogue
cathartics the main measures to be instituted.
  In the  treatment of the chronic form of Bright's Disease, the
patient should  be required to dress warm, with  flannel next
tie skin,  he should occupy a dry and warm dwelMng,  and avoid
all sudden changes of temperature, and all exposure to the night
air,  or to cold damp weather.   When the circumstances will
permit of it, the patient should remove to a warm moist climate,
for by this change, not only is the function of the skin excited  to
increased activity, but the changes of the body are less, and the
amount of work performed by the kidneys necessarily/linunished. 
108
Clinical Memoranda.
  Owing to the constant loss of albumen from the blood, as well
as to the poisonous action of the constituents of the urine,  it is
necessary that the diet should be more nutritious than in the
acute form.                                                    »
  The German physicians have claimed important results in the
treatment of chronic Bright's Disease, by confining the patients
to an exclusive diet  of milk, without  any medicine  whatever.
Iu this plan of treatment, from five to six pints of good undiluted
cow's milk were administered daily;  and some  of the patients,
who  prior to the treatment, had  been in the most wretched
condition, got rid of their  dropsy, recovered an appearance of
health, and regained so much of their strength,  as to be able to
resume their business and even to perform hard labor.
  From the active measures should be excluded blood letting and
mercurials ;  and reliance, for the relief of the dropsy especially,
and the elimination of the deleterious materials from  the blood,
should be placed upon the judicious establishment of diaphoresis,
diuresis and purgation.
   One of the most efficient  modes of establishing active diapho-
resis, as  previously indicated, is by the daily use of the hot bath
followed by sweating for one or two  hours in woolen blankets.
   Stimulating diuretics  should be avoided on  account of  their
irritating action on the kidneys;  such diuretics as the Tar-
trate and Bitartrate of  Potassa, may be employed persistently
for a great length of time and as far as my experience extends,
if administered in  the  manner  previously recommended,  their
action is always attended with benefit and relief of the dropsical
symptoms.
   Of course, in those cases where the stomach is so irritable that
neither the Cream ot Tartar nor any other diuretic is borne,  there
is little or no  chance of recovery.
   The dropsy may also be controlled, and to a certain extent, re-
lieved,  by  the judicious  employment of such purgatives as
Elaterium, Colocynth; Compound Powder of Jalap;  Cream of
Tartar and Sulphur; Epsom Salts and Glauber Salts.
   It  should be borne in mind that the duration and results of
Bright's Disease, depend upon the  extent to which the kidneys
have been altered; the most frequent termination being death,
caused  either directly  by the  affection of the kidney,  or by 
                         Jones—Medical                      109

intercurrent  inflammation;  complete  recovery may take place,
but  it is  very  rare; some  cases  run their entire course  in a
period of from  six weeks to  three months, and in  others the
malady continues for years.   Although in most cases, a cure may
not be effected, the  physician may accomplish  much good by
relieving the symptoms and prolonging life.
  It is important therefore in a disease of such a chronic nature,
that  the continual tendency to the deterioration of the blood,
should be counteracted by the  use of  Iron and Quinine, and
nutritious diet.
Tabular Summary of Cases treated in  Charity  Hospital, Service of Joseph
    Jones, M  D., during  Fifteen Months, l*t  January,  1869, to  l*t  April,
    1870; arranged according to  ihe "Nomenclature of Diseasen of the i„oyal
    College of  J'hysicians of London."
DISEASES.
            General  Diseases.

Small Pox...................................
Measles.........................................
Typhoid Fever...............................
Yellow Fever.................................
Malarial Intermittent Fever..........
   "    Remittent     "  ............
*  "    Congestive    "  ............
Chronic  Malarial Poisoning............
Mumps  .......................................
Erysipelas ..................................
Acute Rheumatism........................
Gonorrhceal Rheumatism.................
Muscular        "     .................
Chronic          "     .................
   "    Gout.................................
Primary Syphilis...........................
Secondary  "    ..........................
Medullary Cancer..........................
Epithelial   "   ..........................
Osteoid      "   .........................
Scirrhus     "   .......................
Scrofula.......................................
Scrofulous Ophthalmia..................
Phthisis Pulmonalis .....................
Purpura  ......................................
Scurvy.........................................
Anasarca, effect  of action of Malaria
  * The two cases of congestive or pernicious fever were bi ought into the Hospital comatose
and moribund, aud died within eighteen hours. Quinine and stimulants had no perceptible
effect.
  1
  4
  3
  1
103
 12
  2
  8
  1
  1
  4
  2
  5
 32
  1
 28
 61
  2
  1
  2
  2
  6
  2
 63
  1
  2
  2
* 01 J Q°P5	
	4
	3
	1
	97
	12
	"8
	1
	1
	3
	1
	5
	20
	26
	45
	"i
	2
	34
	1
	2
	2
•2 t- t"
5 ° c
 2
 1
 2
13
 1
 1

1*2
 1
 2
16
 2
 1

"i
 3

16 
110                     Clinical  Memoranda.
DISEASES.
              Local Diseases.

     Diseases of the Nervous System.

Diseases of the Brain and its Membranes—
  Meningitis.................................................
  Apoplexy..................................................
  Sun-stroke................................................
Diseases of the Spinal Curd and its Membranes—
  Spinal  Meningitis ......................................
  Spinal Atrophy...........................................
Diseases of the Nerves—
  Hemiplegia...............................................
  Panplegia................................................
  Lead Palsy ............ ...........,......................
Functional Diseases of the Nervous Sysiem—
  Infantile Convulsions..................................
  Epilepsy...................................................
  Chorea.....................................................
  Facial  Neuralgia.......................................
  Btow Ague (Hemicrania)............................
  Sciatica ....................................................
  Delirium Tremens  ......................................
Disorders of the Intellect, Brain and Spinal Cord.
  Mania ; Dementia  and General Paralysis of the
    Insane  ...................................................
  Chronic Dementia and Paralysis....................
Diseases  of the  Eye—
  Conjunctivitis ...........................................
  Purulent  Ophthalmia....................................
  Scrofulous Ophthalmia ................................
  Gonorrheal Ophthalmia ..............................
  Opacity of Cornea.......................................
  Syphilitic Iritis ..........................................
  Scrofulous Iritis..........................................
  Cataract  ..................................................
  Blindness...................................................
Diseases  of the Nose—
  Ozsena........................................................
Diseases  of the  Ear—
  Otorrhcea.................................................•

   Diseases of the Circulatory System.

Diseases  of  the Heart—
  Valve Disease—Mitral.................................
                 Aortic.................................
  Fibrous Concretion in Cavities of Heart.........
Diseases of the Muscular Structures if the Heart
  Hypertrophy and Dilatation..........................
  Dilatation..............................................;•••
  Hypenrophy, Dilatation & Fatty Degeneration
  Hypertrophy, Dilatation and Valvular Disease.
  Palpitation and irregular action of Heart........
3	3
1	1
1	
6	1
2	1
3	1
2	...
2	2
 
Jones—Medical
DISEASES.
       Local Diseases—Continued.

Diseases of the Bloodvessels—
  Aneurism of Ascending Aorta, Fatty and Cal
    careous Degeneration and Dilatation of Heart
  Aneurism of Ascending Aorta....................
  Aneurism of Ascending Aorta & arch of Aorta
Diseases of Absorbent System—
  Non-Syphilitic Bubo.................................
  Scrofulous Disease of Glands.....................
Diseases of the Supra-Renal Capsule—
  Addison's Disease......................................
   Diseases of the Respiratory System.

Diseases of the Trachea and Bronchi—
  Acute Bronchitis....................................,
  Chronic Bronchitis..................................
  Asthma................................................,
Diseases of the Lungs—
  Pneumonia ............................................
  Vesicular Emphysema.............................
Diseases of the Pleura—
  Chronic Pleurisy.....................................
  Hydrothorax.........................................

     Diseases of  the Digestive System.

Diseases of Fauces and Palate—
  Tons'liLis ........................»-.....................
Diseases of the Stomach—
  Dyspepsia.............................................
Diseases of the Intestines—
  Acute Dysentery .........,...........................
  Acute Diarrhoea......................................
  Chronic Diarrhoea...................................
  Gbronic Dysentery and Diarrhoea..............
  Constipation...........................................
  Hernia ..................................................
Diseases of Rectum and Anus—
  Cancer of the Rectum...............................
  Haemorrhoids .........................................
Diseases of the Liver—
  Hepatitis ..............................................
  Cirrhosis of Liver  with Ascites.................
  Fatty Liver........................... ................
  Amyloid Disease of Liver.........................
  Jaundice ...............................................
Diseases of the Spleen—
  Hypertrophy of  Spleen.............................
  Leucoeyt hernia........................................
Diseases of the Peritoneum—
  Peritonitis........................................... ••
15 
112
Clinical Memoranda,
DISEASES.
       Local Diseases—Continued.

     Diseases of  the Urinary System.

Diseases  of the Kidney—
  Chronic Bright's Disease......................
Diseases  of ihe Bladder—
  Chronic Cystitis..................................
Diseases  >>j ihe Male  Urethra—
  Stricture............................................
  Urinary Fistula..................................
   Diseases of the Generative System.

Diseases of the Male Organs of Generation—
Diseases of ihe Penis—
  Gonorrhoea..................................................
Diseases of Tunica  Vaginalis—
  Hydr< cele...............................................
Diseases <f Testicle—
  Orchitis.....................................................
  Enlargement and Induration of Testicles........
Diseases <f the Female Organs of Generation—
Diseases  of the Uterus—
  Cancer of Uterus......................................
  Fibrous Tumor of Uterus...........................
  Prolapsus...................................................
Diseases of the Vagina—
  Gonorrhoea  ...............................................
  Vesico-Vaginal Fistula...............................
  Recto.Vaginal Fis ula...............................
Functional Diseases of Female Organs of Genera
      iion-
  Amenorrhcea.............................................
Disorders of the Female Generative System—
  Metritis....................................................
  Abortion.................................................
Diseases  of Organs of Locomotion.
Diseases of Bones—
  Scrofulous Disease of Bones...........
  Necrosis..................................•••••
Diseases of Joints—
  Synovitis....................................
Diseases of the Spine -
  Caries and Necrosis with Curvature
  Psoas and Lumbar Abscess ............
  Lateral  and Anterior Curvature.....
Diseases of Cutaneous System,
Urticaria  ..................................................    1
Paoriasis.....................................................>   2
tfjO'O


5^W
4	4
1	1
1	1
2	1
2	1
5	5
1	1
2	1
35   H 
Jones—Medical
113
	T3			Hi rrt E -- (4
DISEASES.	-»j	jTJ >		£ u<2
	g <	J. 3 <u	ns s	£ ° a a aj 35 H
Local Diseases—Continued.				
Injuries and Ulcers.				
	6	6		
	17 2 3 3 3 1 1 1 1 1	15 1 3 3 3 1 1 1 1 1		2
Amputation for Ulcer ol Foot.....				1
Felon .......;...................				
Contusion of He»d ...............				
Scalp Wound of Head ............				
Concussion of the Brain...........				
Fracture of Rib ...................				
Coniu-ion of Back....................				
				
Contusion of Abdomen*..................				
Inched Wound of Shoulder ...................	1 2 1	1 2 1		
Frrcture of Acromion Process of Scapula .........				
Fracture of Fore Arm .....................				
Incised Wound of Thigh.................................	2	2		
Dislocation of Femur ...........................	1 1 1	"i	"i	1
Fracture of Femur......................................				
Gun-shot Wound of Thigh...........................				
Incised Wound of Leg....................................	2 1 4	2 1 4		
Incised Wound of Knee ...............................				
				...
Conditions not necessarily associated				
with General or Local Diseases.				
	14 3 16 4	11 4	i 3 4	2
				
Old Age......................................................				12
Debility.......................................................				
				
Total.............................................	660	467	67	126
				----
  The cases treated, embraced  white  males, colored males and
colored females.
  The heaviest mortality occurred amongst the colored females;
thus tbe average mortality in all cases treated, was about ten per
cent.; whilst the mortality among the colored  females  was 17.5
per cent.   Nearly one-fifth  of  all the cases, entered upon the
sick reports of the colored females, were primary and secondary
syphilis.
  The diseases  causing death, stand in the following order,
according to the rate  of mortality, as  compared to the whole 
114:                   Clinical Memoranda.

number of deaths:  Phthisis Pulmonalis,  13 deaths, or 19.4 per
cent, of deaths from  all causes:  Diarrhoea  and  Dysentery, 12
deaths, or 17.9 per cent, of deaths from all causes; Diseases of
the  Circulatory  System, 9 deaths, or 13.4 per cent, of all deaths;
Diseases of the Nervous System, 7 deaths, or 10.4 per cent, of all
deaths.  These diseases alone caused 41 deaths out of G7;  whilst
Small Pox, 1;  Congestive Fever, 2;  Osteoid Cancer, 2; Scirrhus
Cancer, 1; Scrofula, 2; Addison's Disease, 1;  Chronic Bronchitis,
1; Cancer of Eectum, 1; Cirrhosis of Liver, 1; Leucocythemia, 1;
Chronic Bright's Disease, 3; Fibrous Tumor of Uterus, 1; Fracture
of Femur, 1; Parturition, 1; Stillborn, 3; Old Age, 4; caused the
remainder.
  No death  occurred  amongst the entire number, 123, cases of
Intermittent and Eemittent fever and chronic Malarial poisoning;
and  these forms of malarial disease yielded in most cases readily
and  satisfactorily to treatment.  The cases of Pneumonia and
Typhoid fever, in like manner recovered.
  Post-mortem examinations were instituted in most cases in the
presence  of  the students  of  the Medical Department, of the
University of Louisiana.
  Through the kindness of my esteemed friend  and colleague,
Prof. Frank Hawthorn, M. D., I was  enabled also to observe
many other interesting cases and post-mortem examinations, and
to obtain valuable pathological specimens.
  The following  catalogue presents a general view of the results
of my labors during  the past  fifteen months, in behalf of the
Pathological Museum of the University of Louisiana.

Patological Specimens,  Illustrating various Diseases, prepared by Joseph
   Jones, M* D., during fifteen months service in the Charity Hospital New
   Orleans, Ist Jan'y 1869—ls< April 1870.
 No.                    Description of Specimen.
  1.—Aneurism of left Ventricle of Heart.  The aneurismal cavity in the
      muscular wall of the heart is capable of  containing about two fluid
      ounces, and the walls of the heart have been reduced to a mere mem-
      brane, a  few lines in thickness.
  2.—Aneurism of Ascending Aorta.  Death occurred in the case  from rup-
      ture  of the aneurismal sack within the pericardium.  Case XXIV.
  3.—Aneurism of Ascending Aorta and Arch of Aorta. Hypertrophy and dila-
      tation and some fatty degeneration of  heart. Death was caused by loss of
      power in the heart, and by the arrest or interference of respiration 
Jones—Medical.
115
     caused by the pressure of the aneurismal tumor upon the bronchial tubes
     and trachea.  Case  XXVII.
 4.—Areurism of Ascending Aorta and Arch of Aorta.  Hypertrophy and
     great dilatation of heart.  The lungs, as well as the heart and aneurismal
     tumor, are preserved in this specimen.   Death was caused by the pressure
     of the aneurismal tumor upon the trachea  and  bronchial  tubes.   Case.
     XXVI.
 5.-^Aneurism of Descending Aorta.  The aneurismal tumor presents an
     hour-glass contraction.  Case  XXIII.
 6.—Vertebrae showing the effects of the aneurismal tumor of the descending
     aorta, in causing absorpton and erosion of the dorsal vertebrae. Case XXIII
 7.—Aneurism of Internal Iliac ;  pelvic bones preserved ; the tumor oc.upies
     a larger space than the pelvic cavity ; heart and aorta in  state of fatty
     degeneration.  Case XXII.
 8.—Hypertrophy, dilatation  and fatty  degeneration of heart; dilatation of
     arch of aorta ; fatty degeneration of arterial system.  Case XXIX.
 9.—Portion of cirrhosed liver, with  thickened  capsule from preceding case,
     XXFX.
10-11.—Dilatation of Heart.  The larger heart in the  superior portion of the
     glass jar was taken from the negro woman Case XIX, and the  lower heart
     from negro man.  Case XX.
12.—Dila'ation, Hypertrophy and Fatty Degeneration of Heart.  Case XVII.
13—Dilatation of Heart.
14.—Calcareous Deposit upon semilunar Valves of Aorta,
15-—Hypertrophy of Heart.
16.—Atrophy of Heart.
17.—Dilatation of Heart and of ascending Aorta.
18.—Hypertrophy and valvular disease of Heart.
19.—b atty Degenerated Heart.
20-28.—Diseased  Hearts,  representing  Hypertrophy  Dilatation, Valvular
     Disease, Fatty Degeneration and Pericardial Adhesion.
29.—Fibrinous clot formed in Cavities of Heart during life.   Patient entered
     Charity  Hospital, January 27th, 1869, with hurried, embarrassed res-
     piration, rapid, irregular pulse, and rapid irregular action of the  heart;
     the action of the heart was  tumultuous,  irregular and  thumping, and
     the sounds of the  right auriculo-ventricular valve,  and  of the pul-
     monary semi-lunar  valves were muffled and suppressed by the  fibrous
     concretion.
       The  peculiar and distressing  dyspncea was not caused by a check of
     respiration, for the respiratory murmur was audible enough, but by the
     arrest of the current of the blood in the lung3.  The dyspnoea evidently
     depended upon the imperfect circulation of the blood through the lungs,
     the damming back of the blood in the  venous system, and the imperfect
     supply of aiterial blood to tho lungs, muscles and nervous centres.  The
     left side of the heart being imperfectly supplied with blood, the arterial
     circulation is weakened, the pulse is small and intermittent, and  the
     surface of the body cold, or more correctly,  the animal temperature was
     depiessed from the diminished supply of oxygen.   At the same time, the
     arrest of the circulation, in the right or venous heart causes stagnation
     of the blood in the venous ciicuit,  and this together  with imperfect
     oxidation was manifested  in the purple  almost black hue of  the
     lips, extremities and cheeks.  The patient continued  to  grow  worse;
     the dvspricea increased ; the action of the heart became more  tumultuous
     and irregular; the restlessness  was progressively aggravated; tne patient
     could obtain no  rest, night  or day  ; was compelled to  maintain  the
     sitting posture, and  threw his arms  about, and heaved  his chest, and
     incessantly groaned  and  called  tor more   breath.  On  the  1:8th, after
     eating  his dinner, got up from his bed, walked a few steps and fell dead.
     The large, dense light yellow,  firm, irregular shaped fibrinous  clot was
     found  firmly attached to the Carneae  Columnar and Chordro tendiuese of 
116
Clinical Memoranda.
      the right ventricle and  extending through the  auriculo  ventricular
      opening; it was attached  to  the  valves, and  sent  off branches which
      were firmly adherent to the muscuW columns of the right  auricle,  and
      sent ofi' a long ribbon-like concretion  through the  pulmonary  artery,
      which divided and sub-divided, and followed "the course of the divisions
      of tie pulmonary artery.
 30.—Fibrin of Blood.
 31.—Fibrinous exudation from  the surface of Pleura.
 32.—Lungs and Heart:  Melanotic Deposit in Lungs:  thickening of Peri-
      cardium.
 33,—Miliary Tubercles and Melanotic deposit in  Lungs.
 34.—Hepatized Lung of  Pneumonia
 35—Abcess of Lungs, wilh Tubercular deposit.
 36—Indurated (Cirrhosed Lung) effects of Chronic Pneumonia.
 37.— Miliary Tubercles in  Lungs.
 38 —Scrofulous deposit in Lymphatic Glands and  Bones.
 39:—Tuberculous deposit in Lungs, Liver and Spleen of Monkey.
 40.—Tubercles deposited  in Lungs and Spleen of Monkey.
 41.—Fatly  Liver.
 42-46 —Fatty Liver and  Fatty  Kidneys.
 47-48.—Cirrhosis of Liver and  Spleen.]
 49.—Tubercular deposits  in Liver
 50.—Enlarged Spleen of  Malarial Fever.
 51.—Lobulated Kidney of Russian  Bear.
 52.—Horse-shoe Kidney.  Both  Kidneys united by a bridge.
 53.—Diseased Kidney and Ureter.   Subject had  but one  large Kidney.  The
     mucous membrane of the pelvis and Ureter was thickened  and altered.
     The Ureter was  greatly enlarged,  thickened and  indurated,  being half
     an  i..ch in diameter.
 64.—Fatty Kidneys,  Bright's Disease.
 55—Fauy Kidneys, Bright's Disease.
 56-59—Fatty Kidneys, Bright's Disease.
 60.—Fatty Kidneys,  Bright's Disease.
 61-63—Fatty Kidneys,  Bright's Disease.
 64.—Diseased Kidney.
 65.—Disease of Supra-Renal Capsule of Kidney.
 66.—Cancer of Kidney, organ greatly enlarged and infiltrated with cancerous
     deposit.
 67.—Cancer of Testicles.
 68—Cancer of Testicle.
 69.—Diseased Intestines,  Chronic Diarrhoea and Dysentery.
 70.—Inflamed Stomach (Gastritis).
 71.—Diseased Intestines,  Chronic Diarrhoea and Dysentery.
 72.—Ulcerated Intestines of Cnronic Diarrhoea and Dysentery.
 73.—Perforation, Ulceration and Fibrinous Deposit in Chrrnic Diarrhoea and
     Dysentery.
 74-76.—Diseased Intestines, Chronic Diarrhoea and Dysentery.
 77.—Cancer of Rectum.
 78.—Human Foetus.
 79.—Human Foetus rendered transparent, showing sfructure and development
     of the  bones.
 80.—Placenta
 81.—Enlarged  and  Inflamed Uterus after delivery, death  from Puerperal
     Peritonitis.
 82.—Extra Uterine Pregnancy.
 83.—Fibrous Tumor of Uterus.
 84-—Fibrous Tumor of Uterus.
85.—Fibrous Tumor of Uterus.
86 —Fibrous Turner of Uterus.
87.—Fibrous Tumor. 
Jones—Medical.                       117
 88.—Fibrous Tumor.
 89.—Colloid Cancer of Thigh.
 90.—Fibrous Deposit and thickening of Meninges of Human Brain, (Chronic
      Meningitis).
 91.—Fibrous D-posit and thickening of Membranes cf Spinal Cord, i Chronic
      Meningitis).
 92.—Human Brain.
 93.—Fractured Ftmur.  The patient, a stout, athletic man, during an attack
      of Delirium Tremens, jumped  out of the second story of the Charity
      Hospital, and fractured the neck of the femur, and died from the effects
      of the severe concussion.
 94-96 —Tibia and Fibula of man who had suffered from Rickets in  child-
      hood.  The bor.es are remarkable for their great strength, solidity and
      density.   If the patient outlive rickets and die afterwards, after attaining
      adult age. it will be found as in this case, that the bones have assumed
      great weight and  density, and in some instances, the cavities  of the
      cylindrical bones are said to have been filled up with earthy  matters.
      In these specimens the cancellated structure of the tibia is very dense and
      compact, and the medullary cavity of the shaft very nearly obliterated.
 97.—Ankylosis of knee joint from mechanical injury.  Patella firmly consoli-
      dated with femur.  Tibia and fibula firmly consolidated with each other,
      and to the femur. Bones present tho characters and dmsity of healthy bone.
 98.—Ankylosis of Knee joint; effect of Syphilitic and Rheumatic Inflamma-
      tion.   Patella consolidated with femur, and tibia  and fibula coni-olida ed
      with each other,  and the tibia (articulatingsurface), with the articulating
      surface of the femur.   The bone> are  light and spongy, and  of far less
      weight relatively than the bones of the  ankylosed  knee joint, resulting
      from mechanical injury.   (No.  97)
 99.—Carious Vertebrae.  Lateral curvature  of Spine  in adult man.   Death
      from sudden cause not connected with the disease of the vertebrae,  which
      was of long standing.
100.—Cranium of common cat, fhowing disease of lower jaw bone of the left
      side.  The ramus of  the maxillary  bone,  is  thickened  and  hyper -
      trophied, and presents a ragged plumose outline.
101.—Seque-trum from Thigh of confederate soldier.
      The fallowing is  an outline of this case:
      Charles R. Barker. C. S. vols. 7th Reg. La. Vols; height, 5 feet 8inches ;
      weight in health, 154 lbs ;  brown hair and eyes ; nervous, sanguine tem-
      perament.  "Wounded in right l?g at first battle of Manassas,  21st July,
      1861.   Minie ball struck the lower portion  of the right femur, about
      two inches above its inferior  termination, the knee joint.  The  Done
      was not fractured; the  ball simply  buried itself in the  femur.    The
      force of  the  ball  must  have been greatly  spent, otherwise  it  would
      have patsed entirely  through  the bone.  The  wour.d inflamed,  and
      assumed an unhealthy.appearance, and twenty days after  the  reception
      of the  wound, the  thigh was  amputated near  the  middle, or about
      eight and a half inches from the trochant.r major, in the General Hos-
      pital at Culpepper  Court  House,  Va.  After   the  operation,  the
      wound  did not heal, and the stump assumed an unhealthy, suppurating
      state   The patient was confined to his bed for more than  four  months,
      during which time, there was but little progress  in the healing of the
      wound,..the discharge continuing, although there was partial union of the
      flaps   At the end of  this period, the  patient attempted to walk on
      crutches, and on  the 20th of February, 1862,  whilst  the snow covered
      the ground, went out.   This caused the stump to inflame, an accumula-
      tion of pus took took place around the  bone, and  the flaps were opened.
      At this time, large quantities  of offensive pus were dischaiged.   The
      pa ient was so much reduced by this condition of the stump, thai he was
      compelled to remain in bed, until the first of June.   After this date, the
      wound  slowly improved and considerable portions  of the flaps united.
      In December,  the patient was able to travel to Georgia,  and enter 
118
Clinical Memoranda.
      the General  Hospital  at  Augusta, January 10th, 1863, and at this
      time came under  my treatment.   After  careful examination, the
      bone was  found to be extensively diseased ; and the discharge from
      several fistulous openings was profuse and foetid.   At the time that this
      patient entered the general hospital, he was inra most  weak  and feeble
      condition, aud suffered from  hectic fever, consequent upon the condition
      of the stump.  The pulse was rapid  and  feeble, and the complexion
      dusky and unhealthy.  The sloughing went on rapidly, until the bone
      of the thigh was exposed and denuded.  The patient was placed upon the
      Tartrate of Iron and Potassa,  Sulphate of Quinia,  generous diet, and
      stimulants and  opiates.  Under  this  treatment,  the  patient gathered
      sufficient strength to resume  the  use of his crutches.  After some im-
      prudence, the patient was again prostrated.   The bone which was exam-
      ined daily, finally  protuded a little  and gave unmistakable evidence
      that it was detached.  On the 24th of May, I placed the  patient under
      the influence of chloroform, and abstracted the bone, 1\ inches in  length
      and extending to the trochanter.   I lost  sight of this patient, until I
      found him in  the Charity Hospital this winter, just after I had exhibited
      the diseased bone to the Medical  class.   The limb healed up  entirely,
      and the patient wears a stump. The periosteum of the bone threw out an-
      other bone, and the thigh feels as if it had a large  bone.
102.—Superior portion of Femur of an adult male, afflicted with Cancer of the
      thigh.
        The trocanter minor and the shaft of the femur  for four inches below,
      present a rough, hypertrophied,  cancellated appearance,  with numerous
      spicules of bone.   The bone is  light, and porous very  different  from
      healthy bone.   The following is  an outline of this case :   John Morris,
      male, age twenty-five; height five feet six inches; weight 160 pounds;
      dark-brown  hair;  blue ej-es; ruddy  complexion; native of Norway;
      seaman ;  has  been subject to  rheumatism, three or four years.  Had
      syphilis one year ago.  Admitted to Charity Hospital,  ward 18, bed 268,
      March 22d,  1869,  with swelling of left thigh, extending to  Poupart's
      ligament, accompanied with pain; says that his leg began to swell two
      months ago.  During a period of two months before the swelling com-
      menced, the patient had been standing in the water, whilst surveying on
      the coast.  As the patient presented the appearance of  a cutaneous erup-
      tion which was supposed to be syphilitic,  he was placed upon Iodide of
      Potassium and  Bin-Iodide  of Mercury.    The eruption  disappeared,
      and the  general health improved under the use of these alteratives,
      and the skin affection disappeared ; but the swelling of the thigh, which
      presented a hard, nodulated feeling like a collection of lymphatic glands,
      continued to inerea-e.  The  local  application of lincture of Iodine and
      Iodine Ointment,  neither relieved the pain  nor arrested the  progress of
      the tumor.  The pain was so intense that it wTas necessary to administer
      opiates freely  at bed time.  The  following are the changes of the pulse
      and temperature:
        April 2d.—Complains of sharp lancinating painsin right shoulder and
      left thigh, and knee.  Pulse  100;  respiration 25.
        April 6th.—Complains of continuous pains during  the  night in left
      leg.  The patient locates the pain in the bone of the leg.   Bowels loose.
      Pulse 100, respiration 32.
        April 15th.—As the  case did not yield to ordinary measures, I called
      a consultation and it was decided to plunge an exploring needle into the
      tumor.  When  this operation was performed, nothing but bloody serum
      to the extent of one or two pints issued.
        May 12th.—Pulse 100 ; respiration 28 ;  temperature of axilla 100° F.
        May 14— Pulse 100; resp. 25; temp. hand97.25° F; temp, axilla 100° 5
         "  15    "  100  " 25   "    "  96.5       "     «   100°75
         »  16     "  100   "  58                      «     «   iou° 5
         "  17     "  100   " 27                      "     «   100°20
         "  19     "  100   temperature of axilla 99.°75. 
Jones —Medical.
119
        May 29th.—Pulse 100; respiration 26 ; temperature of axilla 100.
        May 31st.—Pulse 102 ; temperature of axilla 102.
        June 4th.—Pulse 130; respiration 35; temperature of axilla 101.5°.
        June 6th.—Pulse 105 ; temperature of axilla 100°.
        During an attack of illness with which I suffered in July, the wound
      was freely probed and lanced. Suppuration of the structures ot the thigh
      took place,  the  bowels became  loose, the  patient became restless  and
      feverish,  and was bathed in profuse  clammy sweats, and finally died
      about the middle of July, in a greatly emaciated condition.  Upon post-
      mortem examination a colloid cancer in a  state of destruction and gan-
    *  grene surrounded the upper third of the femur.
103.—Femur of adult female who died from  cancer of the thigh.  The tro-
      chanter  minor  and shaft of the bone for four and a  half inches is
      hypertrophied and roughened, and has shot out wing-like projections
      and elongated spiculae.  These spiculas  are most numerous, forming a
      porous cancellated structure, upon the  posterior surface  of the femur,
      and the roughness extends down, in a line, half an  inch broad on the
      posterior aspect of the bone, within two inches  of the  lower extremity
      of the femur.  The bone is light,, porous and unlike the bones in health.
        The following is an  outline of this  interesting  case:
        Cordelia Hamilton, colored;  aged 47 years; field hand and cook;
      native of Kentucky ; was admitted to ward 34,  Charity Hospital,  July,
      1869.   Patient says that up to July, 1868, one year ago, her health had
      been  good.   At that  time, she  noticed a swelling  in her right  thigh
      about the middle third ;  but this did  not give her much  pain, or inter-
      fere with her duties for several  months.   The swelling increased, with
      lancinating  pains, and occasional loss of sleep  at night.   Patient was
      never married, never had any children, and  the mammae were not de-
      veloped at stll.  Height, 4 feet, 7 inches.   On admission, the patient was
      somewhat emaciated, apparently feeble, and was too weak to stand up
      long at a time, and  was unable to walk without crutches.  The  right
      thigh was very  much enlarged, and felt warmer than  the left and  the
      leg below.   The pulse was about 95  per minute.  Some disturbance in
      action of heart referred to  pericardial effusion.  Respiration normal.
      Patient suffered with a cough which  sometimes  gave trouble at night.
      Temperature under axilla,  100°.  Appetite  poor,  bowels torpid, skin
      moderately cool, except over the affected  thigh.  The thigh felt  nodu-
      lated  and hardened, and the disease was pronounced to be a malignant
      growth surrounding and involving the bone.  Exploration with trochar
      gave no evidence ^f pus.  The right thigh  continued to enlarge,  and
      the knee and leg became cedematus.   On the  18th of August, the right
      thigh measured at knee, 16 J inches in circumference, at middle, 25 inches,
      at junction  with trunk, 22 inches;  the  sound left thigh measured at
      knee, 11 inches,, at middle, 12 inches, and at the junction with trunk,
      12  inches.  The following are the observations on the pulse, respiration
      and temperature upon the four days preceding death :
        Aug. 25. 9 a. m.— Pulse 96;  respiration, 16; Temp, axilla, 101° 2
            "    6 p. M—   "96;      "      16;   "       "   100° 5
        Aug. 26, 9 A. m.—   "  88;      "      16;   "       «    99° 5
            "    6 p. M.—   «  86;      "      16;   ',       "    101° 2
        Aug. 27, 9 a. m.—   «  88;      "      16;   "       •'   100° 5
                 6 P. M.—   "  85;      "      16;   "       "   100° 6
        Aug. 28, 9 A. M.—   «  88;       "      15;   "       '•   99° 5
            "    6 p.m.—   «  86;      "      15;   «       «   100° 0
        Died  August 29th'  The forces  grodually  gave way without  any
      marked symptoms.  Before death tne emaciation had been extreme.
        The following are the results of the post-mortem  examination:
        Exterior.   Great emaciation.   No mammary development upon chest.
      Right thigh greatly enlarged; left a mere shadow; the bone  with the
      skin and thin layer of muscles. 
120
Clinical Memoranda.
        Chest.  No adhesions.   Lungs emphysematous.  Pericardium con-
      tained considerable fluid.
        Abdomen.  Peritoneum very thin ;  sigmoid flexure greatly distended
      with gas ;  small intestines greatly contracted and anaemic.
        Liver  friable,  aid  on  its  convex  surface a small  circumscribed
      abscess. Kidneys lobulated and  contained cysts and small abscesses.
      Generative apparatus poorly developed.  The  abdominal aorta and its
      branches, presented appearances of calcareous degeneration.  The tlood
      was remarkably thin.
        The right thigh was carefully dissected.   A large encephaloid cancer
      involved the muscular structures of the thigh and surrounded the bdne,
      and numerous osseous spiculse extended  from the femur into tbe cancerous
      mass.  Under the microscope the  tumor was found to consist of cancer
      cells,  fibrous tissue,  oil globules and granular masses.  At one portion
      near  the head of the femur, the tumor was undergoing  softening, and
      this portion was loaded with granular  matter.
 104.—Sk leton of adult female, 2^ years of age, exhibiting the effects and
      ravages of constitutional and inherited syphilis.
        I observed  this unfortunate  woman, in the Charily Hospital, only a
      day or (wo before her death.  At the time of my observation,  she ap-
      peared to  be  exceedingly feeble and  was a mass of offensive running
      sores.  I obtained the body after death, and had the skeleton carefully
      prepared.  'Ihe hymen was  perfect, and the disease appeared to have
      been derived  from  inheritance, and to have manifested  itself in early
      childhood.  The feet are very  small—'not much larger than those of a
      child  four years old,  and appear never to have been used in walking.
      All the long bones of the body were more or less  carious, and in almost
      every case were fractured or rather ulcerated through  at one or more
      places.  The pelvic bones were  carious and  the os-sacrum a  mere shell.
      The vertebras were all  carious.  The  upper jaw  contained one small
      tooth  and  the lower  jaw three teeth.  The alveolae were  completely
      absorbed.  Tbe outer and inner tables of the skull were perforated in
      several  different places.  The lower  jaw on the  right side was eroded
      through.  The position of ti ese  fractures  or  erosions,  were marked
      during life by open running sores.
        It is impossible with the pen to portray adequately the terrible condi-
      tion of this unfortunate female, whose bones lite, ally  rotted piece-meal
      by piece-meal during life. And  the best description which we can give of
      the. skeleton is to say that the bones of the feet, ankle, the os  calcis were
      carious; the tibia and fibula;  the femur; the pelvic bones ;  the os-sacrum
      the radius andulna ; the humerus; the scapulaff and sternum  ; the lower
      jaw and the cranium, vtere all eroded through in various places.


   In the clinical report of the  cases, and in  the record of the

 temperature, pulse and respiration, during the term  of  Hospital

 Service,  I  have  received valuable assistance from  members  of

 the Medical  Class, amongst whom  it gives me pleasure to mention

honorably for their  attention  and  courtesy j  Messrs.  W.  P.

Ad kins*, of Texas ;  Henry Bezou,  La.; Rollin T. Burr*, Ala.;  S.

T. Birdsong*, Miss.; Benj. H. Baldwin*, Texas; S. R. Blakewood*.

La.; Wm. H.  Cunningham, Ga.; D.  A.  Cook*,  Texas;  L.  S.

McCrindell, La.;  Geo.  N.  Monette, Miss, j  E. N. Potts*,  B. F.
* Note—Now, M. D. 
CHAiLLfi—Medical
121
Rogers, La.; D. W. Ramsay*, Ala.; R. F. Wright*, La.; H.  M.
Longino*, La.; J. M. Hooper*, Miss.;  J. M. McFarland* ; F. H.
Tucker*; L. C. Cheek*, Miss.; J. D. Terrell*; J. D. Beck*;  H.
McDonnell* ; R. B. Carson* ; TV. G. Mclnnis* ; W. C. Moody* ;
R. G. Williams* ;  S. M. Jordan*.  My  thanks  are also due to Dr.
Jno. M. Cullen,  of this  city,  for valuable  assistance in the
preservation of the pathological specimens.
 The Yellow Fever, Sanitary Condition, and Vital  S'atistics of N~eic
     Orleans during its military occupation, the four years 18G2-5.
     Article No.  II.  By Stanford E. Chaille,  A. M , M. D.  Prof.
     Physiology, and Path. Anat., Medical Department, Univ. of La.
  u II faut modifier la theorie pour  I'adapter d la nature, et non la nature
           pour I'adapter a la theorie."—Claudk Bernard.

 The military occupation of this city was characterized by three
 exceptional facts; the  absence  of epidemics,  notwithstanding
 the annual presence of Yellow Fever, and of an unusually large
 number of the unacclimated; the  existence of  a Quarantine,
 more perfect  than civil authority  can possibly  effect, aud so
 perfect that an able advocate  (Dr.  Elisha  Harris, U. S. San.
 Com.,  1865, Supt. K. Y. Met. Board Health, 1870,) says, "by tbe
 exercise of absolute and relentless military authority, an impreg-
 nable system of Quarantine  was maintained;" and the enforce-
 ment of "excellent sanitary regulations" by an efficient sanitary
 police, so efficient, says the same advocate, that " so clean  a city
 had never before been seen upon the continent."  It is not singular
 that the co-existence of these three exceptional facts should have
 produced a deep impression upon the  minds  of the officers,  by
 whom  the Quarantine and  scavenging were enforced;  of the
 medical profession which in part has advocated  the former, and
 unanimously the latter;  and of the public which enjoyed  an un-
 usual exemption fiom the scourge.  The first and last ot these are
convinced that the unusual Quarantine and  cleanliness were the
unquestionable  causes of the unusual exemption  irom Yellow
 * Mow M. D. 
122
Clinical  Memoranda.
Fever epidemics, and concur with General Butler,  who  on De-
cember 24th, 1862, after seven and a half months' rule, recounts
in his " Farewell address to the Citizens," very many benefits
conferred on them, and among these " I have demonstrated that
the pestilence can be kept from your borders."  Parton, the en-
thusiastic biographer, devotes pages to the illustration of this
noble deed of the " Hero of New Orleans."  General Banks, his
successor, entertained the same views, and  the U. S,  Provost-
Marshal of New Orleans,  General James Bowen, writes in 1865,
that "from a  careful observation during  two years in  New
Orleans, I am satisfied that it was only by the vigorous exercise
of military power in the enforcement of the sanitary regulations,
that the city was exempt from the yellow fever; and that  with
the usual lax administration of such laws by civil authority, the
city will again be subject to its  visitation."
   The medical profession has been divided in its views.  Many
physicians   coincide  with  the  military  and  popular  opinion;
among these are Drs. E. Harris (U. S. San'y Com., Memoirs, 1867).
E. D. Fenner (N. O. So. Jour. Med. Sciences, May, 1866), A. Flint
(Pract. Med., 1866), and M. Clymer (Am.  Ed. Aitken's Practice,
1868).  It is believed that much the larger number  of the old
resident physicians of New Orleans oppose the opinion so generally
accepted; among these are Dr. J. C. Paget,  (Report of 1864 as a
member of a " Consultative Commission" appointed by General
Banks),  the author of  an  able  editorial (Nov.  No. 1866 So.
Jour. Med.  Science), and he, Avhose professional opinion is more
potent in this community than any other's, and who has for nearly
forty years served in the Charity Hospital, and annually observed
the yellow fever of New Orleans, Prof.  Warren Stone (published
lecture in New  York, 1867).  The question is important, and
requires for its decision a fair consideration of all the facts known
as to  yellow fever here during the War.  To appreciate  even
these, other facts are needed,  which shall now preface the
former.
   Facts referring chiefly to population, 1862-1865.
   Louisiana seceded from the United  States January 26th, 1861,
and aided to form the l' Provisional Government of the Confederate
States," February 8th, 1861. From this time to May 1862, thousands 
Challle—Medical.
123
of the citizens, with musket in hand, were scattered from the Rio
Grande to the Potomac; many found a last home from Bull Run
to Shiloh, and in the city there was an endless coming and going
of brother soldiers.  Commodore Farragut's  fleet  (U. S.  N.)
arrived in front of New Orleans, April 25th, 1862, and on May
1st, Gen'l Butler, U. S. A., with some 15,000 soldiers took military
possession of the city, whose civil population was diminished by
the thousands of citizens who had abandoned it.  On December
16th,  1862, Butler was relieved by Gen'l  Banks, who  was suc-
ceeded by Gen'l Canby, in May, 1864.  Civil replaced military
government March 19th,  1866.  The  military Board of Health
extended its mortuary records of the civil  population from No-
vember 1862, to May 20th, 1866.  The war had been virtually
terminated by the surrenders of Gen'l Lee, April 9th, Johnston,
April 26th, Taylor, May 4th, and Kirby Smith, May  26th, 1865.
Succeeding these surrenders, thousands of Confederate soldiers
and refugees, and  many freed men  flocked to the city,  giving it
during the balance of 1865 the largest civil population it had
ever contained.  There was now some relaxation, probably, in the
enforcement of Quarantine, and certainly some in the  vigorous
execution of scavenging and sanitary regulations.
  The facts given  indicate that the civil  population was  at its
minimum in 1862, and its maximum in 1865.  The general opinion
of intelligent citizens  who remained in New Orleans is that the
population was much diminished from May 1862, to May 1865.
Dr. Harris, in July, 1865,  estimated that then " the total popula-
tion,  including the permanent or the transient military forces,
was little less than 200,000."  Dr.  J.  J.  Woodward, U. S. A.
Surgeon General's Office, writes:  " As to  the civil population of
New  Orleans during  the period referred to, I have myself no
doubt at all that, the army of camp followers, sutlers, traders,
etc., far  exceeded  the number of fugitives, and should not be
surprised if, in fact, the civil population were shown to be really
larger than  before the war, but I  know of no  reliable  reports
bearing on the case."
  The United States census, 1860, estimated the population at
168,675, whieh. fact associated  with  the considerations above 
124
Clinical Memoranda.
 given satisfy me that the civil population varied from about 150,000
 in 1862 to 185,000 in 1865, or say for the four years 6C0,000.  It
 is quite certain it did not exceed 200,000 per annum,  or 800,000
 for the four years.  For the benefit of the death rate of  new Or-
 leans,  let  the above figures be accepted as the  extremes, and let
 full t stimates be  assigned  for statistical purposes, as follows :
 Total civil population of New Orleans, 160,000 for 1862; 170,000
 for 1863; 180,000 for 1864, and 200,000 for 1865.   It certainly
 cannot be complained that these figures under-estimate the facts.
  Fads as to yellow fever in New Orleans prior to 1862.
  During sixty-five years, viz., from the first yellow fever epidemic
 in 1796, (seventy-eight years after the foundation of the  city), to
 1862, there occurred about thirty-five epidemics, some too slight to
 deserve the epithet; however, of these thirty-five, not less than
 eleven were violent, aud the one of 1853 was so exceptionally terri-
 ble as  to have well deserved its characteristic designation, " The
 Great  Epidemic."  This, though supposed  at  the time to have
 exhausted the unacclimated material  on hand, was nevertheless
 followed by the epidemics of 1854 and 1855, each of which caused
 a  mortality which brought them in rank  with  their vilest
 predecessors, except 1853.   Two years exemption was followed
 by  the epidemic of 1858, which in this evil comparison attained
 an eminence never surpassed to the present day, except by 1853.
 Thus then, the six years, 1853-58, and more  especially the three
 successive years, 1853-4-5, constitute a culminating epoch in the
 yellow fever and  mortality history of  this city, from its  founda-
 tion to the present day;—and, for subsequent use, it is  important
 to insist on the  fact, that in the  entire history of New Orleans,
 no  three successive years  can be found at all  comparable in
 fatality with those mentioned.
  Though epidemics occurred in about one half only of the sixty-
 five years, yet it is probable that there were some cases of yellow
fever every year,  and it is certain that such  was the case from
 1840 to 1861. Though averaging  one  epidemic every two years,
yet their recurrence was so irregular  that several intervals of   '
exemption occurred, of as much as three, four and even five years,
viz: 1805-8, 181346,  1844 6, 1848-52, for the slight  mortality
in 1848 and 1849 scarcely justifies the designation of epidemics; 
C n atlle—Medical
125
 and to this list must be added the three last of these sixty-five
 years, those three which immediately preceded the military occupa.
 tion of the city.  During these the yellow fever mortality was less
 than for any  other three successive years  of which we have
 authentic reports, viz:  91 deaths in 1859, 15 in 1860, and none
 in 1861.
   In many past years, the first cases of yellow fever have been
 traced to the shipping, and in many others there has been as
 complete proof, as such negative proposition admits of, that there
 was no such connection, nor other reason to assign the origin of
 the disease to contagion,  or other mode of foreign importation.
 During the thirty-five years since 1843, an epidemic has never oc-
 curred when the first case was  later than  the month of June;
 I believe this would hold good for the whole time since 1796.  The
 only apparent exception, I have found, is for the severe epidemic
 of 1822, in which there was uncertainty as to the date of the
 first cases, but it was certainly " as early as the beginning or
 middle of July."  First cases have appeared as early  as June
 without being followed by epidemics.
  The first Quarantine  established was maintained only four
 years, 1821-4,  having been abandoned early in 1825 from the
 general conviction that it had  proved worse  than useless,  for
 yellow fever was present every year, and to the extent of a very
 violent epidemic in 1822, and an epidemic in  1824.  After thirty
 years discontinuance, the Quarantine  was re-established  iii
 March, 1855, and is still enforced.  Very violent epidemics occurred
 in 1855,1858, and 1867, and excepting perhaps the year 1861, there
 have been cases of yellow  fever every every year of the existence
 of the present Quarantine.
  Thus including the whole time, seventy-three years, from 1796
 to 1870, there have been nineteen years with Quarantine.   During
 thesa, there  have been cases of yellow fever every year (1861
 perhaps to be excepted), and there have been five epidemics of
 which four were very violent.  Now with these facts as to epi-
 demics and Quarantine, let there be associated  another  fact so
 notorious as to require no proof, that the sanitary condition of New
 Orleans for the whole time, excepting the fou r  j ea 1862-5, has
been one long, disgusting  story of stagnant drainage, foul  sewer- 
126
Clinical  Memoranda.
age, environing swamps, ill- and un-paved streets,  no sanitary
regulations, and  filth, endless filth every where.   An  official
description of this notorious and habitual filth will be found on
a subsequent page.  There has been no improvement since the war
in these matters, which could never have been worse than in 1868
and in 1869.  This year, 1870, has brought a little hope, small as
a babe, may it grow as well!
  A logical mind, which, cautious as to facts,  is yet self-sufficient
enough to judge for itself, and wh;ch analyzes the motives and
reasons for the decisions of the multitude,  knows  well how fear
exaggerates facts, and hope jumps at  conclusions, and will not
be surprised, after reading the above brief record of the epidemics
of sixty-five years, that the hostile population of New Orleans,
so greatly  scourged  by yellow fever,  should have  confidently
anticipated  that  if the eaemy should take  New Orleans, the
yellow fever would take the enemy.   Nor is  it surprising, that
the U. S. authorities should  have  shared these anticipations,
and that all should have attributed the  non-realization of them
to the only exceptional conditions known to and comprehensible
by them, viz ; the rigid enforcement of Quarantine and of Sani-
tary Regulations.  Is it necessary to  warn, that  conclusions
originating in hopes and fears, and founded on insufficient pre-
mises are not trustworthy %
               Theories of  Yellow  Fever.
  Some prefatory remarks  on this  subject should  precede the
record of 186J-5; in order that each reader may  judge for  him-
self, which theory the evidence favors.   The various opinions
entertained by the profession may be summarized under three
heads, with a fourth for numerous modifications of the three.
  1. Yellow fever is communicable by both person and fomites,
i. e.,—is both contagious and portable,  as is small-pox.
  2. Yellow fever is communicable by  fomites, but not by person,
j, e>}—is portable but not contagious.
  3. Yellow fever is not communicable either by person or
fomites, i. e.,—it, like malarial fever,  is neither  contagious nor
portable; and attacks those only  who are  exposed, to the places
(never the person) where the poison is. 
Chaille—Medical
127
  4.   Yellow fever is produced by two different poisons ;—or by
one which causes different results, depending on the place where
it  is generated, the quautity  produced,  and the different con-
ditions of those poisoned.  Thus, the poison is sometimes either
contagious or portable, or both, and at  other times  is not.  To
illustrate, some physicians in New Orleans who have favored con.
tagion and Quarantine, and yet been forced to acknowledge that
the disease originates here, have contended that only foreign
yellow fever ever caused epidemics, and that the domestic poison
never manifested itself except endemically and sporadically.
This fourth theory or theories embrace  La Roche's "contingent
contagionists."
  In considering these theories, it is well to recall that there are
many medical questions in  regard to  which, the evidence  is too
contradictory, and the premises are insufficient to justify an abso-
lute  conclusion ;  and that  it has been said, well if not always
truly, that "when two physiciaus  quarrel over their  opinions,
there is in the midst of  their  contradictory arguments but one
thing certain,  which is that their theories are  insufficient  to ac-
countforall the facts, and that neither represents the whole truth."
  Unbiassed minds are now properly prepared, as I think, not
only to receive, but also to judge, each for itself, the facts which
follow:
          Yellow Fever in New  Orleans, 1862-65.

  1862.   No evidence of the existence of the disease has been found
in the official records, which however  are defective from July to
November.  Dr. E. D. Fenner says  (May ^So. 1806,  Southern
Jour. Med. Sciences): " I myself saw a fatal case of'yellow fever
near St. Mary's Market, in July, 1862, that was  imported from
Key West, Florida.  There may have been others which have
not been brought to light, for  every effort  was made to  ignore
the existence of yellow fever in the city,  to  prevent panic among
the soldiers."   The editorial  in the  November No., 1866,  So.
Jour. Med. Sciences, says :  " On the 12th of September, 1802, we
saw, with our own eyes, as malignant a case of the disease near the
St. Mary's Market, as we ever  beheld.  It was characterized by
black vomit, haemorrhage, etc.   The subject was a robust  man
        17 
128
Clinical Memoranda.
 from New York, who had arrived  here recently on a  tug-boat
 from that city, the boat having laid in the harbor of Nassau [in
 the British Bahama Island  of New Providence,] at  which  place
 the disease was for the first time prevailing, four  days, and this
 man having gone ashore more than once.  He died on the fourth
 day of his illness.  He  was  attended by  unacclimated persons
 male and female, and we made it our business  to watch the
 neighborhood until October 1st following, but up to that date
 no new cases appeared."  There is then ample proof of the exist-
 ance of imported cases of yellow fever in New Orleans  in  1802,
 and of the non-extension of the disease to any observable degree.
   1863.  The official records of the  civil population,  report only
 two d^cths by yellow fever  in 1863, occurring in the two weeks
 September 6th—20th.  Dr Harris writes (no doubt as to the same
 cases), that  two well marked  and fatal cases occurred in the
 autumn of 1863, and were received in the Charity Hospital, both
 were boat hands from a river tug.   " Nearly one hundred cases
 of the fever occurred in the  river fleet  and  in the * Naval  Hos-
 pital that season.  The history  of all these cases in detail shows
 that they were not of imported  origin.  They nearly  all occurred
 in crowded, filthy and unventilated gunboats that were at anchor
 in the  river at  New  Orleans."   The Quarantine  officer  (Dr.
 Baldwin),  reported  at  the  Quarantine,  about  sixty-five miles
 below the city,  three of the river fleet sent down from  New
 Orleans with twenty-three cases of yellow  fever, of  which  nine
 died (September 22d, to October 20th); and on  July 4th, +1863,
 the Spanish man-of war Pizarro from Havana was ordered into
 Quarantine  while on the  way up the river.  There were fifteen
 cases of yellow fever on board.

  * The Naval Hospital occupied " a large pile of old buildings," located one square from the
 river levee, and between Hew Levee, Tchoupitoulas, and  Erato streets. The "Sailors
 Home," located in the same place, has interest for the epidemic of 18C7; and Girod street  a
 few squares lower down the river than Erato street, was the chief scene of the cases which
 occurred in 1857. The " St Mary's Market," which has been  referred to for 1102, is between
 New Levee, Tchonpitoulas and St. Maiy's streets, (the last is about three-quarters of a mile
 above Erato street.) Lake Pontchartrain and the " Basin" are to be referred to: The Lake
 is north of New Orleans, and four and a half to seven  and  a half miles distant from the
 various parts of the seven miles of ri^er upon which the city fronts.  There are two
 " Basins," each a terminus in the rear of the city of the two canals which extend to the Lake.
 One is about three-quarters of a mile from the river and from the Naval Hospital; the other
 is about half a mile from the river, and one and a half miles from the Naval  Hospital
 tDr. J.J. Woodward, "Ci  cular No. 1, Surgeon-General's Office, 1868," gives this date as
July 4th, 1864.  The report of the Quarantine Officer and of Dr. Harris indicate positively
the date given in the text. 
Chaille —Medical.
129
  Dr. Harris says that,  from July 4th, 1863, to  September 10th,
1865, the Pizarro was the only vessel at Quarantine which brought
yellow fever from any other place than from New Orleans.
  1864.—The official records report six deaths by yellow fever of
citizens; the first occurring during the week September  26th-
October 2d, and the last, December 12th-18th.  One of these six
deaths occurred October 19th,  in the  Charity Hospital, from
which was discharged, November 29th, the second and only other
case which entered this hospital. There is then a total of seven
cases with six deaths officially reported for  1864. It is no  doubt
to five of these six deaths that Dr. Harris thus refers :  " In 1864
there  were five undoubted and  fatal cases of yellow  fever,
terminating in black vomit."  They " occurred in persons who
resided or daily visited in the vicinity of" the Naval Hospital.
" They were exposed to known causes  of the fever.   Other
cases may have occurred; if so, they  have eluded all search.
A few lines  below he  rather singularly adds,   " *  *  *   the
five cases occurred outside of the hospital premises.  Other cases
occurred, but they were directly dependent on  intercourse with
the infected vessels, and the bedding brought from those vessels."
  The above account of yellow fever among the citizens of New
Orleans in 1864 might no doubt be qnlarged by research even
now,  but sufficient has  been given to prove all which  greater
research  could  prove,  viz., that in spite of an " impregnable
Quarantine " and an " efficient sanitary police," yellow fever ex-
isted, but did not become  an epidemic, nor extend to any notable
degree.  One additional fact, as to the six deaths in this year,
should be borne in mind,  as applicable  to  all  years.  So  many
deaths by yellow fever seldom indicate less than three  times as
many  cases, and generally more; and that in many years, as is
well known, civil physicians have rendered themselves liable to
Dr. Tenner's criticism of fhe military authorities, inl862 "every
effort was made to ignore the  existence of yellow fever in the
city, to prevent panic."
  What may be termed the naval history of yellow fever in New
Orleans in 1864 is  much  more important  than the above civil
history, much of its interest is due to the facts, that it supplies
the best  evidence probably  ever given or attainable; 1st, that 
130
Clinical Memoranda.
an "impregnable Quarantine" enforced by "rigid and relentless
military authority," and the absence of any discoverable source
of importation, did not  avail to keep the disease out of  New
Orleans; and, 2d, that it originated in New Orleans in 1864, just
as the majority  of our physicians,  having a long practical ex-
perience, have constantly maintained that it did in other years.
  The three following statements deserve consideration :
  1.   " The official usages and the armed  discipline of the naval
fleet in the harbor of New Orleans and upon  the river,  enabled
the medical officers to trace to its source every case of yellow
fever that occurred in the gunboats."
  2.   " The infected vessels were under an aimed surveillance and
discipline,"  and  " no  communication  with infected vessels was
allowed."   (It is observed of two only of  the twenty-five vessels,
to be referred to, that free communication with  infected vessels
or the shore did occur).
  3.   No  infected vessel  from a  foreign  port arrived  even  at
Quarantine.
  Now, notwithstanding all this, twenty-five  vessels, iron ckd
gunboats, etc., were attacked with yellow fever.   More than 200
cases, of which fifty-seven died, contracted the disease on board.
Many of these cases were removed to the Naval Hospital, where
thirteen persons  are  specified as being on duty,  (there  were
doubtless more) of whom twelve were attacked,  and three  died.
Thus a total is given of more than 212 cases,  and certainly not
less  than  sixty deaths.   Of the  thirteen  cases contracting the
disease at the Naval Hospital, five were in a guard of six soldiers,
of which one died.  Of the many United States soldiers in New
Orleans in  1804,  there were probably more cases and deaths than
in these six; but unfortunately I have  not been able to procure
any reports of the army, so as to enable me to  complete the civil
and naval history of yellow lever in New Orleans in 1864 with
its military  history.  In alluding to this defect,  I will close the
list of omissions  to be regretted : these are the failure to  state
what was the total number of vessels of  which the twenty five
were a part; what the  number of the unacclimated exposed on
board of  these twentvfive  to the poison infecting them- and 
Chaille—Medical.
131
whether those on duty at the Naval Hospital, and attacked there
had certainly not been on board of any of the infected vessels.
  Of  the  twenty-five vessels, two were tin clads in the Lake
Pontchartrain police service, and one was a sloop from the Lake
(probably  a trader)  " lying in the Basin, tied up alongside of the
wharf." This sloop had free communication with the shore.
The  other two were certainly  not less than four miles distant
from, and had no  communication with the  river or city.  The
first  case  on these  three vessels occurred September 23d, in the
" Fort Gaines, a tin clad in the lake police service." The remaining
twenty-two vessels were in the river service.  Four were in what
may be comparatively termed, active service, two tug boats, and
two  " steamers," running between New Orleans and the blockad-
ing fleet off the Texas coast.  The eighteen others  were moored
at the wharves, or at anchor in front of the city,—one, however,
was  two miles below the city, from whence  it had not moved for
a year, whilst a second " laid probably three and a quarter miles
farther up the stream than most of the others."  The river fronts
the city for about seven miles, and " most of the others " seem to
have been near the Naval Hospital.
  The first of all the cases known in 1864, occurred on September
12th, and  the last death was on December 18th.  The first case
occurred on the "Meteor," \%hich came from the "Head of the
Passes" of the Mississippi Paver, ninety five miles below the city.
She  had been at anchor at New Orleans some two months.  The
next two  cases occurred on  September 21st, one in the " Ports-
mouth" which " had been lying at anchor before the city for two
years;  no communication  with infected  vessels allowed;  has
viaited no other port since leaving Portsmouth, New Hampshire:"
tho  other in the  ordnance  ship  "Fear  Not,:'  which had had
yellow fever badly  in .1803, but had not moved for a year from
Trhore she then was "lying two  miles below  the  city."  The
fourth case recorded was on  Lake Pontchartrain, as above men-
tioned. The fifth case was the first on the four vessels referred
to as being in more active service, and occurred September 24th,
on the steamer "Arkansas" which had been lying in the river,
at the foot of Erato street, for about three weeks before the out-
break of the fever, and had been running between New Orleans 
132
Clinical Memoranda,
and the Texas blockading fleet.   After  September 2Gth,  forty
cases with fourteen deaths (included in the totals given), occurred
on the "Arkansas," during a trip of twelve days from New Orleans
to the fleet,  and back to the Quarantine station.  A sixth case of
interest is recorded, as occurring September 26th, on the ironclad
" Tennessee" which was captured August 5th 1864, in Mobile Bay,
and brought to New Orleans.  [Dr. Fenner says that "at Mobile,
where we remained during the summers of 1803 and 1864,  there
were no unquestionable cases of yellow fever")  It was manned from
various healthy vessels of the fleet.  "The first man taken sick
was a negro, native of New Jersey, who  had not been on  shore
since he left New York."
  It is said of these twenty five vessels generally, that they were
remarkably  close  in  their exterior construction, hot, filthy, ill-
ventilated and overcrowded " gunboats and other vessels  lying
idly at anchor within a mile from the densest portions of the
city."   It is also  asserted " that vessels  and river boats  of
ordinary construction and in active service escaped yellow  fever
almost without exception."  Of one hundred and  twenty active
steamers and sailing  vessels under  the  control of the quarter
master  in  charge of water transportation,  " only  one   had
yellow fever on board;" these  were "open, ventilated, and
moving briskly about from place to t>lace, yet infinitely more ex-
posed to  all sources  of  exotic  iniection."  In connection  with
these statements, should be re-called that  which  has been re-
ported of seven of the  twenty-five vessels, in  active  service
comparatively to the  other eighteen.  Three of the seven  were
not in the Mississippi river, and had sixteen  cases of which four
died; the other four were in the river, and  had sixty-one  cases
of which twenty-five died.
  The preceding Naval History is only an abbreviated account
of Dr. Harris' details, which account contains, it is believed,
every fact of any importance, and completes the history of yellow
fever in New Orleans  so far as I have been enabled to gather
the facts.
  1865.   Only one death  by yellow fever is officially  recorded.
It occurred in the week August 20th—27th. 
Chatlle—Medical.
133
   The details of the sanitary history of New Orleans for the five
 years, 1866-1870, will be given in a subsequent article,  however,
 the following facts in  reference to yellow  fever and other epi-
 demics, have an interest in connection with the present subject.
   1866.  There were 192 deaths by yellow fever, of which  93 oc-
 curred in the Charity Hospital out of 130 cases; and 07 of the 192
 died in the month of October.  The first case occurred August
 9th.   On July 14tb,  the  cholera, prevailing in  Europe and
 America, appeared,  causing  1294 deaths, of which 99S occurred
 in the months of August and September.  There were 188 deaths
 by variola and varioloid.  The total deaths were 7754.
   1867.  There  were 3107  deaths by  yellow fever, a greater
 mortality than by any preceding epidemics, except those of 1853
 and 1858.  Of 1493 cases in the Charity Hospital, 672 died.  Of
 the 3107 deaths, 2709 occurred in the months of Sepember and
 October.   The first case sickened  on the 5th and  died on the
 10th of June.  There were  581  deaths of cholera, and 444  of
 these in  November and December. There were 47 deaths  of
 variola and varioloid.  The total  mortality was 10,096.
  1868.  There were 5 deaths only by yellow fever.  These are
 recorded as having occurred in the Charity Hospital, where three
 was a total of eight cases.  There were 129 deaths by cholera,  of
 which 120 occurred in January.  Variola and varioloid caused 14
 deaths.  The first official annual  statement published  is in the
 April No. 1870 of this Journal, and reports a total  mortality  of
 5343, which indicates the smallest death rate which has occurred
 since  1845.
  I960.  There were only 3 deaths by yellow fever.  One of these
 occurred in the Charity Hospital where  there were  three  cases.
 Cholera has  disappeared since January 1868 to the present time.
 Variola and  varioloid caused 141  deaths, of which 122 were in
 November and  December;  these diseases have continued to
 date (June 1870), causing a monthly mortality of from 56 to 122,
 and a total mortality for the five months of 446, more than three-
fourths of which has been of negros.  The total mortality for the
year 1869 was 6001; indicating a gaina small death rate for New
Orleans. 
134
Clinical Memoranda.
Mortality in New Orleans by all Diseases, During tiie
                     four Years 1802-65.
  I owe to the official courtesy of Surgeon General J. K. Barnes,
U. S. A., and to the  personal kindness of  his aid,  Brevet. L't.
Colonel,  J. J, Woodward, U.  S. A.,  the weekly reports of the
civil population as  recorded  by the  Military  Board of Health,
from November 1862, to May 20th, 1866.  For the remaining ten
months of 1862, I have procured from data  at the  Board  of
Health's office, and in the daily papers, reliable reports for the
first six months, whilst for the remaining four months, July—
October, no  records have  been found  which  justify  anything
more than an approximative estimate  (from total deaths of thirty-
five weeks known) of 6278 as the total mortality for the ytar.  If
there be an error in this, it inclines to an under, rather than an over
estimation.  The official records furnish, with as  much precision
as usual,  the total  civil mortality of the three years, 1803-65.
From all the facts the following table has been constructed :
Addendum to Table No. 1.   (See N. 0. Journal of Medicine, Jan'y 1870.)
Years.	Total Population Estimated.	Total Deaths of Civil Population 3y Board of Health.	No. of Deaths in every 1000 Population.
1862 1863 •1864 1865	160,000 170,000 180,000 *200,000	6278, Est'd. 7306 8498 7016	39.2 43. 47. *35.
4 years, 1862-65	710,000	29098	41.
  * If the population did not exceed 185,000, as I believe, the death rale was
38 per 1000 in 1865.
  If the above estimates be deemed unacceptable, then it will be
found that a maximum greater than ever claimed, (viz., 200,000
per annum)  gives  a death  rate for the four years of more than
36.  per 1000,  and  that  the minimum  population  which may
reasonably be claimed for the four years, (viz. 660,000), gives" a
death rate of  more than 44.  Thus it may  be accepted as
certain that the death rate during the war averaged from 36. to
44.  per thousand  population, and  that 41. per thousand as
above given, is an acceptable average for the four years. 
Chaille—Medical
136
  In order that the mortality  in New Orleans during  the war
may be thoroughly compared with the mortality in preceding as
well as in  succeeding years,  the  three  last colnmus  (Auuual
Averages) of Table No. 23 are referred to.  It is the only portion
of the pages of figures which follow, to which the general reader's
attention is especially solicited.  For these three columns accumu-
late, as to a focus, the  most important facts, and effectually dis-
pose of some  very  positive, but erroneous  assertions   To ap-
preciate rhe information given, the following facts must be kept
in mind. The first column of "Annual Averages" gives the annual
average of the three years 1863-1865, and not of 1862, because
it is for these three years only, that we have complete aud reliable
official records. Thesamereasonhaslimitedall of the tables given,
Nos. 22, 23 and 24 to the same years.  The second column gives
the annual  averages  of  the five years 1856-1830, the  first five
years immediately preceding the war, of which  we have  complete
official records.  The last column  gives  the annual averages  of
the four years which have elapsed  since the war, the details  of
which,  with  1870,  will  be published in a subsequent article.
This comparison shows plainly, that notwithstanding the facts,
that in the five years 1856-1800, there was one jear (1858) ot the
next to the most fatal  yellow  fever epidemic on record ; aud
that  iu  the four jears 1866-1869, there  was  an epidemic of
cholera in 1866, and in 1867 of yellow fever, tie  third in fatality on
record; yet the total annual average mortality of the three war
years (non-epidemic) was actually  greater than in the jears pre-
ceding or succeeding thein.  Still lartherand more important, that
there were annually more deaths of females, more deaths  of chil-
dren under ten yearsof age, and more deaths of men over seventy
years of >'ge, duriug the  war, than annually during the two otber
periods of time cited.  Now, however unsatisfactory mil) be the es-
timates of population, no one can claim that the  populat on of fe-
males, of children under ten years, and of men over seventy years,
was greater during the war than during the years which both pre-
ceded and succeeded the war.  Yet the mortality vri s greater.   It
should be remembered, as to the three columns of annual averages,
that it with the three war years, there had been compared the
18 
136
Clinical Memoranda.
three years which immediately preceded the war, viz, 1859, 1860,
1861, and the three non-epidemic yellow fever years which im-
mediately succeeded the war, viz, 1S66, 1868, 1869; then in such
case the comparison  would  have been, not slightly, but im-
mensely to the disadvantage of the three war j ears.  The official
records then permit no discussion, and leave no  doubt whatever
that the civil death rate in New Orleans, during the war, was
fully equal to the non-epidemic ante and post-bellum death rate.
Among other facts of interest demonstrated by the tables, is the
augmented mortality of negros, doubtless due, in large degree, to
an augmented population of negros. 
Chaille —Medical.
137
                            TABLE No. 22.
    Mortality Report  of New Orleane for the three years,  1863—1865.
(Nomanclature and Classification of the Royal College of Physicians, England.)
Population of New Orleans by the U. S. Census of 1860, was 168,675.
    "          «'       from 1863-65 supposed to have been  150,000 to 200,000

             General Summary for Three Years, 1883-65.
Diseases by Classes and Orders.
  * General Diseases A.......
  f     "      "     B.......
  Local Diseases—
  Nervous System...............
  Eye...............................
  Ear and Nose..................
  Circulatory System.........
  .\bsorbent System............
  Ductless Glands...............
  Respiratory System..........
  Diiresave     "    ..........
  Urinary      "    ..........
  Generative    "    ..........
  Locomotory   ".........
  Cellular Tissue................
  Cutaneous System ............
  Conditions Unclassified ....
  Poisons .........................
  Injuries.........................
1 General  Injuries  .............
2 Local Injuries................
  Surgical Operations..........
  Parasites ........................
  Congenital Malformations.
  Conditions Unclassifiable  .
Total Citizens and " Soldiers included ".
Total No., ''Soldiers included"...........,
Total No. Citizens, Soldiers excluded.
Deaths i		n
1863	1864 2105	1865 ■ 582
1151		
1043	1140	922
807	971	1014
0	0	o
0	0	0
178	161	169
0	0	0
1	0	0
503	72 *	510
2190	2352	1532
37	44	36
17	40	44|
1	2	3
0	0	0
8	12	81
727	851	834|
30	35	37
147	147	141
$155	53	49,
0	2	11
2	8	12
3	0	2l
258	213 8864	124 7020
117258		
86	366	4
7172	8498	7016
 Total
Deaths
 3 yrs
1863-65.

  4838
  3105

  2792
     0
     0
   508
     0
     I
  1741
  6074
   117
   101
     6
     0
     28
  2412
   102

   435
   257
     3
     22
     5
   595

 23142
   456
22686
  * "Zymotic, apt to be Epidemic."
  f " Constitutional, apt to be inherited."
  £ 133 of these 155  were " Gunshot Wounds."
  || Export of 2d- week, August 1863 defective —Only 2 Cemeteries  out of 15
to 20 sent in Reports, giving only 24 deaths for 2d week, whilst there were 177
deaths in the 1st, and 158 in the 3d week Augt.   IS ot  less than 134 deaths
should be added to supply this deficiency ;  thus making total deaths of citizens
in 1863 not less than  7306. 
138
Clinical Memoranda.
               TABLE No. 22—Continued.
Detailed Report < f the Preckdinq General Summary.
Diseases.
Small Pox and Varioloid.....
.vieasles............................
Scarlet Fever ....................
Diphthei ia........................
tioopit g Cough .................
Gangrene .........................
Erysipelas .....................
Puerperal Fever.................
Pyaemia  ..........................
JTyphus Fever....................
iTyphoid  "  ...................
'Brain and Nervous Fever  ...
!" Fever "..........................
[Malarial Fever..................
Congestive Fever...............
Pernicious Fever......... .....
iYell<«w Fever...................
Other Diseases of this Class.
Total of General  Diseases A.
Rheumatism...................
Gout..............................
Syphilis .........................
Cancer ...........................
Tum.»r->...........................
Lepro-y (Elephantiasis)...,
Scrofula and Tab.  nesent
Phihisis Pulm malis.........
Pu-pura r.nd  Scurvy........
Anaemia.........................
Dropsy..........................
Total General Diseases B.
•' Disease of Brain "..........
 'ongestion  of Brain .........
Encephalitis ...................
Meningitis.......................
Softening of Brain............
Apoplexy........................
Sun-struke.......................
Hydrocephalus.................
Insanity..........................
Di;-ea>es of Spine..............
1 aralysis........................
Tetanus..........................
Tri-mus Nascentium.........
Convulsions Adult.............
    "       Infantile.......
Epilep y..........................
Hydrophobia....................
Catalepsy, Hysteria.-..........
Neuralgias, "Nervousness
1863  1864
  2
 !8
 43
188
 55
 19
 15
 12
  8
  9
257
 33
 75
145
110
 79
  2
  1
1151
TV)tal Diseases Nervous System...............   807
 15
  2
  3
 46
  7
  0
 36
76i
  5
 15
153
1043
  4
 81
 57
 44
 13
 61
  6
 20
  9
  7
 28
 74
 79
 29
265
 25
  2
  0
  3
605
 34
200
337
 39
 11
 26
 11
  4
 11
268
 48
 25
164
194
122
  6
  0
1865
2105
 18
  2
 11
 66
  2
  1
 21
839
  9
 23
148
1140
 10
111
 47
 58
 11
 75
  1
 20
  7
  5
 35
 85
137
 12
296
 55
  1
  3
613
 31
161
104
 13
  9
 20
 18
  2
  5
154
 26
 17
132
169
105
   1
  2
Tnt'ld'fbs
 3 years,
 1863-65-
1582
 16
  2
  5
 67
  2
  0
 21
664
  4
 35
116
922
971
  0
 97
 62
 71
 13
100
 22
 26
  7
  7
 37
109
125
 18
275
 43
  0
  1
  1
1220
 163
 404
 629
 107
  39
  61
  41
  14
  25
 679
 107
 117
 441
 473
 306
   9
   3
4838
101'
  49
   6
  19
 169
  11
   1
  78
2264
  18
  73
 417

3105
  14
 289
 166
 173
  37
 236
  29
  66
  2;l
  19
 100
 268
 341
  59
 836
 123
   3
   4
   6

2792 
ChatllS—Medical
139
TABLE No. 22—Continued.
O
Diseases,
" Disease of Heart.".......................
Perocard- and Endocard-itis.............
\ngina Pectoris..............................
Aneurism.......................................
Cyanosis........................................
Haemorrhage..................................
Other Diseases of Circulatory System.
 Total Diseases Circulatory System.

6 Goitre.......................................
3 8
Lpryngitis...............................
Croup.....................................
Catarrh...................................
Bronchitis...............................
Asthma and Emphysema ..........
Pneumonia ..............................
Abscess and Gangrene of Lungs.
Congestion of Li-ngs..................
Haemoptysis..............................
Pleurisy.......... ......................
Hydrothorax............................
Total Diseases Respiratory System
 Angina—Inf.  Throat and Tonsils.........
Teething ..........................................
Cholera Infant.................................
Hasmatemesis....................................
Inflammation Stomach and Bowels.......
Cholera, Cholera Morbus and Colic.......
Diarrhoea..........................................
Dy sen fry ........................................
Entero-Colitis....................................
Hernia ...........................................
Inf Congest, arid " Diseases "' of Liver.
Abscess of Liver...............................
Cirrhosis...........................................
Jaundice .................................. .......
Peritonitis.......................................
Other Diseases of Digestive System.......
Total Diseases of Digestive System,
" Disease," Inf. Kidney, Albuminuria,
Inflammation of Bladder..................,
Other Diseases of Urinary System........
Total Diseases of Urinary System.
 nf. Uter..s and Ovaries.......................
 laemorrhage from Womb....................
 lifficult Parturition............................
 'uerpTal  Convulsions.........................,
Other Dis. of Female Generative System.
Am mi—
w
■93=
S5^_
1863  1864
142
  5
  6
  6
  4
 12
  3
178
  0
 64
 26
 60
 13
282
  1
 24
 14
  9
 10
503
  71
 104
  68
  12
 303
  38
1126
 328
  36
   5
  38
   8
   2
  16
  26
   9
135
  5
  1
  7
  5
  7
  1

161
2190
28
 7
 2
37
 3
 3
 5
 3
 3

17
  0
 90
 48
 84
 18
417
  4
 32
 12
 16
  7

728
 158
 214
  80
   4
 351
  62
 913
 432
  27
 '  5
  47
   8
  13
   6
  23
   9

2352
28
10
 6

44
13
 3
10
 7
 7

40
1865
130
  8
  0
  4
  2
 23
  2

169

  0

  2
 46
 32
 62
 28
287
  1
 17
 13
 16
  6

510
  56
 164
  79
   1
 315
  51
 425
 292
  32
   3
  50
  10
  16
   7
  24
   7

1532
27
 6
 3

36
 9
 4
 8
18
 5

44
Tot'l d'ths
 3 vears,
 1803.65.
407
 18
  7
 17
 11
 42
508
   2
 200
 106
 206
  59
 986
   6
  73
  39
  41
  23

1741

 285
 482
 227
  17
 969
 151
2464
1052
  95
  13
 135
  26
  31
  29
  73
  25

6074

  83
  23
  11

 117

  25
  10
  23
  28
  15

 101 
140
Clinical Memoranda.
TABLE  No. 22—Continued.
o o
 311
13
Diseases.
Inflammation and Ulceration of Bones.
Psoas, Lumbar, and Pelvic Abscesses..
Total Diseases Locomotory System
" Disease of Skin,"...
Carbuncle (Anthrax)
Penphigus...............
" Abscess "..............
" Ulceration " .........
Total Diseases Cutaneous System.
  Conditions"  not necessarily  associated
  with General or Local Diseases :
Premature Birth...............................
Still Born ......................................
Debility  Infantile............................
Marasmus   "    ............................
    "    Adult............................
Debility     "     ............................
Old Age.........................................
Atrophy.........................................
Inanition........................................
Total Diseases of this 01a?s
Poisons..................,.......................
Delirium Tremens and Intemperance.
Total of Poisons.
Drowned .........................
Asphyxia and Suffocation.....
Burns and Scalds...............
Exposure, Privation, Want
Killed acciden'ally............
Killed or Murdered............
Suicide ............................
Other General Injuries........
Total of General Injuries.

Wounds........................
   "    Gunshot............................
Compression and Concussion of Brain.
Fracture of Skull and Spine.............
Otner Local Injuries........................
Total Local Injuries..........................

" Amputation "...............................

" Worms".......................................

Congenital Malformations.................

Diieases Unclassiflable, Unknown, etc.,

    Grand Total of all Diseases.,
 
Chaille—Medical
141
                            TABLE No. 23.

Deaths by  Nativities, Races,  Sexes, Ages, during the three years 1863-64-65
    also the Annual Averages of .<vch deaths, during these 3 Fears, compared with
    the Annual Averages during the five years preceding, and the four years suc-
    ceeding 1803-1865.
	1863 7258 3342 1274 2642 5015 1735 508 4405 2578 275 952 694 643 279 2568 411 782 725 595 367 236 155 84 37 14 1284	1864	1865	Total foi 3 Years 1863-65	Annual 5 Years 1863-65 *7714 3911 1417 2386	Average 5 Years. 1856-60 7427	s of the 4 Years. 1866-69
Total Deaths..................		8864 4345 1500 3019 6032 2832 4895 3739 230 1365 806 962 595 3728 535 803 780 717 600 358 .183 110 38 21 991	7020 4047 1477 1496 4688 2231 101 3846 2963 211 1375 578 624 446 3023 383 H50 728 649 4^5 301 159 66 34 12 520	23142 11734 4251 7157 15735 6798 609 13146 9280 716 9319 1329 2235 2233 1961 1462 895 497 260 109 47 2795			7298
							
Deaths by Nativities. Born in United States						fr404n 2707 { Lll24j	4103 2007
Not Stated..............							1188
							
Deaths by Races					5245 2266 203	J6327 1100	5027
Blacks and Mulattos... Not Stated...............							2023 248
							
Deaths by Sexes.					4382 3093 239	4535 2792 100	4185
Not Stated..............							2873 240
							
Deaths by Ages.					3106 443 745 744 654 487 298 166 87 36 16 932	3072 396 1308 1108 712 350 187 98 52 19 5 120	
							
2 to 5 * " ...............							
5 to 10 " ...............							
							
Total from							2816
10 to 20 " .........							402
20 to 30 '• .........							1022
30 to 40 " .........							900
40 to 50 " .........							685
50 to 60 " .........							491
60 to 70 " .........							305
70 to 80 " .........							145
80 to 90 " .........							57
90 to 100 " .........							21
Over 100..................							11
Not Stated..............							443
  * An. Av. of Citizens, 7607.
  | An. Av. for the 4 years 1857-60.
  t The An. Av.  White Deaths for the 4 years, 1856-60 excluding the yellow
fever epidemic year 1858 was 6267. 
                                                               TABLE NO.  24.
                 Monthly Report for three  years (Hov. 1862—Oct. 1865 both included) Consolidated.
N; B.—This Report differs from Tables Nos. 22 and 23  in two respects:  1st.  The def< ct in tie report of  second  week of August, 1863 has been corrected by
   adding 134 deatls to this month.  2d. JSov. and Dec  1862 having li91 total deaths,  have been substituted for Kov. and Dec 1865 having i093 total deaths.
No. of wks. in the 3 mos.	12 wks	13 wks.	14 wks.	12 wks	13 wks.	14 wkp.	6 months. ivov-Ap I	12 wks. May	13 wke. June.	14 wks.	12 wks.	13 wks Sept.	14 w' 8. October	6 months Ma\-Oct	12 months.
Monthly mortality of..	>nv.	ec	•>an'y.	Feh'y-	March	Ap il.				dulv.	Aiignst				Total 3 vis.
Citizens alone.........	180C	1765	1685	1451	1410	1777	9894	1699	2217	2555	2049	2110	2285	12915	228 9
*No. soldiers included.	1 1807	9	39	86	96	157	388 1.282	53 1752 "54	11	3	1	5	4	77	465
Total Citizens <£ Soldiers		1774	1724	1537	1506	1934			2228	2558	2l50	2115	2289	12992 7 920	23274
	1 82	1 51	"41	"•is	"35	"51	2 288		"97	152	1 167	2 252	4 198		9
Malarial Fever........															12C8
"Fever" and "Brain"															
"Nervous Fever"..	16	14	7	~	13	6	63	15	24	48	12	21	40	161	223
	45 56	45 14-J	42 166	36 176	34 177	49 163	251 880	36 85	67 90	81 66	73 36	97 30	82 26	436 333	687
tSmall Pox arioloid															1213
	14 4	21 8	31 18	43 11	26 22	34 25	169 88	43 12	59 18	58 22	46 13	17 9	14 6	237 8)	406
HMensl.-s ..............															168
	70	42	47	24	23	41	247	23	52	60	68	89	92	384	631
IP'Aimina" and Int.															
Tli t oat and Tonsils	14	19	19	27	17	20	116	19	11	29	25	41	42	167	283
Phthisis Pulmnnalis___	214	173	196	2 6	196	196	1181	166	173	196	140	187	215	1(77	2258
Congestion of Brain ....	15	21	M	16	18	25	105	20	35	30	40	25	26	176	281
Enc.ephalitis& Alon'gtis	13	21	14	19	26	35	128	26	35	47	32	43	26	209	337
	13	io	21	23	17	27	12)	20	13	22	22	19	11	1 7	227
	2-2 34	23 41	2) 3>	19 27	25 2)	16 19	125 171	15 17	16 Hi	22 30	2 1 23	3i 33	25 49	128 168	253
Trismus Nascent.....															339
Convulsion^ Infant___	51	49	47	33	49	70	299	74	128	108	59	85	78	532	831
''Disease of Heart" ...	37	44	37	31	34	48	231	34	34	32	33	3fi	37	206	437
Croup ...............	20	23	22	15	11	16	1 7	6	8	13	12	22	28	89	196
Bronchitis and Catarrh.	26	37	34	33	3)	28	183	19	15	25	2a	27	26	137	325
Pupiun. &. C'ug'st.L'ngs	75	96	143	136	116	139	695	65	5)	63	49	4!)	84	360	ior.5
	3) 7	22 5	13 8	12 1	16 7	24 18	117 46	66 52	96 58	88 39	58 13	33 8	29 8	370 178	4M7
Cholt ia Infant ........															224
Inf Maiasm'sjfcDebility	36	46	35	19	26	44	2 0	57	9.)	99	66	CO	79	451	657
Still Born&Pnm Births	85	91	86	71)	69	81	491	06	82	9.)	87	96	145	566	1 57
Inf Stomach & Bowels	6J	43	68	33	53	82	344	I16	12)	142	93	86	93	640	984
Diarr'cea, (Mio'era Chol-															
era Morbus, Co'ic.	303	198	162	1C4	118	185	1070	ISO	308	355	241	222	316	1622	2692
Dvsnt'ry, Fnt^ro-colitis	97	87	39	39	52	7.)	384	93	129	168	110	123	124	53	1137
Disea es of Liver.....	13 1453	12 139!)	22 1378	14	21	16	98	17	23	24	19	18	17	118 1 fill	216
Totals of above Diseases.				1211	1241	1528	8210	1386	1847	21 9	1589	1760	192 1		18821
" of all other "	323	328	319	269	254	339	1832	297	334	385	285	3 3	305	19 9	3741
" Diseases 'unkn'wn'	31 18 J7 '	47 1774	27 1724	57	11	67	240	69 1752	47	61	176	52	64	472	712
Gr'nd tot'l Citz'm&Sld'rs				1537	15 6	1934	11282		2228	2558	205:1	2115	2289	12992	23274
724
   *Of the total deaths, 465 of-'oldiers dating the thr»e years, 338 oeeuned in the four months. Febrnary-May, 18b4.
   tOf    '       "   1213 of Small 1 ox and V arioloid during the three years  322 occurred in the five months, March—July. 1864.
    «>     .<       ••     ..      n     -i        "        "     •■      ■'      724    "      "    six    "    November, 1864,—April, 1865.   And of these
                                                 6"4 occurred in the four months. December, 1864 — Varc-ta, 1865
   ♦ Of   "      «'     4°6 of Scarlet Fever during the  three years. 31 ) occurred in the 16 mouths, jjpril, 1864—Tuly. 1865.
   «r\e   ••       »     108 of Measles (luring the time years, one-half occurred in the given months. January—July. 1863.
   6 Of the total deaths  631 of Diph h«t ia dining the three years, the deaths occurred chiefly in i863 and 1864, during the half yea^s, June—November.
   Itqj.   ,. '     ii  ' g83 0f -. Angina," etc., durit g the thiee yeais, the deaths oernried fit peiiods of time similar to  those of Diphtheria.
   ** Of the total deaths 227 of Ap. ploy diuiiiji the three \e»rs, > 01 e thai, double the monthly average occurred in  ugust. Ig65, when occurred 18 deaths Out
0f tije 29 deatb8 by tun btroke repoilta for three years.  Duyng this tame " Sun Siroko " month, ojher deaths by brain diseases were also augmented. 
CHAiLLfi—Medical.
H3
  The records of the Charity Hospital for the four years, 1802-65,
will complete all the statistical facts kuown to me, bearing upon
the vital statistics of New  Orleans during this time.  The ad-
missions for these four years were 22,296 or an annual average of
5574,  which is considerably  less than for the yeais immediately
before and since the war.  This diminution was due in greater
part,  to  pecuniary  and  economical causes.  The total  deaths
were  2891, or  an  annual  average  of 723.   This  gives  a
mortality of 1  in  every 7.7 cases,  in comparison with  one
death iu  8 cases for  the  six years  immediately  preceding
the war (1850-61),  and with  one death  in  every  7.6  cases
for the four years immediately  succeeding the war  (1866-69).
These facts fail to  indicate any diminution in the fatality of
diseases during the war.
  Sanitary condition of New Orleans  1862-65.
  Two facts, so-called, have been stated, each of which demands
investigation.   Was  the Quarantine  "impregnable;"  aud is  it
indisputable that " so clean a city had never before been seen upon
the continent"?
  Quarantine.— Dr,  Fenner writes,  "In  this, we learn, Dr.
Harris was misinformed.  Vessels of war  were rigidly quaran-
tined  ; but vess Is for transportation were not.  Military necessity
sometimes required their admission at all hazards, and thus the
disease  was introduced on  several occasions."  Now,  Dr.  J. 0.
Faget, who of the three  was  the only one present in New
Orleans, and in a semi-official position, reports :  " LaQuarantaine
n'a exis(6  cette annde, 1864, que contre la  marine marchaude;
elle a eie nulle pour la marine militaire."
  Hygienic Oleauliness of the City.—There is evidence  enough
to establish that New Orleans was kept in much cleaner condition
than it ever had been before, or has been since.  As clean pei haps
as an "effieeut sanitary police" could keep it.  However, Prof.
Warreu  Stone asserts from  personal observation, that the clean-
liness evident  iu the best portions of the city was much less mani-
fest iu th<> rear, where live the poorer aud larger number of the in-
habitants; aud Dr. J. 0. Faget wrote, Juue,  1863, "cette anuce,
        19 
144
Clinical Memoranda.
1863, les conditions locales et atniospherique, demeurent, comme
toujours, effrayablemeiit favorable  a l'eclosion du fieau."  Iiut
leaving aside all contradictory evidence,  it is well to recall that
the objects of civic cleanliness are to secure purity of water and
air; and that,  since  New  Oileans drinks river  water,  the
benefits to ensue here from cleanliness are reduced to the single
and all important one of maintaining the purity of health-giving
air.  Therelore the question is, whether  a  sanitary  police  how-
ever efficient, can possibly secure this good in a city,  where its
innumerable privies are all underground with floating contents
close to the  surface;  where the drainage is a  most  wretched
specimen of the wretched  system of superficial drainage; where
the sewerage is,  by this fact, necessarily bad;  where near  at
hand on every side are malarial swamps,  neither drained nor yet
kept covered with water; and where heat  and humidity, the hand-
maids of decomposition and putrefaction, ever prevail-to notable
extent %  That an " efficient sanitary police" can and did diminish
the aerial adulteration is not  doubted, hut it  is  beyond the
power of human skill to determine the extent of this  diminution;
and the  facts  already given establish conclusively that the
extent was too slight to demonstrate that any benefit whatever
was conferred on the women, the children under  ten years, the
men over seventy years, and even on any portion of  the whole
population remaining  in New Orleans.  Notwithstanding this,
common sense, medical experience founded on hundreds of years,
suffice to establish the  fact that  benefit was and  always is con-
ferred  by an efficient  sanitary  police.   Whenever the proof of
this fails, as in  the present case, it can be answerd with absolute
assurance, that however bad the health may have been with, it
certainly would have been worse without such a police.
  In concluding this portion of my  subject (the  record and evi-
dence of facts), I may add that neither in the climatic and meteoro-
logical conditions of this city  during the wrar was anything ex-
ceptional observed,  nor were there any  conditions  whatever
other than those already mentioned, at  all unusual. 
CHAiLLg —Medical.
145
   Erroneous Assertions and Conclusions Rectified.
  It is not the purpose of these articles to discuss theories.  It is
a duty, however,  to call attention to incorrect assertions  and
false conclusions which have led astray not only the public, but
also the profession.  Amidst assertions and conclusions the fact
remains indisputable, that yellow fever existed in New Orleans
during every year of the war, but in no  year became epidemic.
Iu explanation of  this apparently exceptional fact, it is boldly
asserted and widely credited that:
  1.  The Quarantine was " impregnable."
  2.  " So clean a city was never before seen on this continent."
  3.  The mortality by all diseases was much diminished.
  The conclusions are that  the diminished  mortality, and the
epidemic  exemption  were due especially to  the exceptional
cleanliness.  Such is the position of a very  large party, which
has Dr. Elisha o arris as its fullest historian, and ablest representa-
tive ;  others have  only repeated his assertions and conclusions.
For this- reason alone, certainly from no personal motive, or lack
of proper respect, his views will be. considered, and his party
answered through him.
  This answer is  begun, with  the emphatic,  but not willingly
discourteous accusation, that Dr. Harris  has  been  guilty,  no
doubt unintentionally, of exaggeration of  facts,  suppression
of truths, suggestion of falsehoods, and conclusions not logically
deducible from the  true premises.  I proceed in  the interest
of science,  which is always the vindication of truth, to prove
the justice of the accusation;  reminding  the reader, that Dr.
Harris and  that party  obtained their few  statistical facts
from the  very same  sources from which I, in this  and the pre-
ceding article, have given  all the facts,  viz., from the official
records and reports of the Board of Health.
  1.  Example of  exaggeration  of facts.  Dr. Harris says, that
the deaths in the seven weeks, July 26th to September  13th, 1863,
were 1159, the deaths in the eleven weeks,  June 25th to Septem-
ber 10th, 1835, were 1691; and implies July  1865, that the civil
population,  even  in  1865 when at its maximum, was less than 
116
Clinical Memoranda.
200,000.  He says, " New York |an example not to be envied by
any healthy city J cannot boast a lower death rate for the  same
period"; and  page 11 (N. Y.  Report of Metrop.  B. of Health,
I860; he says, that the death rate of New York in  1863 was
"31.25 in 1000," and in 1865 " 30.3 in 1000."  Now, the number
of deaths  in  New Orleans, for the limited time given as above
by Dr.  Harris, indicates, (even on the exaggerated  supposition
that the civil population  was, more than he claims, 200,000,)
a death rate of 43 in 1000 for 1863, and of 40 in 1000 for 1865.
If the mortality  for the whole year be taken,  the  death  rate
was, under the most favorable  suppositions, not less than 39 in
a 10J0 for 1863, aud 35 in a 10UO for 1865.  Thus Dr.  Harris'
figures  prove his own assertion to  be exaggerated;  and  that
New York did have a  lower death rate for the same period.
  2.   Not  satisfied with  this  exaggeration, Dr. H.  exclaims
"compare  this |the number of deaths above given for 1863-5]
with tbe mortality in that  city [New O-leansj in  August  1853,
when 620 L of the  inhabitants died."  As well visit an eight feet
giant, and then denounce every man  of five and a half feet as a
dwarf!  "Or compare with the average mortality of the  three
years 1853, 1854 and 1855, which gave more than 1000 deaths
per month, though the population was far less than during the
past summer."  Why  should an earnest seeker for the  whole
truth have gone so far back as 1853, why should he select for
comparison the three consecutive years of greatest fatality in
the history of New Orleans, and why did he not select by pre-
ference the three years immediately preceding the war, and there-
fore  best illustrative  of his  subject?   It is true that, 1853-5
strongly favor that which 1859-61 totally defeat  the theory he
advocates.  In the aoove quotations, as in the one which follows,
he is convicted not only of exaggeration and suppression of facts,
but also of the suggestion of what is false. He says of yellow fever,
that" that enemy and pest of the city had been wont to destroy its
thousand victims every year, and sometimes to kill no less than 5000
in a single month." Associate this with his previous statement "in
August 1853, when 6201 of the inhabitants died," and what reader
would imagine the facts as they are ?  The whole truth is, that 
ChatllG—Medical.                   147
 in August 1853 there did die 6201 inhabitants, of which 6201 there
 were over 5000  by yellow fever.  Both the 6201, and the 5000
 belong to the same month, the latter being a part of the former;
 and so far is it from being true that 5000 "died sometimes in a
 single mouth," the fact is, that nothing at all comparable ever
 occurred in any other month from the origin  of this  city to the
 present day.  The nearest approach to  anything similar was
 2204 yellow fever deaths in September 1858.  Take all of the 216
 months in the. eighteen years 1S44-61, and there were  but twelve
 months in which the yellow fever  mortality exceeded even 500,
 and these twelve  months were  all  parts of only five  of the
 eighteen  years, viz., 1847-53-4-5-8* The  other  portion  of his
 statement that  yellow  fever  "had been  wont  to destroy  its
 thousand victims every year,"  is  so  notoriously false, that it
 would be waste of time to reply farther than has been  done in
 previous pages.  However, taking the eighteen years referred to,
 it is true that the five epidemic years in these eighteen years did
 destroy a number sufficiently large, to make an annual average of
 over 1300 yellow fever deaths.
  Let the historical facts given be compared with Dr.  Harris'
 assertions, and if these latter be judged to be a correct representa-
 tion of the former, then I am willing to  grant any conclusions
 whatever from premises so stated,  even that a horse-chesnut is a
 chesnut-horse.
  3.  Believing that my  accusation of the  " suppressio veri,
 suggestio falsi," has been indisputably established, I  proceed to
 prove  that Dr. Harris  has  been  guilty  of  a conclusion not
 logically deducible from the true premises.  Avoiding  tedious
 quotations, here is his syllogism in brief:  New Orleans  has for
 many years  been  desolated  by yellow fever epidemics  which
 destroyed " every year its thousand victims," and " sometimes
 5000 in a  single month,"  and during this time  it has  been a
 notoriously filthy city.  In the four years 1862-65 it was exempt
 from  epidemics, and was the  cleanest city ever before seen on
 this continent.  Theiefore, concludes  Dr. Harris, it owed its
unusual exemption to its unusual cleanliness.  Now, with equal
brevity; I will state the correct syllogism with the true premises. 
148                  Clinical Memoranda.
     New Orleans enjoyed  during eight years, 1859-66, an exemp-
   tion, unexampled in her history, from yellow fever epidemics.
   Duriug four of these eight  years, viz., 1859-60-61-66, the  city
   suffered notoriously with its habitual filth, and during the four
   remaining years, viz., 1862-65, it enjoyed an unusual degree of
   cleanliness.  Therefore,     ----     ----     ----     what?
   Enough!  quite enough to prove, that, even if Dr. Harris' con-
   clusion were an absolute truth, yet such conclusion is not logically
   deducible from his own,  much less  from the true premises.   To
   justify this conclusion at least one other fact must be introduced
   into the premises, viz., that a  yellow  fever epidemic never  has
   prevailed in any place as clean as New Orleans was during the
   four  years, 1862-65.  The student of yellow fever  literature
   knows well that we have abundant assertions, and  evidence as
   good as Dr. Harris', to the contrary.  The " marble promontory "
'   of rock-bound Gibraltar suffered a terrible epidemic in 1804, and
   also subsequently;  Port du Passage, " remarkable for its  sa-
   lubrity," was devastated in  1823; etc.  Can it be  believed, that
   a " sanitary police," however  efficient, could purify the air iu
   New Orleans,  as much as even unaided Nature accomplishes in
   these  and other places where yellow  fever epidemics  have oc-
   curred ?
     Those who have adopted the views prevalent as to the exemp-
   tion of New Orleans from yellow fever epidemics during the war,
   and who are disposed to press  the pertinent, but unanswerable
   question,  why, being present did yellow fever not become  epi-
   demic, especially in 1864, have  apparently omitted all considera-
   tion of the many previous non-epidemic years.   Let this omission
   be supplied by furnishing,  as one  example out of many,  the
   history of yellow fever in 1857, which is in some respects strikingly
   similar to that of 1864.  I submit brief extracts from the " Annual
   (official, published) Report,  1858, of Dr. A. F. Axson, President
   Board of Health, New Orleans."
     " It will  not fail to be noticed that the mortality from yellow
   fever (1857)  runs up to a figure of 199, against 74 in 1856, and 2670
   in 1855.  How this fever originated, whether from the  operation
   of causes  natural  to  our locality,  or by its introduction from 
Chaill£—Medical
149
 abroad, it is difficult positively to state."   The first unquestion-
 able death " was not until the 20th  September," the patient had
 Wd to  Sebtember 12th  on Girod street.  " It is well known
 that nearly the whole  mortality occurred within a comparatively
 narrow strip of the city,  and occurred too in houses contiguous
 to  each other and occupied by a class of persons, whose inter-
 course is  regulated by none of the conventionalities obtaining
 among those living under different social necessities."  Singularly
 enough, this "comparatively narrow strip  of the city" to which
 the disease  was confined, is nearly the same locality as the
 Naval Hospital of 1864, viz.,  "New Levee, Tchoupitoulas and
 Girod streetsj"  Girod  street being less than a half mile lower
 down the river than  Erato street.  Now, what was the condi-
 tion of this " comparatively narrow strip" in 1857 ?  "There were
 no  reeking  offals, no  vegetable  and animal remains,  no heaps
 of  putrefying  matter,  no  overflowing  privies,  no excessive
 dampness under foot in the quarters or rooms, or in the atmos-
 phere, and no over-crowding."  " In truth so exceptional  —   —
 was the appearance presented by this locality, that the Mayor----
 declared it to be singularly cleanly."  And now, what was the
 condition of the city at large in  1857 ?  The official report says
 that the lack of cleanliness was such as  " would be shocking  to
 the eyes of one accustomed to tbe filth of Constantinople or Cairo.
 Streets uncleaned for weeks together, two  of our  largest hotels
 pouring  the  contents  of  their  privies into  one  of the  main
 thoroughfares  of the  city, with  the ceaseless resources  of the
 Charity  Hospital, swelling the stifling  current, gutters choking
 with fiith, or else emptying themselves by municipal authority
 into vacant lots and unpaved  streets, canals seething and bub-
 bling with  their putrid waters  were the customary spectacles
 greeting the senses in all quarters; and yet the fever appeared
 and lingered,  with  few occasional  exceptions, in  a portion  of
 the city, which, in the language of the Mayor, presented " an
unexpectedly clean condition." " If infectiousness were a property
resulting  from filth  and putrescent organic matter, the  whole
city was a laboratory for its generation, unsurpassed in magni-
tude and extent, and yet, over its entire length and breadth, the 
150
Clinical Memoranda.
 fever was confined to a narrow strip presenting an exception to
 the aspect of general immundicity "  Under such local conditions,
 only some 200 deaths occurred, which indicates  not  less than
 500 cases, each producing contagion say some, or endless quanti-
 ties of fomites say others; and yet  these 500  manufactories did
 not produce an epidemic in a city which was as filthy as des-
 cribed, and contaiued so many of the  unacclimated, that in the
 very  next year,  1858, the yellow fever carried 4855  victims to
 the giave.
  If a sanitary police saved  us in 1864, and the other war years,
 what saved us in 1857 and other non-epidemic years, before and
 since  the war ?  " La seule preuve, qu'un phenomene joue le role
 de cause par rapport a un autre, e'est qu'en supprimant le premier
 on fait cesser le sec end "
  Notwithstanding the weight due to the facts now stated, there
 are others to be considered,  before Dr. Harris' hasty conclusion
could be accepted.  Among  these, there is no need to go as far
 even  as  Philadelphia  to illustrate, that  of  which  there are
innumerable examples,  that  yellow  fever has gradually and
 mysteriously abandoned certain localities which had  long been
 subject to its frequent visitations.  There have been intervals iu
 various such places often, twenty, fifty years, between its visits;
 whilst in the mean time a defective sanitary police has been, by
 no means improved, and  whilst a  " wide-spread epidemic ten-
 dency " has repeatedly  prevailed.   It  has suddenly  appeared
 and domiciliated itself, so to speak, in old and populous cities
where there had been no appreciable change in any local  condi
tions.   All this, and much more was well known to  our predeces-
sors and has been repeated ad nauseam, but without solving that
mystery which Gen'l Butler  and others outrof, and Dr. Harris
and many others in the profession have utterly failed to solve.
  No  one deplores more than I, that Dr. Harris'  conclusion is
not logicaly deducible from the true  premises.  Would  that it
were  proved that the  dire scourge could  be driven by  " an
efficient sanitary police " beyond our borders!  Yet, let it not be
understood for a moment, that I would willingly utter oi e word
against sanitary regulations, or fail to advocate  with all my 
Chaill£—Medical.                   151
power, drainage, sewerage, paving, and an efficient sanitary police
as indispensable  to the prevention or mitigation of all  diseases,
and therefore to the welfare of this city.  As to these unquestion-
able benefits, I may say to Dr. Harris, that—
       I am. " with him upon this theme,
         Until my eyelids will no longer wag ;"
       " 'Swounds  show me that thou'lt do :
         Woo't weep ? woo't fight ? woo't fast ? Woo't tear thyself 1
       Woo't drink up eisel ? Eat a crocodile ?
         Plldo't."
  But I will not do ill that good may come—will not  torture
nature to half-utter  the few words I may wish to  dictate, but
humbly bend a listening ear to all those which flow voluntarily
from her teaching lips.

                       CONCLUSION.
  Thus far it has been attempted to establish and illustrate his-
torical facts. These facts furnish evidence upon certain questions
which have ever  been involved in  professional discussion.  On
these doubtful subjects I shall now venture to briefly present
some of my opinions.
  1.  Origin of yellow fever.—In 1864 the first cases occurred, there-
fore the disease  originated on various  vessels, some at anchor
in front of New Orleans, and others several miles distant  from
the  city.   The rigid  Quarantine failed to  discover any  cases
whatever, elsewhere than  from New  Orleans.  The  closest ob-
servation of the medical and other U. S officers, exercised under
the great advantage of the strictest military and naval discipline,
failed to trace any cases to any foreign or exotic infection.  These
facts strongly confirm the opinion long and ably upheld  in this
city, that yellow fever is one of our own domestic products, and
that New Orleans is  very certainly within the " Yellow Fever
Zone," whatever  the limits of such Zone may be.  This evidence
also indicates for the poison a choice of birth-place in vessels,
and says Dr. Faget  in their holds;  as is  known  there  is  much
other evidence to the same effect.
  2.  Contagion.—O ur more recent text books, particularly the En g-
lish, French, and German, influenced  greatly by the Southamp-
         20 
152
Clinical Memoranda.
ton and St. Nazaire accounts, teach that yellow fever is con-
tagious.  It is well then to recall some familiar local  facts for
the benefit of those who found their conclusions on these, rather
than on the opinions of others,  however  distinguished.   These
facts have been denounced  as negative in character, and  there-
fore without weight against  such positive  facts as have been
credited.   I  respectfully submit that  the negative  facts occur
generally, and that,  if  the  positive  facts occur at  all, they
are altogether exceptional.   Such apparent exceptions  cannot
justify us in ignoring the general rule.
  During the past eleven years, cases of yellow fever have been
present in New Orleans not less than ten years ; in one year only
(1867) the disease spread or became epidemic.  During the fifty
past years,  the  New Orleans  Charity Hospital has annually
(three or four exceptions only) received cases of yellow fever.
(See table No. 4, Article No. 1,  January  No. 1870,  N. 0.  Med.
Journal). Notwithstanding  these annual cases, whether domestic
or imported, the many different house surgeons and visiting phy-
sicians endlessly repeat that  there has been no evidence of the
transmission of  the disease  to  the  unacclimated in the  same
ward, though watched for weeks after exposure ; no cases origin-
ating in the Hospital unless the disease prevails in the neighbor-
hood surrounding the Hospital.   In 1853 when  I was Resident
Physician of the U. S. Marine Hospital, then located opposite
the city, more than 100 unisolated cases of yellow fever had been
present for more than a month before a single case originated in the
Hospital; and when this  occurred the  disease, gradually as-
cending the river's bank,  had  gained and was prevailing in
the residences near to the Hospital.  During the  same  year,
one  case  of variola  was  admitted,  at  once  isolated and in
less than  a month there  had been  twelve cases  with  three
deaths, and  this limit was secured by vaccination.  Hundreds
of cases are recorded, thousands known, of persons contracting
yellow fever in New Orleans, and dying even a  few  miles from
the city, without communicating the disease to any one whatever.
Many of  our most  honored and experienced physicians  (even
after forty years' observation) assert that this is  a rule to which 
CHAiLLfi—Medical.
153
they have never seen a single exception, and none deny that it
is, beyond all question, the general rule.  Such facts as these are
annnually observed in this city and when multiplied by the same
facts occurring elsewhere, amount to uncountable myriads.  So that
it is useless  to  weary the reader with prolix details, illustrating
facts, which time has so augmented the strength of, that theories
which discard their consideration, must stagger under their weight,
and can be accepted by  those only who know yellow fever in
books, and not at the bedsides of its native land.  No intelligent
physician, experienced in the yellow fever of New Orleans can
possibly grant  more than,  that if yellow fever  be contagious
here, then it is only so in rare and exceptional circumstances,  and
due to unusual  aud unkuown conditions.  Teach  contagion if
you will; but if you would merit  a permanent reputation, let it be
only the introduction of your chapter which explains those general
instances of  contagious  failure  which are certainly very much
more  numerous,  than any  disease  known to  be contagious
ever presents.  An explanation  is demanded which will justify
us  in  supposing  that a  disease may be contagious  generally
on  ships, but  never  (certainly not generally)  contagious in
hospitals and jails; often  violently contagious (?) in one special
season only of the year, but never so  in other seasons.
  If it be giauted that the yellow fever of New Orleans  may or
does come  from local causes, is  there any system of reasoning
which justifies or  renders necessary  the introduction of another
cause  to account for the   same effect?   Human experience
teaches that correct judgment is not frequent, and correct ob-
servation  still  less  so; and that others may  be amenable to
this criticism as well as ourselves.  In fine, if a conclusion as to
the unknown is to be reached through what is known, then it is
a very safe conclusion, that the poison of yellow  fever does not
manifest itself as  those poisons  do,  which we  know to be con-
tagious.
  I find difficulty  in comprehending the distinction which is ap-
parently made  between the  non-contagiousness of a patient in
his clothes, and the portability of the disease by  the same clothes.
It is readily  comprehensible that if  the poison be generated in 
154
Clinical Memoranda.
any place,  say the hold of a ship, it will attack all liable  to it
who  may expose  themselves to such place, just as the malarial
poison manifests itself; and that when the place moves, as a ship
does, then the poison in her moves too, and is thus portable.
  3.   Quarantine.—As to Quarantine, and all practical sanitary
questions involved  in  professional discussion  and doubt,  the
public is perfectly justifiable, even praiseworthy, which acts upon
the safe side of the doubt.  Quarantine laws are then  perfectly
defensible,  however false may be the theory upon which they may
be based; provided that their execution be practicable, satisfactorily
enforced, and presents any evidence whatever that benefit  has
ensued.   If the New Orleans Quarantine has any  one important
object, it is to keep out of the city all cases of yellow fever, which
after nineteen years trial it  has never  accomplished in a single
year.   Even the "impregnable"  war  Quarantine,  so  much
superior to anything which, in my estimate of republican  civil
government,  can  be  possibly hoped  for  again, failed  every
year of the four.  If any benefits have ensued, I fail to comprehend
them.  The execution of our Quarantine laws has been such, that
it is constantly denounced by the very persons who make, execute,
and advocate them.  Ought not the opponents of Quarantine to
be spared the  explanatory  apologies,  which  its  advocates
are annually so profuse of? Consideration is due  the following
remarks (Nov. No. 1866  So.  Jour. Med.  Sciences)  as  to the
practicability of Quarantine, " Is  it true that disease travels only
over the sea—over salt water ?  Does disease shun transportation
by rivers, railroads and dirt roads ?  UDder every practical view
this is the  decision of our Board of Health."   " The front doors
are half opened, the back doors are all left wide  open, and the
public is asked to believe that the city is Quarantined."  " Quaran-
tine is impossible.  The fitful voice of communities is both for
aud  against it; and it is just as absurd  to attempt to enforce
Quarantine, as  to  enforce  gambling  laws or "Maine liquor"
laws.  The weakness of man will not admit of Quarantine being
enforced."  I will not insist that, because in any special matter,
perfection  is not reached, therefore no good at all is obtained; but
I do insist that,  even accepting  the views of  the advocates  of 
CHAiLLfi—Medical
155
Quarantine, its injuries are certain, its  benefits most uncertain.
Therefore common sense dictates that New Orleans should invest
its money in, and insist upon those sanitary means whose benefits
are certain, all good and no evil; and about which neither doctors ,
nor outsiders disagree. Advocates of Quarantine have at least I
one strong argument in their  own favor, it supplies many with a
means of livelihood.
  4.    Sanitary  Improvements are glaringly  deficient  in New
Orleans, and are a certrain means to unquestionably good results.
For the accomplishment of these it should be a matter of com-
parative indifference to the public, whether they present or  not
an easy  mode to rid the city of yellow  fever epidemics; for on
this  subject contagionists and non-contagionists, quarantinists
and  anti-quarantinists, ex-rebels and radicals, cordially shake
hands, and  endorse it with unanimous approval.  If exemption
from yellow fever should  result, so much the better; if not, we
would still be  left with abundant reason for rejoicing.  My own
decided opinion is that the " swamp " poison,  annually present,
causes more suffering, disease and  death in New Orleans, than
even the yellow fever poison, which is only occasionally present.
This greater enemy  can certainly be vanquished by sanitary im-
provements.
   5.  Questions.—What is the poison of yellow fever, "under what
conditions is it generated, how is it propagated, and what limits
it in most years  and places, but extends it in other cases to epi-
demic manifestations %  Notwithstanding very much professional
talent and labor, and much professional pretension, these questions
remain unanswered.   Additional facts must be discovered, and
science extend its boundaries before the wearisome discussions of
doctors  can  confer any  substantial   benefits on  the  public.
Much said  and written on these questions recalls the reply of a
physician most  familiar  with our epidemics  to one of less ex-
perience, " every doctor who has seen one epidemic  thinks he
knows all about  yellow fever, whilst those who have seen many
do not pretend to know anything."  No need to go to European
or Northern cities,  but only step out  of any door in New Or-
leans  in order to find some one in sight and  ready  to answer, 
156
Clinical Memoranda.
satisfactorily to himself at least,  questions which the  wisest
physicians refuse a reply to.  For instance, will we have an epidemic
this season, is demanded at the street corners ?  Whoever attempts
to reply, as many do, is guilty of that irritating ignorance which
is unconscious of its own ignorance.  All our knowledge justifies
only  such prognosis as a robust man would receive as to the
date of his death—every  year without it is a year nearer to it!
  Prophets and "bright lights"  without number have,  here  in
New Orleans, sprung from eyen the floor of the Representative,
the sanctum of the editor, the office of the lawyer, the  counter
of the merhant, to bid us hope or  beware; yet the former have,
without exception, modestly declined to recall their prophecies
after the  day  for their fulfillment had elapsed, and an ungrate-
ful  public knows not  of them;  and the latter,  however bril-
liant, have never dazzled enough to keep their  own  ignorance
from being plainly visible.
  Those who really know most feel very sure that as yet there
are but two  certain means which  can be confidently recommen-
ded to avoid yellow fever, viz.,  get out of the  place whilst it
prevails,  or have it once  and be thus  done with  it  forever.
As to all the other questions propounded, they cannot reply,
as well even as science now can,  about that  wind which, says
St. John,  " bloweth where it listeth, and thou hearest the sound
thereof, but can'st not tell whence it cometh,  and  whither  it
goeth,"—nor why.

End of Akticle No. II. 
 
 
 
 
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