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LECTURES 
 
 ON 
 
 CLINICAL MEDICINE, 
 
 DELIVERED IN THE 
 
 HOSPITAL SAINT-JACQUES, OF PAKIS. 
 By M. Le Dp, P.^JOUSSET, 
 
 Physician to the Hospital Saint- Jacques, of Paris; Professor of Pathology and Clinical 
 Medicine; formerly an Interne Laureate of the Hospitals of Paris; Editor of 
 I? Art Medical ; late President of the Homoeopathic Medical Society 
 of France; Author of "The Elements of Practical Medi- 
 cine"; Honorary Member of the American 
 Institute of Homoeopathy, etc. 
 
 TRANSLATED, WITH COPIOUS NOTES AND ADDITIONS, 
 By B. LUDLAM, M.D., 
 
 Professor of the Medical and Surgical Diseases of Women and of Clinical Midwifery 
 
 in the Hahnemann Medical College and Hospital, of Chicago; Author ,of 
 
 "Clinical Lectures on the Diseases of Women," and "Clinical 
 
 Lectures on Diphtheria"; Member of the State 
 
 Board of Health of Illinois, etc. etc. 
 
 JVo. . 
 
 \£> i8m c<^j 
 
 CHICAGO: *" ^ 
 
 S. 0. GRIGGS AND COMPANY. 
 
 1880. 
 
-*V\ 
 
 3« 
 
 COPYRIGHT, 1879, 
 
 By S. C. GRIGGS AND COMPANY. 
 
 | KKISHT & LEONARD | 
 
 DONOHUE & HENNEBERRY, BINDERS, CHICAGO. 
 
AUTHOR'S PREFACE. 
 
 By permission of the authorities of the Hospital Saint- 
 Jacques these Clinical Lectures are now oifered to the med- 
 ical public. The notes and cases that form the basis of 
 the volume have been taken by the students, and the only 
 warrant for their publication is the good work that has been 
 done in the wards of the hospital.* 
 
 During the three years in which these Lectures have been 
 given we have encountered some cases of almost all the dis- 
 eases on the list; but, among acute disorders, we have prin- 
 cipally treated pneumonia, bronchitis, pleurisy, typhoid and 
 the eruptive fevers, erysipelas, diphtheria, dysentery, acute ar- 
 ticular rheumatism, hemorrhages, asthma, affections of the 
 heart, the stomach and the liver, aortitis, phthisis, herpes, hy- 
 drarthrosis, sclerosis of the kidney, scrofulous keratitis, hem- 
 orrhoids, vaginismus, pelviperitonitis and peri-uterine hema- 
 tocele ; and chronic affections have likewise furnished their 
 proportion of cases for study and treatment. 
 
 The publication of these Lectures will afford physicians 
 an opportunity to judge of the value of the Homoeopathic 
 treatment. 
 
 The doctrine of Hahnemann, like all other scientific doc- 
 trines, has made great advancement, and we can only judge 
 of the value of this progress by the application of its prin- 
 ciples at the bedside of the sick. As a faithful disciple of 
 the experimental method, we accept what it has demonstrated 
 to be true, and reject what it has shown to be false. Fol- 
 lowing this rule, we have taken the Materia Medica that is 
 founded upon a knowledge of the effect of drugs upon the 
 
 * This hospital is on the official list of the government hospitals in Paris, 
 and is an authorized center of medical teaching, like the Hotel-Dieu, La Charite* 
 and others. — L. 
 
iv author's preface. 
 
 healthy man, and the law of similars, verified in the clinic; 
 or, in other words, physiological experimentation and pro- 
 fessional experience, as the basis of what we may justly call 
 positive therapeutics. 
 
 We cheerfully acknowledge and insist that Hahnemann 
 was the first to enter on this path, and we very willingly 
 recognize him as our leader, who took the initiative in ther- 
 apeutics ; but, in a science of observation like that of thera- 
 peutics, we place experience above all our masters, and are 
 forced to reject whatever he has said that does not conform 
 therewith. 
 
 We have been reproached by some very radical members 
 of our school of practice with a want of faith in Homoeopathy 
 exclusively, and we do not deny the charge ; for, as the title 
 of our journal (I? Art Medical) indicates, we believe in ex- 
 perimental therapeutics. 
 
 We do not make this declaration because we intend to 
 desert the cause of medical reform, or to accept any posi- 
 tion in the gift of the Old School. Our entire professional 
 life is a protest against such an interpretation of our posi- 
 tion. For forty years we have submitted to unheard-of re- 
 proaches rather than abandon what we have believed to be 
 the proper ground of truth in therapeutics ; and at the end 
 of so long a career, we shall make no compromise of our 
 opinions that we might have occasion to regret. Our state- 
 ment of the case is offered, therefore, because, for the good 
 of the sick, for the honor of the profession, and for the in- 
 terest of physicians, it is very important that this misrepre- 
 sentation should cease. 
 
 The three points of the therapeutical reform that we ad- 
 vocate and defend are an experimental Materia Medica, in- 
 dications that are drawn from the law of similars and the 
 use of such doses as shall he determined' by clinical experience/ 
 and where is the society or the Faculty, or where are the 
 physicians who believe it their right and their duty to reject 
 such a system of treatment? 
 
 There are those, also, who accuse us of discarding entirely 
 the employment of attenuated remedies, and the use of in- 
 dications that are to be drawn from the law of similars, in 
 
author's preface. 
 
 order that we may resort to almost any kind of irregular 
 medication ; but our practice, which is open to the public, 
 will show the falsity of these accusations. At the same time 
 it will also show how seldom we resort to palliatives, and 
 to empirical means, and in what cases we prefer the stronger 
 preparations to those which are infinitesimal. 
 
 Moreover, this volume will serve as an answer to an "ex- 
 planation" which our adversaries enjoy having given of our 
 success. They say that : ' ' Intelligent Homceopathists reserve 
 their little pills for the trivial cases that would get well of 
 themselves ; but that, in grave disorders, they give the same 
 doses that are prescribed by the Allopaths." A very slight 
 examination of our clinic will convince the most skeptical 
 that, as we have already said, with us the size of the dose 
 does not depend upon the mildness or the severity of the 
 disease, but rather upon its complex and complicated char- 
 acter. 
 
 Apart from the therapeutical subjects that form the essence 
 of our work, we have discussed and answered certain very im- 
 portant pathological questions. Whenever it has been neces- 
 sary to make our instruction more clear, we have added such 
 illustrations as would render the text more easy of compre- 
 hension, as well as more minute and exact. 
 
 We sincerely trust that this volume may aid in spreading 
 the truths of positive therapeutics, and also in diminishing 
 those prejudices which are as decidedly opposed to the true 
 interests of the profession as they are to those of our patients. 
 
 We believe that it will be useful to physicians who have 
 not yet surmounted all the difficulties of the Homoeopathic 
 method, because, by the side of the general precepts that 
 are given, they will find the application to a case in point ; 
 and special cases are the doctor's daily bread. It surely is 
 something to know that bryonia, phosphorus, tartar emetic 
 and arsenicum are the chief remedies in pneumonia ; but it 
 is much more important to know the peculiar remedial char- 
 acteristics that would lead us to prescribe one of them in 
 preference to the others. But we cannot have a complete 
 knowledge of the special therapeutics of pneumonia without 
 having the history of a certain number of cases to aid us 
 
vi author's preface. 
 
 in the choice of our remedies, and clinically to demonstrate 
 the value of our therapeutical indications. This is the real 
 object of these Lectures ; and it is this peculiar feature of 
 the work that distinguishes it from a treatise on general pa- 
 thology. 
 
 P. JOUSSET. 
 
TRANSLATOR'S PREFACE. 
 
 The science and the art of Medicine represent the two sides 
 of a piece of coin which cannot be separated without violence. 
 Clinical experience is the gold, the silver, the copper, (or the 
 brass) that has been stamped in the medical mint, and that is 
 kept in store and in circulation by physicians the world over. 
 The stamp may vary with the caprice or the credit of the gov- 
 ernment that issues the coin; but the exchange value of the 
 metal that carries the mark will be the same everywhere and at 
 all times. 
 
 In preparing and publishing these lectures, the author's 
 object seems to have been to harmonize and to unify the sci- 
 ence and the art of medicine, to balance them properly, and 
 not to extol either at the expense of the other. How far he 
 has succeeded the English reader will now be left to judge. 
 
 The reasons that might be assigned for the re-issue of this 
 volume are that, having read it carefully, and having known its 
 author personally as a man of rare attainments, of high per- 
 sonal character and veracity, and of a large and extended ex- 
 perience under the most favorable circumstances, the translator 
 was led to believe that he could not confer a greater favor upon 
 his American and English friends than to bring it out in its 
 present form. 
 
 He begs, however, to say that the translation — which has 
 been made with Dr. Jousset's sanction and approval — is a 
 liberal and not a literal one, great pains having been taken not 
 to misinterpret the text on questions that are still at issue 
 among us. 
 
 The notes and additions are designed to increase the interest 
 and value of the work without adding greatly to its size. The 
 clinics on puerperal pelviperitonitis , and puerperal pneumonia 
 
viii translator's preface. 
 
 especially, it is hoped, will be acceptable to the general prac- 
 titioner. 
 
 The translator hereby returns his thanks to Drs. Small, 
 Comstock, Yilas, Ha wees, Fellows, Jessest, Peottoyer and 
 others for their kind and valuable contributions : to his friend 
 and former pupil, Dr. W. A. Barker, for his careful super- 
 vision of the proofs as the volume passed through the press ; 
 and also to his publishers, for the taste and perfection with 
 which they have issued the work. 
 
 The index is very complete ; and a table of French and 
 English weights and measures is added for ready reference. 
 
 R. LUDLAM. 
 
 526 Wabash Ave., Chicago, Sept. 1879. 
 
OO^TEl^TS. 
 
 LECTURE I. 
 
 PAGE 
 
 Summary. — The Clinic. Homoeopathy, and its place in therapeutics: 
 note. The legitimate role of empiricism and of palliative medica- 
 tion : note 1 
 
 LECTURE II. 
 
 Summary. — Asthma, case; of emphysema, both transitory and confirmed; 
 indications for ipecac, in asthma. Puerperal pleurisy followed by phthi- 
 sis; indications for cantharis and for arsenicum. Chlorotic neuralgia; 
 indications for belladonna. Bronchitis; indications for ipecac, and 
 bryonia. Ascites, case; differential diagnosis of; indications for apis, 
 jodium, arsenicum and primus spinosa; good effects of china. Rheu- 
 matic endocarditis; aggravation by the cactus grandiflora 9 
 
 LECTURE III. 
 
 Summary. — Rheumatic endo-pericarditis (continued), case; indications for 
 the cactus grand. Medicinal aggravations; indications for arsenicum, 
 nux vomica and cuprum in the treatment of asthma. Asthma, case 
 (continued). Pleurisy, then phthisis following labor, case. Incipient 
 phthisis, case; cure by bryonia and a vegetable diet. Semiotic value 
 of pain in the superior intercostal spaces. Pemphigus, case; indica- 
 tions for rhus toxicodendron and cantharis. Lumbago, case; indica- 
 tions for the actea racemosa: note. Erythematous angina, case; indi- 
 cations for belladonna 18 
 
 LECTURE IV. 
 
 Summary. — Signs of emphysema. Louis and the numerical school. Indi- 
 cations for antimony in the treatment of asthma. Menorrhagia, ham- 
 amelis in. Lobular pneumonia is grave bronchitis. Articular rheu- 
 matism and endopericarditis, case (continued); the evolutions and 
 modifications of the cardiac lesions demonstrated by the sphygmograph. 
 Aggravation from the cactus; happy effect of spigelia. Pleurisy fol- 
 lowed by phthisis, case; vegetable diet; indications for jodium and 
 arsenicum. White swelling; indications for argentum in scrofulous 
 
CONTENTS. 
 
 PAGE 
 
 affections of the bones. Mild typhoid fever, case; indications for Bry- 
 onia and china. The inconvenience of a fanciful diagnosis. The 
 homoeopathic treatment may shorten the duration of disease: note 32 
 
 LECTURE V. 
 
 Summary. — Of the suspension of the remedy in the treatment of chronic 
 diseases, and of the repetition of the dose. An intermittent febrile 
 action in hysteria; effect of the tarentula. Laryngeal phthisis; phos- 
 phorus and argentum. Hysteria; nervous vomiting; case; indications 
 for nux vomica, ipecac, ferrum, bryonia and Pulsatilla. Grave bron- 
 chitis, or double lobular pneumonia, case; ipecac, and bryonia, then 
 tartar emetic; cure. Intercostal neuralgia, case; indications for bryonia 
 and nux vomica 44 
 
 LECTURE VI. 
 
 Summary. — Hysteria, case; indications for tarentula, belladonna, hama- 
 melis and hydrotherapia : case; the hysterical delirium and belladonna. 53 
 
 LECTURE VII. 
 
 Summary. — Phthisis; indications for sulphur and jodium. Of the duality 
 of phthisis. Dysentery; indications for mercurius solubilis and mer- 
 curius corrosivus, ipecacuanha, arsenicum, phosphorus, colocynth and 
 secale cornutum; case. Mild pneumonia, case. The first stage of 
 pneumonia is already one of hepatization. Ascites, case (continued). . 61 
 
 LECTURE VIII. 
 
 Summary. — Interstitial nephritis, case. The diagnostic indications for 
 arsenicum, phosphoric acid, belladonna, cantharis, and plumbum, in 
 albuminuria. Of certainty in therapeutics. Puerperal phthisis ; great 
 improvement; indications for phosphorus, sulphur, and drosera. The 
 vegetable diet 75 
 
 LECTURE IX. 
 
 Summary. — Acute articular rheumatism; indications for chininum sulph., 
 china, aconite, mercurius and bryonia. Chronic rheumatic endocarditis, 
 case. A new example of medicinal aggravation; indications for cactus 
 and aconite. Indications for aconite, Pulsatilla and ipecac, in rubeola, 
 and for ipecac, and bryonia in the grave bronchitis of measles. Hys- 
 teria and the bromide of potassium. Asthma and its treatment by 
 iodine. Chronic aortitis, case. Indications for nux vomica, bryonia 
 and the arseniate of antimony 83 
 
CONTENTS. XI 
 
 LECTURE X. 
 
 . PAGE 
 
 Summary. — Simple ulcer of the stomach, case; indications for mix vomica, 
 arsenicum and argentum nitricum. Pneumonia of the apex of the 
 lung, case; bryonia, phosphorus and tartar emetic; treatment of pneu- 
 monia. History of the introduction of homoeopathy into the Paris hos- 
 pitals; Tessier and his enemies; the report and the favorable statistics 
 of M. Davaine. The Expectant and the homoeopathic treatment of 
 pneumonia. Sciatica, case; indications for bryonia, rhus toxicoden- 
 dron, colocynthis, arsenicum, belladonna and chamomilla, mix vomica, 
 sulphur and veratrum. The common form of phthisis, case; indica- 
 tions for bryonia and drosera. On the choice of the attenuation 93 
 
 LECTURE XL 
 
 Summary. — Typhoid fever; indications for arsenicum. Phthisis and chlor- 
 osis; indications for bryonia and sepia. Of the use of iron in phthisis. 
 Sea-baths in ditto. Chronic aortitis; the common and the painful 
 forms of angina pectoris ; description of chronic aortitis, cases; angina 
 pectoris; case 107 
 
 LECTURE XII. 
 
 Summary. — Typhoid fever, case. Asthma, case; indications for bryonia. 
 Asthma and trifacial neuralgia, case. On the choice of the attenua- 
 tion 134 
 
 LECTURE XIII. 
 
 Summary. — Croup; indications for tracheotomy ; case. The cure of phthi- 
 sis, case; the vegetable diet in phthisis. Rule for the choice of reme- 
 dies. Individualization 148 
 
 LECTURE XIV. 
 
 Summary. — Remedies. The Materia Medica Pura; indications; exam- 
 ples. Case of abscess of the liver; indications for the opening of these 
 abscesses. Case of chronic pleurisy; indications for thoracentesis; sup- 
 puration following the operation made with Dieulafoy's aspirator; the 
 abuse of thoracentesis; indications for it in empyema. The law of 
 contraries and the law of similars 164 
 
 LECTURE XV. 
 
 Summary. — Hemoptysis, case. What is hemoptysis? Differential diag- 
 nosis of hemoptysis from hematemesis and epistaxis. Varieties of 
 hemoptysis and their semiotic value. Therapeutic indications for the 
 
Xll CONTENTS. 
 
 PAGE 
 
 relief of hemoptysis; ligation of the extremities; ice and cold; acon- 
 itam, arnica, millefolium, ledum palustre, ferrum per 'chloricum, ipecac, 
 phosphorus, hamamelis and nux vomica. The old-school treatment of 
 hemoptysis. Hemoptysis is never the cause of phthisis. Niemeyer's 
 error. A rare case 179 
 
 LECTURE XVI. 
 
 Summary. — Hemorrhoids, case. Are hemorrhoids only varices of the 
 hemorrhoidal veins, or do they constitute a disease ? The connection 
 between gout and hemorrhoids. Hemorrhoids with profuse hemor- 
 rhages. Indications for sulphur, nux vomica, cesculus hippocastanum, 
 hamamelis, millefolium, ferrum perchloricum, aloes, the phosphoric 
 and muriatic acids, arsenicum, carbo-vegetabilis, capsicum, collinsonia 
 and sedum acre 196 
 
 LECTURE XVII. 
 
 Summary. — Chronic gastritis, case; the potencies vary with the disease. 
 Broussais and gastritis. Typhoid fever. J. Davasse and reform in 
 the doctrine of fevers. Confusion in the German school. Distinction 
 between chronic gastritis, dyspepsia and gastralgia. Treatment of 
 these three affections. Remedies correspond to the suffering organ 
 more than to the disease itself. General and special indications for 
 remedies in gastritis, dyspepsia and gastralgia. Nux vomica, ignatia, 
 carbo-vegetabilis, cocculus, arsenicum, lycopodium, sulphur, Pulsatilla, 
 plumbum, chamomilla, belladonna, veratrum and graphites; the alter- 
 nation of nux vomica and graphites. Case of chlorotic dyspepsia 209 
 
 LECTURE XVIII. 
 
 Summary. — Chronic Congestion of the Liver, case. What is a chronic con- 
 gestion of the liver? The diseases in which it occurs. Its symptoms. 
 A study of the symptoms of hepatic dullness. Gravity of this con- 
 gestion. Indications for the animal poisons and for nux vomica. Hypo- 
 chondria, case. Indications for nux vomica and aurum 231 
 
 LECTURE XIX. 
 
 Summary. — Scrofulous ophthalmia is an affection which has three forms. 
 Blepharitis; indications for mere, precipitatum rubrum, euphrasia, 
 senega, colcarea carbonica, hepar sulphuris, digitalis. Hordeolum; 
 indications for Pulsatilla, staphysagria, silicea. Inflammation of the 
 lachrymal ducts; indications for silicea and colcarea carbonica. Scrof- 
 ulous conjunctivitis; indications for ipecac, and apis; cases. Scrofu- 
 lous lupus of the pharynx; indications for hepar sulphur, arsenicum and . 
 opium. Phthisis pulmonalis, two cases , 243 
 
CONTENTS. Xlll 
 
 LECTURE XX. 
 
 PAGE 
 
 Summary. — Pelvi-peritonitis and peri-uterine hematocele. Case of sup- 
 purating pelvi-peritonitis. Description of pelvi-peritonitis. Differ- 
 ential diagnosis from inflammation of the broad ligament and in the 
 iliac fossa. Treatment: Aconite 265 
 
 LECTURE XXI. 
 
 Summary. — The treatment of pelvi-peritonitis, continued; indications for 
 colocynth; case. Indications for cantharis, conium mac; pelvi-peri- 
 tonitis and rheumatism, remedies for; the suppurative stage of; aconite, 
 china, arsenicum and the chin, sulph. in; hamamelis, thlaspi and 
 sabina, opiates, hot- water irrigation, hygienic care, and -a good diet. 
 Puerperal pelvi-peritonitis 281 
 
 LECTURE XXII. 
 
 Summary. — Peri-uterine hematocele; hematocele and pseudo-hematocele; 
 hematocele from rupture; hematocele from retention; vicarious hemor- 
 rhage. Case: menorrhagic hematocele. Case: differential diagnosis 
 from pelvi-peritonitis, and from uterine fibroids. Case: treatment, 
 aconite, colocynth, arnica, belladonna and digitalis 300 
 
 LECTURE XXIII. 
 
 Summary. — Eczema: Definition. It is a symptomatic affection; eczema 
 rubrum (pseudo-exan thematic); seat; scrofulous eczema, case; dart- 
 rous eczema, case; arthritic eczema, case; treatment: Rhus toxicoden- 
 dron and vernix; pathogenesy and indications: cantharis, arsenicum ; 
 case; plumbago, mezereum, dulcamara, viola tricolor, sepia, sulphur, 
 mineral waters. External treatment 324 
 
 LECTURE XXIV. 
 
 Summary. — Typhoid fever of a benign form, case. The ordinary form, 
 case. The diagnosis of typhoid fever; prodroma; thermo metric tracings 
 in typhoid and inflammatory fevers, variola, pneumonia, and acute 
 phthisis. Value of the thermic record; it gives a startling picture of 
 the ensemble of the disease. The diagnostic value of these records, and 
 their confirmation of the doctrine of critical days. Bilious and mucous 
 fevers are nosological errors. The acute catarrh of the stomach is 
 nothing more than the old theory of universal gastritis proposed by 
 Broussais. The pretended gastric symptoms belong to stomatitis, an 
 affection which is common to the most varied diseases. The ordinary 
 form of typhoid fever prolonged, case. Importance of this form 344 
 
XIV CONTENTS. 
 
 LECTURE XXV. 
 
 PAGE 
 
 Summary. — Typhoid fever, continued; the different varieties of; clinical 
 importance of this subject; necessity of a careful diagnosis of the forms 
 of this fever, even for the homoeopathic physician; treatment; indica- 
 tions for belladonna and for the muriatic and phosphoric acids, arsen- 
 icum, ipecac, and baptisia. These fevers never cut themselves short; 
 regimen. Dr. Small's experience. The meningoencephalitis of typhoid 
 fever 360 
 
 LECTURE XXVI. 
 
 Summary. — Of pneumonia, case. Rapid termination of the disease. Lack 
 of defervescence. Importance and difficulty of the diagnosis. Of indi- 
 vidualizing and of curing by name or title. Arsenicum and tartar 
 emetic. Case of pneumonia with absence of the usual signs. No defer- 
 vescence. Critical days. Necessity of examining all febrile patients 
 by auscultation. The expectant system, and the errors and fallacy of 
 its statistics. The boasted success of Dr. J. Hughes Bennet. Puerperal 
 pneumonia, case 380 
 
 LECTURE XXVII. 
 
 Summary. — Rheumatism, continued (see Lectures III, IV, V and IX). 
 Case of rheumatism with endocarditis. Aortic insufficiency. Two 
 sounds in the crural artery. How to distinguish the systolic from the 
 diastolic murmur. Theory and practice. Science and art. Theory of 
 the two arterial murmurs in insufficiency. Mono -articular rheumatism. 
 Good effects of china. Articular rheumatism. Contraction of the 
 mitral orifice. Hemoptysis, case. Millefolium. Certain rare compli- 
 cations of articular rheumatism. Hematuria, case. Hamamelis and 
 Spigelia. Spinal rheumatism, case. Acute parenchymatous myelitis 
 of the anterior gray columns of the cord. Plumbum. Locomotor ataxia, 
 cases 403 
 
 LECTURE XXVIII. 
 
 Summary. — Scrofulous keratitis, case. Apis mellifica and apium virus. 
 Acute articular rheumatism terminating in white swelling, case; sal 
 croisici 427 
 
 LECTURE XXIX. 
 
 Summary. — Hydrarthrosis, case. Jodium. Diagnosis of hydrarthrosis. 
 Hydrarthrosis acutus, case. Apium virus. Periodical hydrarthrosis, 
 two cases. Sea-bathing. Asthma with epileptiform vertigo, case. 
 Arsenicum. Hemoptysis in asthma, case. Arsenicum and nux vom'ca. 434 
 
CONTENTS. XV 
 
 LECTURE XXX. 
 
 PAGE 
 
 Summary. — Vaginismus, case. Causes and treatment. The French sur- 
 geons and Dr. J. Marion Sims. Note: case. Hemorrhagic variola. 
 Influence of vaccination upon the suppurative stage, and the therapeutic 
 fallacies which spring from it; case. The hemorrhagic rash and the 
 scarlatinal rash. Phosphorus. Hemorrhagic variola without increased 
 frequency of the pulse; death; case. The malignancy of disease 445 
 
 LECTURE XXXI. 
 
 Summary. — Putrid diphtheria. Premature paralysis. The spasmodic ele- 
 ment of croup denied by Bretonneau and his followers, case. Death 
 by syncope can only be explained by the diphtheritic paralysis of the 
 heart. Cyanuret of Mercury, indications for. Is there a preventive 
 treatment for the syncope? Alimentation and its difficulties. The poi- 
 sons : lachesis, vipera and apis, camphora, agaricus muscarius, bella- 
 donna and arsenicum. Pneumonia and pleurisy from diphtheritic 
 paralysis of the nerves, which preside over the nutrition of the lungs 
 and of the pleura 464 
 
 LECTURE XXXII. 
 
 Summary. — Slight albuminuria. Consecutive Bright's disease. Serious 
 albuminous nephritis in typhoid fever, case. Prolonged typhoid fever, 
 serious albuminuria; inflammation of the parotid gland. Terebin- 
 thina; cure; case. Prolonged typhoid fever; albuminuria with hem- 
 aturia, phosphoric acid; symptoms of spinal meningitis, sulphate of 
 strychnine, remission of the fever which is rebellious to the sulphate 
 of quinine; cure. Relapsing typhoid, case. Its character is not that 
 of a relapsing typhus. The pernicious paroxysms, and their peculiari- 
 ties in typhoid fever. Typhoid fever without fever. 478 
 
 Table of French and English Weights and Measures 494 
 
 Index 495 
 
THE MEDICAL CLINIC 
 
 OF THE 
 
 HOSPITAL SAINT- JACQUES, OF PARIS. 
 
 LECTURE I. 
 
 Summary. — The Clinic. Homoeopathy, and its place in therapeutics: note. 
 The legitimate role of empiricism and of palliative medication: note. 
 
 The Clinic. 
 
 Gentlemen : In opening these Clinical Lectures, I feel it 
 my duty to answer a question which is perhaps in your 
 thoughts, and which certainly has addressed itself to me. 
 Have you come hither from mere curiosity, or from a desire 
 to learn and to practice a branch of the Healing Art % 
 
 I trust it is the latter motive that has prompted you ; for, 
 in the future, it alone will encourage you to persevere, and 
 to make the time which you consecrate to the study of 
 Homoeopathy alike profitable to yourselves and to your 
 patients. 
 
 You all know that the Clinic consists in the application,, 
 at the bed side of the patient, of the medical knowledge that 
 you liave acquired from books and from the lectures of your 
 teachers. It ought not, therefore, to be, as Trousseau under- 
 stood it, a mere lesson in nosography ; nor, as other professors 
 have made it, simply a course upon therapeutics. For us, the 
 Clinic has a well-defined purpose or object ; and that object 
 is, firstly, the application of semiotics and of therapeutics at 
 
jL the medical clinic. 
 
 the bed-side of the sick ; and secondly, to demonstrate the 
 superiority of homoeopathic remedies in the cure of those pa- 
 tients whom you will have occasion to see in our wards. 
 
 Homoeopathy, and its Place in Therapeutics. 
 
 But, gentlemen, there is an important question which it 
 is necessary to answer before beginning our course of in- 
 struction, and that question is, What is Homoeopathy? And 
 what place should it occupy in Medicine I 
 
 Without having read the ancient authors very profoundly, 
 you perhaps know that, until the seventeenth century, the 
 thera23eutic ideas of Galen were almost sovereign in our 
 art ; and that its roots were so deeply implanted in the 
 ground-work of medicine, that even now, after three hundred 
 years of strife, we still find the deep and indelible traces of 
 its influence. And there is nothing in this that should 
 astonish us. Its strength was in the very simplicity upon 
 which his hypothesis rested. Admitting that there are four 
 humors in the animal economy, and that their alteration or 
 their combination was the cause of all diseases, we have two 
 indications, id est. for antidotes and evacuants. Surgical dis- 
 eases and cases of poisoning gave palpable proof of the 
 validity of this doctrine. A dislocation occurs : place the 
 articular surfaces in apposition, and you have a cure. In a 
 case of poisoning, evacuate or neutralize the poison, and the 
 patient is saved. The substance of this doctrine is found in 
 the well known axiom, ' ' Sublatd causa tollitur effectus and 
 contraria contrariis eurantur." No one can deny the truth 
 of these principles when they are applied to diseases arising 
 from external causes, such as cases of poisoning, parasitical 
 affections, etc. ; but when, as the disciples of Galen did, we 
 attempt to apply the same principle to diseases that are due 
 to internal causes, we are wrong. It is not necessary for me 
 to tell you that an internal and an unknown cause are synony- 
 
HOMOEOPATHY, AND ITS PLACE IN THERAPEUTICS. 3 
 
 mous ; yon do not, I am sure, confound the conditions which 
 may favor the development of a disease with the cause of the 
 disease itself. For what is contingent and what is essential 
 cannot be identical. Cold is not the cause of rheumatism, of 
 pneumonia, or of quinsy ; but it is the accident which favors 
 the development of these diseases. The cause is in our own 
 bodies, which are more or less likely to contract this or that 
 disease. The proof is that the same external influences will 
 produce a variety of diseases, according to the susceptibility 
 of the persons upon whom they act. 
 
 If I have digressed, it is to more firmly establish the fact 
 that the internal cause of disease is unknown ; and that, if 
 it is unknown, we cannot reasonably expect to find its oppo- 
 site. Before giving an antidote, you must know the poison. 
 And so humorists, solidists, animists, and all those who 
 have sought for the internal cause of disease, have strayed 
 away from the truth, and have thrown aside the one useful 
 thing, which is the mode of action of the remedies employed, 
 that they might treat a pathological hypothesis by a phar- 
 maceutical one. 
 
 I certainly do not pretend to say that Hahnemann was the 
 first physician to rise above this order of things. For there 
 were those before him who foreshadowed the truth, among 
 whom I may cite you the names of Paracelsus, Yon Hel- 
 mont, Stahl, Storck, and John Hunter, all of whom de- 
 clared forcibly against the errors of Galen, and each of 
 whom felt the necessity of reform. * But no one of these great 
 
 *The name of the celebrated Haller should also have been included in this 
 list. In his Essays on Medicine, page 163, our good friend Dr. William Sharp, 
 of Rugby, England, makes the following forcible quotation from Haller: " In 
 the first place, the remedy is to be tried on the healthy body, without any foreign 
 substance mixed with it; a very small dose is to be taken, and attention is to be 
 directed to every effect produced by it: for example, on the pulse, the tempera- 
 ture, the respiration, the secretions. Having obtained these obvious phenomena 
 in health, you may then pass on to experiment on the body in a state of dis- 
 ease.'" — L. 
 
THE MEDICAL CLINIC. 
 
 masters developed that reform as Hahnemann did. He not 
 only felt the necessity, but he formulated his doctrine and 
 saw it definitely applied. The principle which serves as the 
 basis of Hahnemann's doctrine may be found in this, that 
 if you wish to obtain a prompt, certain and lasting cure, you 
 must choose a medicine which, given to a perfectly healthy 
 person, will produce symptoms that are analogous to those 
 of the disease which you are treating. Hahnemann discov- 
 ered this law in 1790, while he was translating Cullen's 
 Materia Medica on the use of Peruvian bark in fevers. 
 
 Do not imagine, gentlemen, that Hahnemann was satisfied 
 with this first great fact. Those of you who have any doubts 
 on this subject have only to read the admirable chapter in 
 the Organon entitled u Unintentional Homoeopathic Cures" 
 in order to be convinced on this point. There you will see 
 how the reformer labored to demonstrate his new method. 
 But it was not enough to prove the truth by evidence that 
 could be drawn from the past ; it was necessary to establish 
 the new doctrine on a firm and immovable basis. It was 
 with this object in view that Hahnemann relinquished his 
 medical practice, and that he spent ten years of his life, in 
 experimenting upon himself and upon those about him, in 
 order to learn the action and effect of remedies ; and it is 
 as a result of this voluntary seclusion that we have the com- 
 plete and detailed account that he has given us of one hun- 
 dred medicines. In regard to these provings there can be 
 no doubt of their genuineness, for they were all made with 
 ordinary doses of the drugs used. 
 
 This first service rendered by Hahnemann to science has 
 been accepted by the profession, and to-day there is not a 
 therapeutist, or a so-called therapeutist, who dares to publish 
 a materia medica without giving at the same time the results 
 of exj^eriinents both upon the healthy man and upon animals. 
 But the law of similars, although it may be found in Hi])- 
 
HOMCEOPATHY, AND ITS PLACE EN THERAPEUTICS. $ 
 
 pocrates and Yon Helmont, was less universally accepted ; or 
 at the best, it was stolen and adapted for the benefit of the 
 specific school, and afterward decorated by Trousseau with 
 the title of the "Substitutive Method." 
 
 If homoeopathy had rested on these two principles alone it 
 is very probable that it never would have stirred up the wrath 
 of the doctors ; but, unfortunately for the peace of the frater- 
 nity, the law of similars implied the giving of medicines in 
 small doses. In fact, if the ordinary doses were administered 
 according to the doctrine of similars they would almost always 
 prove dangerous to the patient. In trying to imitate us the 
 advocates of specific medication have shown the serious results 
 that may come from giving large doses of strychnia in chorea, 
 for example. Who would dare to prescribe opium or tartar 
 emetic in ordinary doses, — the first for cerebral congestion or 
 the second for vomiting ? The benefits to be obtained from 
 these medicines would be purchased at the price of aggrava- 
 tions that are often dangerous. It was for this reason that 
 Hahnemann himself gave small doses at first, and then, see- 
 ing as a consequence satisfactory results, he reduced them until 
 they became almost infinitesimal. 
 
 Well, gentlemen, that this part of his doctrine has created 
 more or less opposition, that it has shocked the intelligence, 
 and that it appears to be more or less hypothetical, does not 
 concern us. The question of infinitesimal doses knows but 
 one jurisdiction, and is to be settled in only one way ; for 
 clinical experience alone should and must finally decide upon 
 their value or their worthlessness. 
 
 I come now to consider the errors that were shut in with 
 the homoeopathic doctrine, as it was understood by its founder; 
 ■ and who need be astonished that some errors were included in 
 it ? — for where in this world will we find perfection 1 More- 
 over, is it not through or because of their errors that great 
 men are allied to humanity ? Hahnemann' s shortcomings ex- 
 
6 THE MEDICAL CLINIC. 
 
 plain themselves. From the first he had been repulsed, he 
 had lived alone, a target for the persecutions of those to 
 whom he was conscious of being superior ; and then, after 
 all sorts of misfortunes, came success, and with success, flat- 
 tery and adulation and all the intoxication of triumph. Sur- 
 rounded by disciples, whose heads were turned with what he 
 had done, — the acknowledged master and leader, — he imag- 
 ined himself to be almost infallible, and fancied that his 
 mission would not be accomplished until he had explained 
 everything in medicine. He accordingly formulated a pathol- 
 ogy, and also a physiology, as he had formulated a system of 
 therapeutics. 
 
 Such, gentlemen, was the origin of the triple dynamism 
 which is physiological, therapeutical and pathological. I can- 
 not enter into a discussion of this error, for it would carry 
 me too far from my subject, and besides it is unnecessary, 
 for the followers of this extreme view are not so numerous 
 as they were. For myself, I am quite of the opinion of my 
 teacher, Tessier, who made a resume of this question in these 
 words : u The doctrine of Samuel Hahnemann may be divided 
 into two parts, viz., pathology and therapeutics. Term for 
 term, the one comprehends all of his errors and the other 
 all of his truths. So that, in speaking of the pathology, or 
 the errors, of Hahnemann, we mean the same thing ; and 
 his therapeutics, or his truths, are also identical. Consequent- 
 ly, in what is called homoeopathy there is the hemisphere 
 of error and the hemisphere of truth." 
 
 Far from admitting the triple dynamism in physiology, 
 we accept the doctrine of a substantial union of body and 
 spirit; in pathology we are essentialists, — that is to say, we 
 consider diseases as distinct species, not constituting veritable 
 entities, but to be described and studied as belonging to the 
 natural species. 
 
THE LEGITIMATE ROLE OF EMPIRICISM. 7 
 
 The Legitimate Role of Empiricism and of Palliative Medication. 
 
 I must add one thing more, which is, that although homoe- 
 opathy is applicable in a great majority of cases, yet it cannot 
 fill all possible indications. Until the day arrives in which 
 the Materia Medica is perfectly known I must invoke the aid 
 of empiricism. When that day comes the empirical method 
 must disappear from the domain of science ; but, meanwhile, 
 some of its resources are indispensable, for to it we owe the 
 use of the thlaspi bursa pastoris in metrorrhagia ; of the 
 sedum acris in fissures and spasmodic contractions of the 
 anus, and many other similar resources. 
 
 This same thlaspi is remarkably useful in the irritable bladder, which has 
 been so carefully described by Dr. Gant.* We have found it of great service in 
 this condition in the case of women who, it was supposed, were suffering from 
 anteflexion, of the womb. — L. 
 
 Besides, it often regulates the employment of mineral 
 waters, and their administration must be empirical until con- 
 scientious and intelligent physicians shall have given us their 
 pathogenetic and curative history, like that of Cauterets, for 
 example. 
 
 If we get the author's idea, — and it would be very unkind to misinterpret 
 him, — he holds that there is a " scientific frontier " against the empirical use of 
 remedies, but that, until the resources of pathogenesy, and of clinical experience 
 in their application, are better known and more available, we have not abso- 
 lutely secured that frontier. — L. 
 
 Concerning the palliative treatment, of which we should 
 avail ourselves in incurable diseases, u Where the physician 
 cannot ' cure, it is his duty to relieve. ' ' Therefore, in cases 
 of cancer, or of phthisis, that have reached the cachectic stage, 
 do not hesitate to assuage pain. In hepatic or nephritic colic, 
 if you find that the ordinary attenuations do not bring their 
 accustomed relief, it is your duty to mitigate suffering, either 
 
 * The Irritable Bladder: its Causes and Treatment, etc., by Frederick James Gant 
 E.R.C.S., Philadelphia, 1872. 
 
8 THE MEDICAL CLINIC. " 
 
 by an injection of morphine or by some other palliative means. 
 In any case, where a curative result cannot be obtained with- 
 out the use of closes that are relatively large, you should 
 employ them without hesitation. To sum up the whole ques- 
 tion in a few words, we believe and profess that therapeutics 
 were made for those who are ill, and not for the doctors, and 
 that in this branch of medicine, especially, a narrow spirit 
 and a too absolute faith are the sources of the most deplora- 
 ble errors. 
 
 Now, gentlemen, that you understand our doctrines in re- 
 gard to pathology, as well as to the Materia Meclica, we shall 
 enter without further comment into the proper domain of the 
 Clinic, and our next lecture will be devoted to the study of 
 the diseases of those patients who are in our wards. 
 
LECTURE II. 
 
 Summary. — Asthma, case; of emphysema, both transitory and confirmed; in- 
 dications for ipecac, in asthma. Puerperal pleurisy followed by phthisis; 
 indications for cantharis and for arsenicum. Chlorotic neuralgia; indica- 
 tions for belladonna. Bronchitis; indications for ipecac, and bryonia. 
 Ascites, case; differential diagnosis of; indications for apis, j 'odium, ar- 
 senicum and primus spinosa; good effects of china. Rheumatic endocar- 
 ditis; aggravation by the cactus grandiflora. 
 
 Asthma. 
 
 Gentlemen: In No. 1 of the woman's ward is a patient, 
 sixty years of age, whose sufferings began eight years ago. 
 Since that time she has been subject to attacks of asthma 
 and to menorrhagia. The latter is not of a serious charac- 
 ter. She came here to be treated for bronchitis, which, en- 
 grafted upon asthma, is sometimes very alarming. My pred- 
 ecessor had been giving her bryonia, and she was improving 
 under the influence of this remedy when I took the service. 
 At that time her symptoms were as follows : coughing in the 
 morning, abundant expectoration, dyspnoea, and, upon auscul- 
 tation, we found prolonged and double expiration. It seems 
 that in diseases of this kind the expiration may be spasmodic, 
 for, while in a normal state, the inspiration is the longer of 
 the two, the opposite is found to be the case with our asth- 
 matic patients. This woman also suffers from insomnia. I 
 gave her arsenicum, 12th dil., and with favorable results. I 
 then prescribed ipecac, in the hope of diminishing the asthma 
 and the emphysema, but was unsuccessful. I resumed the 
 arsenicum, in the 3d trit., during the day, and gave nux 
 vomica, 3d trit., at night. This is what she is now taking. 
 
 I wish to call your attention, in this case, to the proper 
 lesion of asthma, which is emphysema. This lesion occurs in 
 
10 THE MEDICAL CLINIC. 
 
 two forms, which it is important to distinguish. In fact, one 
 form is transitory, and consequently curable ; while the other 
 is beyond the reach of therapeutics. These two forms of 
 emphysema may be easily recognized by certain symptoms. 
 Transitory emphysema is characterized by an exaggerated 
 sonorousness and a prolonged whistling expiration, which is 
 also spasmodic, and sometimes double. 
 
 These symptoms are most discernible on the back of the 
 thorax. Sometimes this emphysema is of short duration. I 
 have known it to disappear with one attack of asthma. At 
 other times it will last for several months, but in this form 
 it is always curable. It may be experimentally induced by a 
 section of the pneumogastric nerve, and is attributed to the 
 paralysis of the muscular fibres known as Reissessen's mus- 
 cles. The partially-paralyzed vesicles become distended by 
 air ; an effort of the respiratory muscles becomes necessary, 
 which causes the spasmodic breathing. Instead of being 
 sonorous at first only, as is the case in a normal condition, 
 the expiration is sonorous throughout the whole of its dura- 
 tion, and this produces the prolonged expiration. 
 
 In the confirmed emphysema the increased sonorousness 
 of the thorax is coincident with a decided decrease in the 
 respiratory murmurs. These phenomena are very marked in 
 the case of one of our patients, — the woman who is in ~No. 
 5. In this confirmed emphysema, which may be considered 
 as a more advanced lesion, there is not a rupture, but a per- 
 foration of the partition which separates the vesicles, so that one 
 finds in them such cavities in the pulmonary tissue as inter- 
 fere with hsematosis. We see, therefore, why this lesion is 
 incurable. If I have occupied a good deal of - your time on 
 this subject, it has been to prove that there are cases be- 
 yond the power of therapeutics to relieve, and that among 
 them may be included all those cases in which there is any 
 destruction of tissue whatever. 
 
ASTHMA. 1 1 
 
 But to return to our patient in No. 1. I told you that I 
 had prescribed ipecac, for her, and, apropos of this, I shall 
 give you the physiological history of this drug. You know 
 that, given in large doses to animals, it produces slow and 
 difficult breathing ; that is the fundamental character of its 
 action. Observe now the kind and number of respirations in 
 all asthmatic patients, and you will see that they are less fre- 
 quent than in a normal state, and also that they are painful 
 and difficult. Here is, then, the homoeopathic reason for the 
 prescription of ipecac, in asthma. This medicine will, you 
 know, produce paroxysms of dyspnoea analogous to those of 
 asthma. To convince yourselves of the truth of this state- 
 ment, you need only refer to any allopathic treatise on thera- 
 peutics, particularly to that of Trousseau and Pidoux, where 
 you will find examples such as I have cited. 
 
 Now, if you consult Hahnemann, you will find, in the 
 pathogenetic symptoms of ipecac, difficult and whistling 
 expiration, pulmonary congestion, bronchitis, and sometimes 
 hepatization. All of these facts militate in favor of the use 
 of ipecac, in asthma, especially where the disease has been 
 of long duration, and where you will often find a coincident 
 bronchitis, catarrh, and a greater or less degree of conges- 
 tion. 
 
 Lastly, not wishing to omit anything, you will find in 
 the u Dictionnaire des Sciences Medicates" edited by M. Jac- 
 coud, an article on asthma written by Prof. See, in which, 
 after having acknowledged the depressing effects of ipecac, on 
 the muscular system, he advises against the use of this drug 
 in therapeutics, which, he says, in certain cases increases the 
 suffocation, and in so saying contradicts in four lines not 
 only himself but all clinical experience. For myself, con- 
 vinced by observation and by clinical results, of its efficacy, I 
 urgently recommend you to use ipecac, in all cases of asthma 
 and of asthmatic dyspnoea, whether complicated or not with 
 
12 THE MEDICAL CLINIC. 
 
 bronchitis. Yon will find this medicine of the greatest service in 
 cases of difficult, noisy breathing, suffocation, blueness of the 
 lips, etc. If these symptoms are accompanied by nausea I 
 can assure you of an almost certain cure. 
 
 Let me say, in passing, that the characteristic of ipecac, is 
 the spasm ; it is not only indicated in transitory emphysema, 
 where there is a spasm of the respiratory muscles, but likewise 
 in the laryngeal spasm of stridulous angina, and also in the 
 spasm of the rectum which characterizes dysentery. I shall 
 hereafter give you the indications for nux vomica and arsen- 
 icum, the two remedies which, next to ipecac, are most fre- 
 quently used in asthma. Trousseau has also extolled the 
 empirical use of iodine in the form of the iodide of potassium ; 
 and, lastly, belladonna and stramonium have been employed, 
 especially in the form of cigarettes or fumigations. 
 
 Cuprum, which like ipecac, is a remedy for spasms, is 
 indicated in asthma. 
 
 Puerperal Pleurisy followed by Phthisis. 
 
 Xext to our asthmatic sufferer in ]No. 2 of the women's 
 ward is a patient who was delivered of a child three months 
 ago. Several days after her labor she was seized with a chill, 
 that was followed by fever, a cough, pain in the side and 
 difficulty of breathing; in fact, all the symptoms of pleurisy. 
 She has^ however, remained at home until within the last few 
 days, when the persistence of her sufferings decided her to 
 come to us. On a first examination we found an absolute 
 flatness or percussion in the lower part of the right lung, 
 describing the parabolic curve which Damoiseau has insisted 
 upon as characteristic. There was a complete absence of res- 
 piratory murmurs, and of the thoracic movements. Finally, 
 at the point of the scapula there was egophony of a low bass 
 tone. We prescribed cantharis, 3d clil., — a remedy which we 
 have used successfully for twenty years, and the indications 
 for which you will find in the homoeopathic provings. 
 
CHLOEOTIC NEURALGIA. 13 
 
 I am anxious about this patient, not in regard to the pleu- 
 risy, which is really better, but on account of the pulmonary 
 phthisis, of which the pleurisy was the forerunner. She has 
 already had a chill followed by fever at about three o'clock 
 every afternoon. Yesterday during the fever the thermometer 
 indicated 102.9°. At the same time, by auscultation we found 
 moist rales at the apex of the left lung, with difficult breathing, 
 whistling expiration, feebleness of the voice, pectoriloquy, 
 and all the symptoms of pulmonary induration, with some 
 points of softening. 
 
 AYe will not, however, be discouraged, but try to give her 
 relief for at least some time to come. I have prescribed 
 arsenicum, 12th trit., which is particularly indicated in period- 
 ical fevers. 
 
 Chlorotic Neuralgia. 
 
 A little farther on, gentlemen, you will find a very simple 
 case of trifacial neuralgia in a woman who has the carotid 
 murmur, some menorrhagia, intercostal neuralgia ; in a word, 
 the diagnostic signs are evident. I have not, however, pre- 
 scribed iron ; but I have given her belladonna, which seems 
 to me indicated equally by the trifacial neuralgia and the 
 sensitiveness of the skin to the touch. It is but right for 
 me to add that the moment I have the results I expect from 
 the belladonna, I shall substitute for it iron and arsenicum, 
 which are the two remedies that I ]3refer in chlorosis. 
 
 When this form of neuralgia occurs in young hysterical women, we have 
 learned from experience to place great confidence in the citrate of iron and 
 strychnia in the third trituration. Where a similar condition results from a too 
 prolonged lactation, or from nursing and having the menses at the same time, 
 calcarea phosphor ica is the remedy. — L. 
 
 Bronchitis. 
 
 The patient in ~No. 1 is a woman already old, and who 
 says she has been under treatment in the city for pneumonia. 
 However that may be, she was in a most wretched state 
 
14 THE MEDICAL CLINIC. 
 
 when she entered here, and her constitution was well nigh 
 broken from poverty, trouble and disease. An examination 
 of the thoracic organs revealed the existence of an old pleu- 
 risy, which has caused a comparative dullness throughout the 
 whole extent of the left side. She suffered when she came 
 to us from a very sharp and frequent cough, and a relapse 
 of the bronchitis. I gave her ipecac, 12th clil., and hryonia, 
 12th clil., alternately every two hours, and in three days the 
 cough was nearly gone. I recommend these two remedies 
 to you in bronchitis with sub-crepitant rales and pulmonary 
 engorgement, id est, in capillary bronchitis. I know that if 
 we followed the law of similars exclusively, we should pre- 
 scribe tartar emetic, phosphorus and pulsatilla, the patho- 
 genetic symptoms of which correspond very well with the 
 bronchitis. But if I may be allowed to make the assertion, 
 clinical experience is a basis as solid as the law of homoe- 
 opathy itself, and that experience has decided in favor of the 
 course that I recommend to you. The great fault of Hahn- 
 emann and his first followers was in their refusing to admit 
 the truth, in their desire never to vary from the indications 
 of the Materia Medica. In some cases, gentlemen, it will 
 be well to precede the use of ipecac, and bryonia by aconite 
 for twenty-four or forty-eight hours, especially where there is 
 much fever and great .thirst. At some otliei time I shall 
 give you the indications for tartar emetic, for Kermes' min- 
 eral, for the arseniate of antimony, for pulsatilla, for arsen- 
 icum, and for phosphorus. 
 
 Syphilis. 
 
 Next to this woman is a patient with syphilis, and whose 
 case is specially characterized by crusty syphilides, seated upon 
 the face, and by periostitis, located on the frontal bone. This 
 patient is therefore on the line which divides secondary and 
 tertiary syphilis. The iodide of potassium, two grains daily, 
 
ASCITES FROM AMYLOID DEGENERATION OF THE LIVER. 15 
 
 prescribed by my predecessor, Doctor Molin, has had a good 
 effect. 
 
 Ascites from Amyloid Degeneration of the Liver. 
 
 I hasten, gentlemen, to speak to yon of two more inter- 
 esting cases. The first is that of a man with ascites. 
 
 Case II. — Mr. Chanson, forty-one years of age, a printer, 
 entered on the 5th of January ; had never been ill until August, 
 1873. At that time he had an attack of pleurisy in the left side. 
 In October of the same year he still coughed, had sharp pains in 
 the loins, and oedema of the legs. In November the dry cough 
 increased and became frequent, especially at night. Emacia- 
 tion, dyspnoea, and all the symptoms of an incipient phthisis, 
 obliged him to stop work. After taking phosphorus, 3d trit., 
 the cough nearly disappeared, but the pain in the loins con- 
 tinued. On the 20th of December, while riding on the top of 
 an omnibus, the patient suffered from intense cold, and a chill 
 which lasted ten minutes. This was followed by ascites, which 
 in less than a week had assumed immense proportions. When 
 I resumed the hospital service, on the 15th of January, he was 
 pale, cachectic and much emaciated, with an enormous develop- 
 ment of the abdomen. In the latter there was decided fluctua- 
 tion and dullness, the outline of which changed according to the 
 position of the body. The intestines floated in the abdomen, 
 and were pushed toward the epigastrium. The veins were 
 largely developed on the mesian line. There is no tumor 
 evident to the touch. It is impossible to determine the limits 
 of the liver or the spleen, on account of the effusion. He has 
 thirst, — the urine is scanty and extremely red, with a deposit 
 like that in cirrhosis. Upon testing it we found that two-thirds 
 of the urine was composed of this sediment, — but there was no 
 albumen in it. The pulmonary affection seems to have been 
 arrested. He coughs but little ; moist rales, however, may be 
 heard at the apex o,f the left lung. There is also a small cold 
 abscess with caries on the right tibia. He has slight fever every 
 evening. 
 
 All these symptoms may be due to an effusion which is 
 symptomatic of tuberculous granulations in the peritoneum, 
 or to a compression of the vena porta, which sometimes de- 
 
16 THE MEDICAL CLINIC. 
 
 pends upon sclerosis of the liver, and at other times upon an 
 amylaceous degeneration of it. The effusion increased rapidly, 
 notwithstanding apis mel. was given in the third and also 
 second triturations, and jodimn in the third trituration. There 
 was insomnia, with a loss of appetite, and, above all, a dysp- 
 noea, which decided us, on the 27th of January, to resort to 
 tapping. At this operation we removed eight quarts of a trans- 
 parent liquid, greenish in color, pitchy in consistence, contain- 
 ing a large amount of albumen. After the operation we ascer- 
 tained that there was no abdominal tumor*, that the liver was 
 of the proper size, and that the spleen was slightly enlarged. 
 The day of the operation the patient was somewhat feverish, 
 the pulse was 104, and the temperature 101.12°. Continued 
 the jodium. 
 
 The fluid accumulated again so rapidly that, although giving 
 arsenicum, 3d trit., we were obliged to repeat the tapping on 
 the 31st of January, four days after the first one. At this time 
 we withdrew thirteen quarts of liquid. On the 5th of February, 
 the prunus spinosa having failed us, we made a third operation. 
 Since that time, and through the influence of china, 6th clil., 
 the effusion is much less rapid. The urine is more abundant 
 and without deposit, the appetite has returned, and the general 
 condition of the patient is satisfactory. 
 
 The absence of a tumor, and the rapid reproduction of the 
 effusion, oblige us to reject the theory of a tuberculous affec- 
 tion of the peritoneum. The absence of change in the volume 
 of the liver compels us to exclude the idea of cirrhosis, for 
 which, for that matter, the usual cause is lacking. This man 
 is, in fact, neither syphilitic nor intemperate, nor has he any 
 affection of the heart. The rapid return of the ascites, the de- 
 velopment of the subcutaneous veins along the mesian line, with 
 the course of the blood from above downward, and the absence 
 of the oedema of the lower limbs, establish the certainty of 
 a more or less complete obliteration of the portal vein. The 
 tuberculous lung and the cold abscess of the tibia satisfy us 
 that the patient is scrofulous. Our diagnosis is therefore 
 amyloid degeneration of the liver. 
 
RHEUMATIC ENDOCARDITIS. 17 
 
 Rheumatic Endocarditis. 
 
 The next patient of whom I will speak to you, gentlemen, 
 is a young man who, after an acute attack of articular rheuma- 
 tism, has endocarditis. This is not a rare thing, and I only 
 wish to call your attention to a phenomenon in a well-proven 
 case of medicinal aggravation. I prescribed cactus grandi- 
 flora, 12th clil., for this patient. The night following he 
 suffered frightfully with pain in the heart, and anguish, and 
 I found him in the morning exhausted from it. I suspended 
 the medicine for two days, and the pain in the heart ceased. 
 I then gave him cactus, 6th clil. , which was followed at night 
 by the same pain and exhaustion as before. The remedy was 
 so strongly indicated in the case that I held to it, and know- 
 ing, also, that the higher attenuations will sometimes produce 
 an aggravation, I prescribed cactus in the first dilution, which 
 he is taking with good eifect. Here, gentlemen, is, I think, 
 an incontestable proof of the value of infinitesimal doses ; 
 and cases that are analogous to this one are not scarce, I 
 assure you. 
 
 We shall return to this case at another time, and then 
 you will have its complete history. 
 2 
 
LECTUKE III. 
 
 Summary. — Rheumatic endo-pericarditis (continued), case; indications for the 
 cactus grand. Medicinal aggravations; indications for arsenicum, nux 
 vomica and cuprum in the treatment of asthma. Asthma, case (continued). 
 Pleurisy, then phthisis following labor, case. Incipient phthisis, case; cure 
 by bryonia and a vegetable diet. Semiotic value of pain in the superior 
 intercostal spaces. Pemphigus, case; indications for rhus toxicodendron 
 and cantharis. Lumbago, case; indications for the actea racemosa: note. 
 Erythematous angina, case; indications for belladonna. 
 
 Acute Articular Rheumatism with. Endo pericarditis. 
 
 Gentlemen : You may have noticed in one of the private 
 rooms a young man, — a student, — who had 'been under treat- 
 ment for some time when I took the service from my prede- 
 cessor. I found him suffering from ' a high fever, the joints 
 were swollen and painful, and he complained of a sharp pain 
 in the region of the heart. The diagnosis of the cardiac 
 lesion was not as easy as at .first might be supposed. In fact, 
 the general symptoms were those of endocarditis, but upon 
 auscultation we found signs of insufficiency and contraction 
 of the aortic orifice, one predominating after the other, in 
 turn. Two vascular murmurs could be heard at the apex, 
 one, — the stronger and systolic, — corresponding to a mitral 
 insufficiency; the other, less strong, — diastolic, — correspond- 
 ing to an auriculo-ventricular contraction. There was, besides 
 this, a slight friction sound, just where the apex of the heart 
 strikes the thorax. A single vascular murmur could be heard 
 in the carotids. At the end of a short time we had, to com- 
 plete the picture, — the vibrating and characteristic pulse to 
 which Corrigan's name has been deservedly attached. 
 
 In brief, then, the symptoms in this case are insufficiency 
 and contraction of the aortic and of the auriculo-ventricular 
 orifices ; but, as this lesion is still in process of development, 
 
ACUTE ARTICULAR RHEUMATISM. 
 
 19 
 
 the signs of insufficiency and of contraction predominate alter- 
 nately. Here is the detailed history of the case : 
 
 Case III. — M. L. P., twenty-three years of age. In 1864 
 he had his first attack of rheumatism with pericarditis ; was 
 confined to his bed with this attack for three months. This 
 left him with a cardiac affection. In May, 1866, there was a 
 return of the endocarditis, followed by pleurisy, which kept 
 him in his bed two months. In 1871 he contracted syphilis, 
 chancre, roseola and pustules. Since that time his health has 
 been relatively good. In 1873 he had another attack of articu- 
 lar rheumatism. He entered this hospital on the 24th of De- 
 cember, 1873. The condition of the patient at this time was 
 as follows : Considerable fever ; the finger-joints are swollen 
 and painful ; there is sharp pain in the region of the heart, 
 and dyspnoea. There is a noticeable ■ enlargement of the heart, 
 with pericardial friction at the apex, and in this same place 
 the diastolic and systolic murmur in breathing (insufficiency and 
 mitral contraction) ; at the base the systolic and diastolic mur- 
 mur predominate over the first sound (insufficiency and aortic 
 contraction, with excess of the contraction). Traced sphyg- 
 mographically, the ascending line is very short, a little oblique, 
 level ; the descending line very long, without dicrotism, and 
 with some inequalities. The pulse is small, feeble and fre- 
 quent, and the bruit de souffle is heard with the first sound 
 of the heart in the carotids and in the crural artery. 
 
 In this case, therefore, the physical signs of aortic con- 
 traction are the predominating symptoms. 
 
 Trace No. 1. 
 
 January 16. Chininum sulphuricum, 3d trit. 
 
 January 17. Evening, the pulse is 96 ; morning, pulse 92. 
 The breathing is less difficult. The same treatment. 
 
 January 20. Morning, pulse 84. Last evening the pulse 
 was 104, and the temperature 101.3°, with pain in the joints. 
 Chininum sulphuricum, 2d trit. 
 
20 THE MEDICAL CLINIC. 
 
 January 21. The pains in the joints are much less severe, 
 but there is a sharp pain in the heart. Ghininum sulphur icu7ii % 
 2d trit. The bruit de souffle predominates at the base of the 
 heart during its diastole. The pulse is strong and vibrating 
 without intermission. The sphygmographic tracing shows us 
 a type of aortic insufficiency ; the ascending line is vertical 
 and very high, terminating with a hook ; the descending lines, 
 with dicrotism, are very pronounced. 
 
 Trace No. 2. 
 
 January 22. The same condition. Cactus grand. , 6th dil. , 
 two drops in 200 grammes of water ; one teaspoonful to be 
 taken everv three hours. 
 
 January 23. Great agitation since the patient began to 
 take this medicine ; sleeplessness and apprehension. 
 
 January 24. The pulse, which was 92, has fallen to 84 
 this morning. The patient sleeps well. The pain in the 
 heart, which yesterday was intolerable, is much less severe 
 since the remedy was omitted. 
 
 January 25 and 26. The patient has slept well, and has 
 no pain about the heart. The pulse, morning and night, was 
 88. Cactus grand., 12th dil., four globules. 
 
 January 27. A less quiet night. The cardiac pain is very 
 severe. Stop the cactus. 
 
 January 28. Has had a decidedly better night ; no pain. 
 Cactus, 1st dil., three drops. 
 
 January 29. The improvement continues. Cactus, 1st 
 dil., five drops. 
 
 January 30. The patient is greatly agitated and sleepless, 
 with sore throat since yesterday evening, from the effects of 
 which the pulse was last night 124, and the temp. 103f °. This 
 morning the pulse is 92, and the temp. 102^°. Belladonna, in 
 the mother tincture, three drops. 
 
 January 3J. Fever last evening; pulse 112. This morn- 
 
ACUTE ARTICULAR RHEUMATISM. 21 
 
 ing it is 92. The throat is better. The tonsils are less swol- 
 len, and the pain is not so severe. Belladonna continued. 
 
 February 2. No fever ; the throat is well, and we return 
 to the cactus, 1st dil., three drops. 
 
 February 3. The pulse is less vibrating, and there is less 
 pain at the apex of the heart. 
 
 February 4. Less pain in the apex of the heart. 
 
 In view of the general condition of the patient I ordered 
 chininum sulphuricitm — a remedy which has generally been 
 successful in like cases. He had alreadv taken aconite and 
 bryonia. Under the influence of this remedy the general state 
 of the patient was a little more satisfactory and the joints were 
 less painful, but as the condition of the heart remained the 
 same, I prescribed cactus grand., 6th dil. You know this 
 medicine was first recommended to us by Dr. Rubini. Its 
 principal indications are : sharp pains in the heart, producing 
 sometimes syncope ; sensation as though of an iron hand about 
 the heart ; unequal and intermittent pulse ; determination of 
 blood to the head, and intense cephalalgia. Dr. O'Brien has 
 published in the "Monthly Homoeopathic Review," of Lon- 
 don, a cure of rheumatic endocarditis by cactus; and, although 
 this medicine has failed me in a similar case, I recommend its 
 use because I have several times been successful with it. 
 
 The day following the administration of the cactus, finding 
 the condition' of the patient considerably worse, — which was 
 manifested by sleeplessness, intense cardiac pain, anxiety, etc., 
 I suspended the use of this remedy. During the two follow- 
 ing days, the patient being calmer, I prescribed cactus, 12th 
 dil., which caused a return of the exacerbation. I next gave 
 saccharum lactis, and with the same result. I then pre- 
 scribed the first dilution of cactus, with good effect. The 
 young man continues to take it, and, under its influence, is 
 daily improving. I have interrupted its use but once, and 
 that was for three days, during which time he took bella- 
 donna for an incidental angina. 
 
22 THE MEDICAL CLINIC. 
 
 Of Medicinal Aggravations. 
 
 This is the appropriate place, gentlemen, in which to say 
 something on the subject of medicinal aggravation, — a sub- 
 ject which, as you are aware, has been frequently discussed 
 in our school of practice, but which has never yet been set- 
 tled. You will find among our physicians many who utterly 
 deny the whole matter of medicinal aggravation ; while there 
 are others, on the contrary, who see proofs of it every day, 
 or who think they do. In my opinion, neither one class nor 
 the other is exactly right ; for, in this case, as in many 
 others, the middle ground is the best. The question is a 
 delicate one, and the more delicate because of the diversity 
 of opinion as to what constitutes medicinal aggravation. 
 
 If, after giving a remedy, you find that your patient grows 
 worse, you should be able to distinguish between its action 
 and the natural progress of the disease. For example, the 
 pathogenetic symptoms of diarrhoea, or of the exanthemata, 
 which may appear during the administration of arsenic, should 
 not be referred to medicinal aggravation as a cause. What, 
 then, are we to understand by this term ? It is the aggravation 
 of the symptoms of a disease produced by the homoeopathic 
 medicine itself analogous to its own proper symptoms, — an 
 aggravation that is generally followed by improvement in 
 the morbid condition, when the use of the perturbing agent 
 is suspended. 
 
 Certain mineral waters produce similar effects, — Eaux- 
 Bonnes, for instance, and notably the Mont-Dore, for con- 
 sumptives. During the cure, and immediately after, the 
 patients often experience an aggravation of the disease symp- 
 toms, — the cough, the haemoptysis and the fever. Where 
 the treatment is successful the bad symptoms disappear, and 
 the patient is greatly improved. 
 
 In the same way, from having taken the cactus, our pa- 
 
ASTHMA. 23 
 
 tient suffered an aggravation of the pain and sleeplessness, 
 followed by a marked improvement, until at length he was 
 able to take the remedy in stronger doses. 
 
 In our next lecture we shall speak again of the different- 
 phases of the cardiac lesion. 
 
 Asthma — (Continued from page 12.) 
 
 Let us now glance at the patients who are actually under 
 treatment. A propos of the asthmatic woman in No. 1, and 
 who is still improving, I gave you, as you will remember, 
 the pathogenetic history of ipecacuanha in this disease. Next 
 to it in point of importance we should place arsenicum., the 
 use of which has been so valuable, and the employment of 
 which is traditional in like cases. It is to the presence of 
 arsenic in the waters of Mont Dore that we must ascribe their 
 efficacy in phthisis. Arsenic, for that matter, contains in its 
 provings the following symptoms : coryza, with incessant 
 sneezing and running at the nose, difficult, whistling respira- 
 tion, with constriction of the chest ; and it is not Hahnemann 
 alone who has asserted this ; for Morgagin, Grildenkee, Ran 
 and Guilbert have observed the same symptoms among its 
 effects. The indications for arsenic are drawn from the pre- 
 dominance of the symptoms during the night, such as anxiety, 
 a tendency to syncope, burning in the chest, but, above all, 
 the expectoration of a frothy substance resembling the beaten 
 white of an egg. 
 
 After arsenic come nux vomica and cuprum, which will 
 render you signal service, especially in dry spasmodic asthma, 
 with spasms of the diaphragm. Nux is most appropriate 
 when there is coryza, with sneezing, when the attacks come 
 on after eating, or in the morning, and where the patient is 
 subject to hemorrhoids. Cuprum* is the great remedy for 
 
 * See an article on the use of Cuprum in Asthma, by Dr. Claude, published 
 in the ''Bulletin cle la Societe HomGeopathique," 1872. 
 
24 THE MEDICAL CLINIC. 
 
 cramps, especially when accompanied by blueness of the lips, 
 and where the spasmodic element predominates. 
 
 Case I. — This woman, sixty years of age, is a hemorrhoidal 
 subject. During the winter, for eight years, she has had asth- 
 ma. In our last lecture we left her improving under arsenicum, 
 She was taking that remedy in the morning, and nux vomica 
 in the evening, both in the third trituration. To the symp- 
 toms given respecting the lungs we should add exaggerated 
 sonorousness with prolonged and sibilant expiration, inter- 
 mission in the movements of the heart, but without abnormal 
 sounds, and which, are probable signs of auriculo- ventricular 
 contraction. Under the influence of arsenicum and nux vom- 
 ica the patient is certainly better. She sleeps, coughs and 
 expectorates but little, and still the signs of emphysema con- 
 tinue. Kermes' 1 first trituration, continued during the time 
 the patient remained in the hospital, diminished the expec- 
 toration considerably. She left on the 11th of June, much 
 relieved, but not cured. 
 
 Pleurisy, then Phthisis after Delivery. 
 The next patient, in l$o. 2, is a woman who entered the 
 hospital a few days ago. She came to us for pleurisy con- 
 tracted some days after her confinement. The pleurisy en- 
 tirely disappeared under the influence of cantharis, but the 
 upper part of both lungs show signs of tuberculous softening, 
 and a hectic fever with a daily chill called for the adminis- 
 tration of arsenicum. I prescribed it in the twelfth dilution, 
 and obtained an evident amelioration of the subjective symp- 
 toms ; but unfortunately her temperature is always at nearly 
 104°, and the disease is not arrested. The patient, however, 
 is a little stronger, has a good appetite, the effusion is com- 
 pletely absorbed, and I hope soon to be able to send her 
 into the country, and that such a change will retard the 
 progress of her disease. I prescribe phosphorus for this pa- 
 tient, with a vegetable diet. Here are the notes of this case : 
 
PLEURISY, THEN PHTHISIS AFTER DELIVERY. 25 
 
 Case IV. — Madame Salmon, aged forty, a dressmaker, 
 entered the hospital on the 24th of January, and left it on the 
 14th of March. This patient has always had good health. She 
 was confined three months ago, and caught cold the eighth day 
 after her labor. This resulted in the production of a severe dry 
 cough, and oppression, loss of appetite, and a stitch in the right 
 side. She kept her room for one month, and, at the expiration 
 of that time, commenced work before her health was fully re- 
 established. For two months she walked a long distance each 
 day to . and from her work. On returning she would have a 
 chill, and during the night, sweats that were limited to the 
 right side. The appetite had almost entirely disappeared, and 
 the feebleness was so great that she was finally unable to walk 
 home. 
 
 On entering the hospital, we found an absolute dullness on 
 the right side extending over the inferior two-thirds of the 
 thorax. The upper line of dullness was of a parabolic form. 
 There is a complete absence of the vesicular murmur. On 
 applying the hand to the chest there are no perceptible thoracic 
 vibrations, there is' segophony, but no murmurs ; and want of 
 breath. The menses have not returned since her confinement, 
 although until now she has always been regular. The fever 
 generally comes between one and five o'clock in. the afternoon. 
 Her temperature is always between 102° and 104°. 
 
 January 25. Cantharis, 3d dil., three drops in 200 grammes 
 of water ; one spoonful every three hours. The diet to be a 
 vegetable one. 
 
 January 26. Evening, temp. 102.5°, pulse 100; morning, 
 temp. 102.2°, pulse 96. Slight respiratory murmur in the right 
 side. The same treatment. 
 
 January 27. Evening, temp. 102.2°, pulse 84; morning, 
 temp. 102.2°, pulse 92. The respiration is stronger, and the 
 patient has some appetite. The same treatment. 
 
 January 28. Evening, temp. 102.9°, pulse 100; morning, 
 temp. 102.5°, pulse 96. The effusion continues to decrease. 
 The same treatment. 
 
 January 29. For two days the patient has had a chill at 
 about two o'clock in the afternoon, during which the pulse has 
 been 108, and the temp. 102.9°. This morning the tempera- 
 
26 THE MEDICAL CLINIC. 
 
 ture is 102.2°, the pulse 92. The pleurisy is doing well, but, 
 on a careful examination, the apices of both lungs are found to be 
 the seat of a tuberculous infiltration, which is partly softened. 
 Arsenicum, 12th dil., six globules in 200 grammes of water; 
 one spoonful every three hours. 
 
 January 30. The chills have ceased, but the fever at night 
 still persists. The temperature is 103.10°, and the pulse 88. 
 Morning, temp. 101.8°. The same treatment. 
 
 January 31. No return of the chills. Evening, temp. 
 100.76°; morning, pulse 92, temp. 100.7°. The same treat- 
 ment. 
 
 February 2. The pulse and the temperature are normal, 
 except about 2 o'clock p.m., when she has fever, but no chills. 
 The same treatment. 
 
 February 3. Fever at irregular intervals. Yesterday, at 
 5 p.m., the temperature was 104°, at 6 p.m., 103.25°. This morn- 
 ing the temperature is 102.2° and the pulse 96. 
 
 February 5. At 3 p.m., temp. 104°; at 6 p.m. it was nor- 
 mal. In spite of this fever, the effusion has completely disap- 
 peared. Phosphorus, 30th dil., four globules in 125 grammes 
 of water ; three spoonfuls a day. 
 
 Phthisis and the Vegetable Diet. 
 
 There is another patient with phthisis, in a private room, 
 who is a young pharmacy student. He has, as you may have 
 known from his symptoms, a large cavity in the apex of the 
 right lung. I have put him on a vegetable diet, although I 
 am not certain that he will be able to bear it, as he already 
 complains of diarrhoea. Sometimes a diarrhoea is the conse- 
 quence of this regimen, although its effects are usually of an 
 opposite kind. I will speak to you on this subject hereafter. 
 
 Incipient Phthisis. 
 
 I wish now to speak to you of a young man who is ill 
 of a suspected bronchitis, and who, by the use of oryonia 
 and a vegetable diet, has left the hospital entirely cured. 
 
 Case Y. — Morquet, seventeen years of age, a wood-turner. 
 
INCIPIENT PHTHISIS. 27 
 
 entered on the 14th of January, and was discharged from the 
 hospital on the 23d of January. Men's ward, 'No. 5. 
 
 The father and mother of this patient having both died 
 four years ago, three months apart, after having coughed for 
 years, the family antecedents are unfavorable. The young 
 man presents all the external signs of tuberculosis. He is 
 thin and narrow-chested. He says that, excepting the young- 
 est, his brothers have good health. That brother has had 
 trouble with his eyes from infancy, — a disease which is com- 
 mon in those of a scrofulous constitution. Up to the time of 
 this sickness our. patient has enjoyed good health. On the 
 25th of December he took cold, which was followed by a dry 
 cough, a slight expectoration without blood, and no fever. 
 When he entered the hospital, on the 14th of January, he had 
 had no treatment. An examination showed his condition to 
 be as follows : 
 
 On percussion we observed an obscure sound at the back 
 and upper part of the left lung. At the apex of the right one, 
 and at the base of both lungs, the sound is normal. 
 
 By auscultation, a loose rattling is heard at the apex of both 
 lungs, — now over the right, and again over the left one. The 
 expiration is harsh and prolonged on the left side. The patient 
 complains o£ a pain, which is aggravated by the cough and by 
 pressure. He has had this pain ever since the cough com- 
 menced ; it is located on the left side in front, in the inter- 
 costal space, and below the spine of the scapula behind. 
 
 January 15. Since entering the hospital this man has been 
 on a light diet. He has no fever. The pulse is 50. Bryonia, 
 12th dil., four globules. 
 
 January 19. The neuralgic pain in the back has disap- 
 peared, but it continues in front. It is, however, much less 
 severe than when he entered. The cough is less frequent, but 
 a little troublesome at night. ~No fever. Pulse 54. Bryonia, 
 12th dil. 
 
 January 21. The general condition of the patient is im- 
 proved ; the neuralgic pain in the back of the chest grows less 
 severe each day. The expectoration is greenish and not abun- 
 dant. Bryonia, 6th dil. 
 
 January 22. The cough has entirely left. The pulse is 50. 
 Bryonia, 6th dil. 
 
28 THE MEDICAL CLINIC. 
 
 January 23. The pain from pressure on the back of the 
 chest has gone. Pulse 50. Bryonia, 6th clil. 
 
 January 25. The patient left the hospital cured. 
 
 I invite your attention to the semiotic value of pain in the 
 superior intercostal spaces. In phthisis, this pain, increased 
 by pressure and the respiratory movement, is connected with 
 an intercostal neuralgia, that depends upon a dry pleurisy, and 
 this pleurisy is connected with the tuberculosis of the apex 
 of the lung. Hence we see the significance of the pain in 
 the superior intercostal spaces, in a patient with a cough. 
 Concerning a vegetable diet in phthisis, I will speak to you 
 shortly. 
 
 A Suppurating- Hygroma. Pemphigus. 
 
 Before closing, I will say a word of a young patient who 
 is being promptly cured of pemphigus by the use of rhits 
 toxicodendron and cantharis. Here are the brief notes of the 
 case : 
 
 Case VI. — Jansot, aged seventeen, a student, entered the 
 hospital on the 16th of January and was discharged on the 
 1st of. April. 
 
 A fortnight before coming here, this patient injured his 
 knee by a fall. A slight painless swelling ensued, but which 
 was not sufficient to prevent his walking as usual. At the end 
 of two weeks the knee began to pain him, the swelling pro- 
 gressed, and the patient was unable to make the slightest 
 movement. Several times, after entering the ward, pus was 
 discharged from the wound, and then it healed again. 
 
 On examination we found a transverse wound of slight ex- 
 tent, with an evident rupture of the bursa near the patella. 
 
 January 17. Compression, by means of a silicated band- 
 age was resorted to, and at the same time silicea, 30th clil. . 
 was given internally. 
 
 January 24. The swelling seems closed. Since yesterday 
 he has some fever, and bullae of pemphigus appear on the face 
 and upon different parts of the body. I ordered rhus toxico- 
 
A SUPPURATING HYGROMA. PEMPHIGUS. 29 
 
 dendron, 3d dil., three drops in 200 grammes of water; a tea- 
 spoonful to be taken every three hours. 
 
 January 30. The pemphigus is disappearing from every 
 part of the body excepting under the bandage about the knee. 
 Violent pains in the knee compel us to remove the bandage. 
 The patient has chills and some fever. Aconite, 2d dil. 
 
 January 31. JSTo more chills, but the fever is continuous 
 and very severe ; the temperature being 103.10°, and the pulse 
 92. Continue the same remedy. 
 
 February 1. The fever has declined decidedly. The erup- 
 tion on the leg disappeared, but new bullae showed themselves 
 on the following days. 
 
 It was only after eight days' employment of the cantharis, 
 3d dil., that this trouble entirely disappeared. 
 
 February 6. An injection of iodine, one part to three, was 
 made into the bursa. 
 
 February 7. There is some inflammation of the serous 
 bursa and of the surrounding parts. 
 
 February 15. The silicated bandage was re-applied. 
 
 The application of this bandage was continued until March 
 1, when he complained of so much pain that it had to be re- 
 moved. The sac secreted anew, and pretty freely, a plain 
 serous fluid. . 
 
 March 2. A second injection was used, but it caused no 
 inflammation. 
 
 From this time a graduated compression was applied, and, 
 thanks to this means, in the space of a fortnight the discharge 
 had rapidly disappeared, the extent of the sac had diminished, 
 the wound had contracted, and the patient was allowed to sit 
 up. No new symptoms appeared, and the young man has 
 gone away well. 
 
 There are still two patients who are ill with benign affec- 
 tions of which I must speak to you. One of them has the 
 lumbago, and the other erythematous angina. 
 
30 THE MEDICAL CLINIC. 
 
 Lumbago. 
 
 Case YII. — Alexander Duroy, aged seventeen, entered 
 on the 17th of January, and left the hospital on the 31st of 
 January. 
 
 This patient is a lymphatic young man, scrofulous, and has 
 been subject from infancy to dental inflammation with ab- 
 scesses. Two weeks ago, and without any apparent cause, he 
 was seized with a violent lumbago. Before his reception into 
 the hospital he had taken bryonia, 3d dil., but without relief. 
 I gave him actcea racemosa in the 1st dilution. The pain 
 continued for three days, but was less severe each day. On 
 the 24th, as the patient showed a marked improvement, I 
 continued the same medicine, and on the 31st of January he 
 left the hospital cured. 
 
 There can be no doubt of the efficacy of this remedy in many cases of 
 lumbago, especially when there is an accompanying stiffness in the muscles of 
 the neck and back, and a severe drawing, tensive pain at the points of the 
 spinous processes of the dorsal vertebrae. In women, more than in men, per- 
 haps, it is called for by a feeling of weight and pain in the lumbar and the sacral 
 regions. For spinal pains of a rheumatic or neuralgic character, which are the 
 sequelae of epidemic meningitis, it is almost a specific. Our preference is for 
 the alkaloid — macrotin — in the third decimal trituration. But, in susceptible 
 persons who have had rheumatism with more or less cardiac difficulty, it should 
 be given very cautiously for fear of an aggravation. — L. 
 
 Erythematous Angina. 
 
 Case VIII. — Josephine Tromelet, aged fourteen years and 
 six months, entered on the 22d of January, and left the hos- 
 pital on the 25th of January. 
 
 This patient presents all the appearances of a lymphatic 
 person. She is subject to attacks of angina, which return every 
 winter. She is also a victim to a more or less painful ceph- 
 alalgia. The attack of angina from which she is now suffer- 
 ing began on the 18th of January, and was accompanied by 
 a more than usually violent headache. Prior to this seizure 
 she had not been exposed either to cold or to dampness. 
 
ERYTHEMATOUS ANGINA. 31 
 
 When she entered the hospital her symptoms were as 
 follows : sharp pain in the back of the pharynx, increased by 
 deglutition, and which provokes the accumulation of saliva 
 in the back of the throat ; the voice is very much changed ; 
 the mucus discharged from the back of the throat is red and 
 bright; the inferior maxillary glands are not inflamed. She 
 has but slight fever ; the pulse is 90. Belladonna in the 3d 
 dilution. 
 
 January 23. Deglutition has become easier. The headache 
 is sensibly diminished. Pulse 86. Mercurius sol., 3d trit. 
 
 January 24. The patient improves constantly. The head- 
 ache is entirely gone, and the deglutition is no longer painful. 
 
 January 25. She left the hospital cured. 
 
LECTUKE IY. 
 
 Summary. — Signs of emphysema. Louis and the numerical school. Indications 
 for antimony in the treatment of asthma. Menorrhagia, hamamelis in. 
 Lobular pneumonia is grave bronchitis. Articular rheumatism and endo- 
 pericarditis, case (continued); the evolutions and modifications of the car- 
 diac lesions demonstrated by the sphygmograph. Aggravation from the 
 cactus; happy effect of spigelia. Pleurisy followed by phthisis, case; veg- 
 etable diet; indications for jodium and arsenicum. White swelling; indi- 
 cations for argentum in scrofulous affections of the bones. Mild typhoid 
 fever, case; indications for bryonia and china. The inconvenience of a 
 fanciful diagnosis. The homoeopathic treatment may shorten the duration 
 of disease: note. 
 
 Emphysema — (Continued from page 10). 
 
 Gentlemen : You remember that the bed in ~No. 1 was 
 occupied by a woman with humid asthma. When she came 
 to us she complained of dyspnoea, which troubled her most 
 at night. I shall not refer to the catarrhal affection that ac- 
 companied the suffocation, and which gave to the physiogno- 
 my of our patient a stamp quite peculiar to herself. When 
 she left the hospital her condition was much improved. She 
 still coughed a little, and traces of the emphysema remained, 
 but the dyspnoea and the incessant coughing, of which she 
 complained on entering, had both disappeared. 
 
 In my second lecture I spoke to you of emphysema as 
 the lesion which is proper to asthma, and told you that there 
 were two degrees or varieties of this lesion, the first of which 
 is transient and curable. It is due to a dilation of the pul- 
 monary vesicles, and is a transitory affection. The second, 
 which is utterly incurable, is caused by the permanent dila- 
 tion of the pulmonary vesicles, in consequence of the destruc- 
 tion, by atrophy, of the walls which separate them. This latter 
 is the confirmed emphysema. I must remind you of the unre- 
 
EMPHYSEMA. 33 
 
 liability of the symptoms usually attributed to emphysema, 
 because of the neglect of a proper distinction between the 
 two varieties of the affection. 
 
 Louis, who made no distinction between permanent and 
 transitory emphysema, assigns five symptoms to pulmonary 
 emphysema: 1st, the circumscribed arching of the thorax. 
 2d, its exaggerated sonorousness. 3d, the absence of the ves- 
 icular murmur. 4th, whistling and sonorous rales ; and 5th, 
 harsh respiratory murmurs. 
 
 I wish to call your attention to the fact that this authority, 
 who achieved so singular a renown as an exact and conscien- 
 tious observer, speaks of the absence of the respiratory murmur, 
 instead of its diminution, and that he has entirely forgotten 
 the pathognomonic sign of emphysema, which is a prolonged 
 expiration. Let me add, for the instruction of the present 
 generation, respecting the medical intelligence of the "numer- 
 ical school," that these live signs attributed to emphysema are 
 of no value unless several of them coexist ; and, also, that Louis 
 never saw them all united but four times in ninety cases. We 
 do not propose" to go into the history of the contests and criti- 
 cisms which this subject has survived, but in a few words to 
 give you the signs of the two kinds, or degrees, of this peculiar 
 affection. 
 
 Transitory emphysema. — Exaggerated sonorousness, with 
 prolonged expiration, which is spasmodic and double, almost 
 always whistling. 
 
 Confirmed emphysema. — Exaggerated sonorousness, con- 
 trasted with feebleness of the respiratory sounds. If there is 
 a complication with catarrh, a moist rale may be heard, and as 
 these rales strengthen the respiratory sound, the prolonged 
 expiration may still be recognized. 
 
 In the case of the patient in No. 1, after having relieved 
 the dyspnoea by ipecacuanha and arsenicum, we resorted to the 
 preparations of antimony to control the catarrh. You know 
 
34: THE MEDICAL CLINIC. 
 
 that there are three principal antimonial preparations, id est, 
 tartar emetic, the sulphur of antimony, or Kermes' mineral, 
 and the arseniate of antimony. The tartar emetic is indicated 
 in catarrh when there is fever, the cough is severe, and above 
 all when the face is congested and there is an absence of thirst 
 and a desire to sleep. Kermes' mineral may also be used in 
 catarrh when there is an abundant expectoration in the morn- 
 ing, but only when there is no fever. The experimental study 
 of the arseniate of antimony has yet to be made. Notwith- 
 standing this, it is a good remedy that we may employ empir- 
 ically where the cough is severe and is accompanied by dysp- 
 noea. These medicines should generally be given in the first 
 and the third triturations, twenty centigrammes in 200 grammes 
 of water, and three or four spoonfuls in twenty-four hours. 
 
 Puerperal Pleurisy — (Continued from page 24). 
 
 I will only say a few words to you to-day concerning the 
 patient in ISTo. 2. You recollect that she has phthisis, which 
 was preceded by a pleurisy contracted while she was yet in 
 the puerperal state. For some time past she has had a hectic 
 fever of the retarding type. This fever runs very high, the 
 temperature rises to 104°, and is accompanied by chills. This 
 last symptom, as I have already told you, disappeared under 
 the influence of arsenicum, 12th* dil. For the last eight days 
 she has been taking phosphorus, 30th and 12th dil., which 
 has diminished the fever and the cough. On the whole, this 
 patient is better. I will speak of her again shortly. 
 
 Hamamelis in Menorrhagia. 
 
 In ~No 3 of the woman's ward is an hysterical patient, 
 whose history I will give you some day in the future. To- 
 day let us note that hamamelis in the first dilution has had 
 a most happy effect for the relief of a too abundant flow of 
 the menses, from which she has habitually suffered. 
 
LOBULAR PNEUMONIA, OK GRAVE BRONCHITIS. 35 
 
 Lobular Pneumonia, or Grave Bronchitis. 
 
 You have seen, in one of the private rooms of the hospital, 
 an infant, twenty-three months old, which was a victim to a 
 severe dyspnoea, complicated with somnolence and intense 
 feverishness. This child, the complete history of whose ill- 
 ness I shall give yon in my next lecture, is suffering from 
 an acute pulmonary affection, to which many names have been 
 given, as, for example, lobular pneumonia, capillary bron- 
 chitis, and suffocative catarrh. I call it grave bronchitis : 
 bronchitis, because in fact the primitive lesion is situated in 
 the bronchial tubes, and the congestion, and even the exten- 
 sive hepatization, which usually complicate this disease, are 
 secondary. They follow the inflammation of the bronchii as 
 epidydimitis follows inflammation of the urethra. I will add 
 that the continued symptoms of this affection are those of 
 bronchitis, and not of pneumonia ; also, that the etiological 
 conditions and the epidemic influences combine to place this 
 disease among the catarrhal affections. 
 
 These discriminations in diagnosis are exceedingly practical. There is a 
 wide difference in point of fact, clinically and therapeutically, between an 
 idiopathic and a broncho- pneumonia, or an attack of pneumonia that is second- 
 ary upon and complicated with bronchitis. — L. 
 
 We style this a grave bronchitis because it is a disease 
 that is much more fatal than pneumonia ; for while authors 
 may dispute the name and the nature of the malady, they 
 are in perfect accord as to its dangerous character. Our little 
 patient has already been ill eleven days with bronchitis. The 
 temperature is 104°, and there is considerable oppression of 
 breathing. Both lungs present the sub-crepitant rale and the 
 souffle, and it is therefore as serious a case as need be. But 
 the child is taking ipecac, 12th dil., and bryonia, 12th dil., 
 and we have the greatest confidence in these remedies. In 
 our next lecture I hope to announce that it is cured. 
 
36 THE MEDICAL CLINIC. 
 
 Acute Articular Rheumatism with Endo-pericarditis. — (Continued 
 
 from page 18.) 
 
 I now return to the history of the young man who occu- 
 pies a private room, and whose disease is rheumatic endo- 
 pericarditis. I wish, also, to show you the different sphygmo- 
 graphic tracings that we have taken at different periods of the 
 disease, some of which, you will observe, denote an aortic 
 contraction, and others an aortic insufficiency. In this case 
 we have not a definite lesion, but one that is in the process 
 of evolution, — a fact which proves that with the progress of 
 inflammation these lesions are modified, and that, conse- 
 quently, if they are changeable, they are not necessarily or 
 quite incurable. Let us take up this case where we left it 
 in our last lecture. 
 
 Case III. — February 5. The patient has, for some days, 
 been under the influence of cactus, in the first dilution, which 
 he bears very well ; his nights are calm ; there are no pains 
 in the heart ; the pulse is feeble and intermittent ; the sphyg- 
 mographic trace gives an obliquely ascending line, which is 
 very short, and which ends in a horizontal one ; the descending 
 line is very long and very oblique ; the cardiac pulsations are 
 very unequal, with some intermissions ; the pulse indicates 
 mitral insufficiency, aortic contraction and aortitis. The latter 
 symptom contrasts with the pulse of insufficiency, which we 
 observed a few days ago. The cactus was continued. 
 
 Track No. 3. 
 
 February 12. The pains in the heart have returned. 
 February 13. The pains are increasing ; they are intermit- 
 ting, and the patient suffers greatly, and they prevent sleep. 
 
ACUTE ARTICULAR RHEUMATISM. 6 k 
 
 Nevertheless, the respiratory sounds are diminished in their 
 intensity. 
 
 Stop the cactus, which has been taken in increasing doses 
 np to twelve drops of the first dilution, and substitute spigelia, 
 to be given in drop doses of the mother tincture. 
 
 February 14. Under the influence of spigelia the pulse be- 
 came more full, and the intermissions ceased. Signs of aortitis 
 still exist, but those of valvular insufficiency reappear ; the as- 
 cending line is very long, but not quite vertical ; the level one 
 is very marked, and the descending trace almost without clicro- 
 tism. 
 
 Tii ace No. 4. 
 
 February 16. The pains in the heart are less severe, but 
 the patient has fever. The pulse is 108. There is a return of 
 the pains in the joints, and especially of the sore throat, which 
 necessitates the administration of belladonna. 
 
 February 1 8. There is no longer any sore throat ; the fever 
 persists, and the pulse is 112, and slightly intermittent. Re- 
 sume the cactus, 1st dil. 
 
 February 19. The patient is worse ; there is complete in- 
 somnia ; the intermissions are extremely painful, and especially 
 at night. The cactus was withdrawn. 
 
 February 20. 'No better. Spigelia, 3d dil., in three-drop 
 doses. 
 
 February 21. Better; the pulse is very good, although it 
 beats 120. This febrile movement is kept up by the rheumatic 
 arthritis. The intermissions have disappeared ; we hear noth- 
 ing but the second sound at the base of the heart. The peri- 
 cardiac friction-sound and the signs of mitral insufficiency per- 
 sist. Spigelia, 3d dil., three drops. 
 
 February 23. Slight improvement. Spigelia, 1st dil., three 
 drops. 
 
38 THE MEDICAL CLINIC. 
 
 February 25. The intermissions have ceased ; the pulse 
 has fallen ; the pains in the joints are less severe ; but there is 
 little appetite. Cactus, 1st dil., three drops. 
 
 February 27. There is a return of the painful intermis- 
 sions. Spigelia, 1st dil., three drops. 
 
 The pulse takes more and more the character which accom- 
 panies aortic insufficiency ; the sign of aortitis (which is 
 found in the horizontal line of the sphygmograph) has entirely 
 disappeared. We have the ascending line perfectly vertical, 
 with a hook at the beginning, and the descending line presents 
 only slight signs of dicrotism. A very marked intermission in 
 the fourth pulsation of the tracing shows that the mitral insuf- 
 
 Trace No. 5. 
 
 flciency still exists. The patient, who now leaves us to return 
 to his family, is, on the whole, much improved. He no longer 
 suifers from dyspnoea, and the pain in the heart is gone, but he 
 sleeps and eats very little. 
 
 If you compare the five tracings obtained from this pa- 
 tient, you will be convinced that at one time the symptoms 
 of aortic contraction were unmistakable (see Trace 'No. 1); 
 that these symptoms, joined to a certain degree of asystolie 
 (or incomplete systole), and to the signs of mitral insufficiency, 
 reappear in Trace ~No. 3 ; and that, before this, we have a 
 trace which is the exact type of aortic insufficiency, — I refer 
 to Trace No. 2. Finally, the patient, evidently relieved by 
 spigelia, presented day after day the most conclusive signs 
 of aortic insufficiency joined to mitral insufficiency, and it is 
 probable that these two lesions will remain indefinitely. For 
 ourselves, we are convinced that the contraction of the aortic 
 
PHTHISIS PRECEDED BY PLEURISY. 39 
 
 orifice, and of the aorta itself (since there was a manifest level 
 line in the tracing), was caused by the loss of elasticity of 
 the tissues, due to a relapse of inflammation. Let us note, 
 from a therapeutic point of view, the happy influence of spi- 
 gelia over the painful intermissions of the heart and over all 
 the symptoms of endocarditis. 
 
 For it was during the use of this remedy that the tracing 
 showed aortic insufficiency, at the same time that the state of 
 the pulse and of the respiration indicated a decided diminu- 
 tion of the inflammation of the lining membrane of the heart. 
 We have observed the bad effect of the cactus, tried three 
 times and with the same results, which, indeed, compelled us 
 to stop its use entirely. For it was after its persistent use in 
 increasing doses, until twelve drops of the first dilution were 
 taken, that the first painful intermission occurred, and this 
 symptom reappeared each time that we gave it. 
 
 The Vegetable Diet in Phthisis. 
 
 I wish to say a word to you concerning the patient with 
 phthisis, now occupying a private room. It is another ex- 
 ample of pleurisy in the right side coincident with phthisis. 
 The regimen that I have prescribed for this patient may sur- 
 prise you a little, but I will speak to you some other time 
 of the vegetable diet in this disease. 
 
 Phthisis preceded by Pleurisy — Improvement. 
 
 Case TV. — M. D , aged twenty-four, a student of phar- 
 macy, entered the hospital on the 28th of January, and left 
 it on the 31st of March. Up to the age of twenty-one this 
 young man enjoyed perfect health. His family antecedents 
 are excellent. His parents are strong and vigorous, and have 
 never been subject to a cough. 
 
 In 1871 the patient was seized with pleurisy in the right 
 side, which was accompanied by considerable effusion. At the 
 end of two months, just when this disease was about cured, he 
 suffered a relapse, which extended its duration to four months. 
 
40 THE MEDICAL CLINIC. 
 
 Since that time he has coughed, but less in summer than 
 in winter. In summer the cough is slight, with morning ex- 
 pectoration only, and the matter raised is of a yellowish white 
 color. In winter, since the attack of pleurisy, he is very sub- 
 ject to colds ; and these colds always last for two or three 
 months, and are accompanied by a dry and very rebellious 
 cough, with fever and sweats at evening. Notwithstanding 
 this cough, his general health has remained good. His appe- 
 tite is the same as before the pleurisy. He has not lost 
 flesh. Three weeks ago, in consequence of taking a fresh 
 cold, he began to cough more frequently than usual. A few 
 days later he had a chill, which was followed by a pain in the 
 right side, above the nipple. 
 
 Physical Examination. — On j^ercussion, the left side is 
 normal. At the apex of right lung are decided sub-crej)itant 
 rales ; and there is pectoriloquy, especially if the patient 
 speaks in a low voice. 
 
 January 20. Jodium, 3d trit., and a spare diet. 
 
 January 30. The patient has a diarrhoea. Arsenicum, 3d trit. 
 
 January 31. No more stools. The same treatment. 
 
 February 2. The diarrhoea has returned. Stop the vege- 
 table diet. Arsenicxim, 3d trit. 
 
 February 3. No return of the diarrhoea ; the cough is 
 much better, and the appetite good. 
 
 February 6. The diet was resumed. Continue the same 
 treatment. 
 
 February 9. The cough has increased, and he has night 
 sweats. The same treatment was continued until the 18th of 
 February. The patient being unable to support the exclusive 
 diet, it was changed. The cough is better. His strength is 
 returning. Jodium, 3d trit. 
 
 February 24. He is up and has walked about during the 
 day. The same treatment. 
 
 March 1. The patient has had strength enough to be out 
 all the afternoon. The cough has almost entirely ceased. The 
 arsenicum, 3d trit., was continued until the patient left the 
 
WHITE SWELLING. 41 
 
 hospital, on the 31st of March. He left us with bright hopes 
 of future health, but having a perfectly well-defined cavity in 
 the apex of his right lung. 
 
 "White Swelling'. 
 
 One word only concerning the young man with the white 
 swelling on the knee. He improves constantly. The fungous 
 tissue which at first existed has given place to the more solid 
 anatomical elements ; the softness, that was perceptible to the 
 touch, is disappearing also. We prescribed argentum, which 
 produces, on the healthy person, pain in the bones and joints, 
 and which has several times cured scrofula of the bones. I 
 remember having treated a lady for two scrofulous attacks, 
 which had, up to the time she became my patient, resisted 
 all treatment. The first was a cold abscess in the back. I 
 opened it and discharged it, but the pus formed again. I 
 then gave her argentum, which completely cured it by 
 absorption. 
 
 A short time after, this same lady suffered from caries of 
 one of the metacarpal bones. I prescribed argentum at once, 
 and she was cured in a short time. 
 
 This woman had a frightful metrorrhagia, which was kept 
 up by the presence of a uterine fibroid. It was this state of 
 things that led me to prescribe the argentum, oxydat. in pretty 
 strong doses. She took of the first trituration five centi- 
 grammes in two doses during the day. 
 
 We were not aware that any one in our school of practice had succeeded 
 in controlling the hemorrhage that is incident to uterine fibroids, or in anywise 
 checking the growth of these neoplasms, by the use of argentum oxydatum. 
 And we sincerely regret that the author has not spoken more at length upon 
 this very interesting subject, more especially since he "knows enough to know " 
 what a uterine fibroid is, and would not hesitate to speak the truth of his 
 experience with this remedy. 
 
 In our own practice, we have had some very remarkable results from trillin, 
 in the third decimal trituration, for the relief of this form of menorrhagia. In 
 one case especially, — and it was a very bad one, — occurring in the practice of 
 my friend Dr. W. C. Barker, of Waukegan, 111., the trillin not only relieved a 
 
42 THE MEDICAL CLINIC. 
 
 very alarming hemorrhage, but put an end to a tedious and harassing cough 
 that had worried and weakened the patient almost as much as the loss of blood. 
 It also relieved a severe neuralgia to which this patient had been subject. — L. 
 
 A Mild Type of Typhoid Fever. 
 
 Case V. — -Miss Piniere, twenty-six years of age, was ad- 
 mitted on the 22d of February, and left the hospital on the 6th 
 of March. This patient came to the hospital on the tenth day 
 of her illness, which had commenced with copious vomiting of 
 a greenish matter, and diarrhoea. She had been treated in the 
 city for bilious fever. On examination, she had very few symp- 
 toms. She complained of headache, principally in the forehead, 
 and of a stitch in the right side and in front under the false ribs. 
 Auscultation and percussion are negative. The sensibility of 
 the abdomen is normal. There are no spots of discoloration, 
 and there is no diarrhoea, but a loss of appetite and continued 
 fever. The epistaxis at the onset, and the duration of the dis- 
 ease are diagnostic of a mild attack of typhoid fever. 
 
 February 23. The pulse is 84 ; temperature at evening 
 101.12°. Bryonia, 3d dil. 
 
 February 24. Morning temperature the same ; the pulse 
 84. Evening temp. 100.40°, the pulse 80. The pain in the 
 side is much less, but the fever persists, being higher in the 
 morning than at night. 
 
 February 25. The pain in the side has gone. Morning 
 temp. 101.48°, pulse 80. Evening temp. 101.12°. 
 
 February 26. The fourteenth day of the fever. Morning 
 temp. 101.12°, pulse 80. Evening temp. 99.68°, pulse normal. 
 The general condition is very good. China, 6th dil. 
 
 February 27. Morning temp. 100.75°, pulse 76. Evening 
 temp. 99.50°. She has a desire for food. From this time she 
 has steadily improved ; the fever has gone, the appetite has 
 returned, and she sleeps well. The china was continued until 
 she left, on the 6th of March. 
 
 A propos of this case, I wish to make two remarks : the 
 first concerns the strange abuse that physicians make of a 
 fanciful diagnosis of bilious fever. What does the term sig- 
 nify % To a physician who is au c our ant in pyretology it has 
 
A MILD TYPE OF TYPHOID FEVER. 43 
 
 no signification, and is nonsensical ; to a practitioner who 
 does not know enough to make a proper diagnosis, it is a 
 something upon which he fastens, — and when it is not a 
 "bilious fever," it is a "mucous fever," for one name is as 
 unscientific as the other. 
 
 The second remark that I wish to make is, that we fre- 
 quently observe that when typhoid fevers are treated homoeo- 
 pathically they terminate prematurely on the fourteenth or 
 the seventeenth day. Doubtless in such cases, as in the case 
 of all cyclical diseases, our treatment is incapable of aborting 
 them at once, or of arresting their natural evolution, but it 
 certainly may shorten their duration, and that is a great deal 
 to accomplish. 
 
 The typhoid fever is practically an eruptive fever, and, as a rule, one 
 attack gives exemption in the future. In exceptional cases, however, as with 
 variola, scarlatina and rubeola, it may repeat itself in the same patient. But, 
 as with the modifying- influence of vaccine over subsequent attacks of smallpox, 
 and as with recurrent attacks of each of the eruptive fevers, so the second or 
 the third repetition- of this disease will not be exactly the same as the first. 
 Some of its symptoms, or one or another of its stages, will be lacking. It will 
 be an imperfect echo or reproduction of the original disease. 
 
 When remedies are given for this recurrent form of typhoid fever, and its 
 course is shorter than usual, and its concomitants and sequelae are either cut off 
 or very much changed, it is not just or proper to conclude that such a result is 
 always and altogether due to our treatment. This spurious type of the affec- 
 tion may be, and often is, aborted ; but it is very doubtful, at least in our own 
 mind, if any remedy or remedies can abbreviate the duration of a genuine, 
 primitive attack of typhoid fever. — L. 
 
LECTUKE V. 
 
 Summary. — Of the suspension of the reined}' in the treatment of chronic dis- 
 eases, and of the repetition of the dose. An intermittent febrile action in 
 hysteria; effect of the tarentula. Laryngeal phthisis; phosphorus and ar- 
 gentum. Hysteria; nervous vomiting-, case; indications for mix vomica, 
 ipecac, fer rum, bryonia and Pulsatilla. Grave bronchitis, or double lobular 
 pneumonia, case; ipecac, and bryonia, then tartar emetic, cure. Intercostal 
 neuralgia, case; indications for bryonia and mix vomica. 
 
 Of the Suspension of the Remedy in Chronic Diseases, and the 
 
 Repetition of the Dose. 
 
 Gentlemen : During the consultation, a little while ago, 
 you may have been surprised to hear me tell certain patients 
 not to come here again for several days after they had fin- 
 ished taking their medicine ; and also to see me stop the 
 use of remedies in other cases. Although you may find that 
 this practice is recommended occasionally in the prevalent 
 system of treatment, and especially in the use of baths, it is 
 really due to Hahnemann. Physicians who confine themselves 
 to the use of mineral waters agree that, occasionally, it is well 
 to suspend all treatment for a time, in order that the organism 
 may react against the disease. 
 
 Hahnemann made use of this idea in principle when he 
 treated chronic diseases ; and homoeopathic physicians, follow- 
 ing his example, habitually give intervals of repose to their 
 patients, during which time all medicine is proscribed. The 
 reason offered for this suspension of remedies is that, having 
 a duration of action that is sometimes very much prolonged, 
 for ten, twenty, thirty days or more, this peculiarity should 
 be respected, and not embarrassed by unreasonable interfer- 
 ence. I regard this as false reasoning, because this duration 
 of the action of the medicine, which is hypothetical in the 
 
SUSPENSION OF THE REMEDY IN CHROIC DISEASES. 45 
 
 case of a healthy man, is certainly modified by the diseased 
 condition. What does clinical experience prove to us on this 
 very subject 1 That sometimes a few doses will produce an 
 effect that will continue, without other therapeutic influence, 
 until a radical cure is established ; that, at other times, a 
 single dose of medicine has improved the patient's condition, 
 and would have cured him if it had been persistently taken. 
 
 For example, one gramme of the sulphate of quinia may 
 cause an apyrexia of from eighteen to twenty days in a case 
 of intermittent fever of the quartan type ; or one of fourteen 
 days in a tertian intermittent ; and of seven days in a quotidian. 
 But, if one stops at a single dose, the fever will surely return ; 
 whereas, repeated doses may prevent the recurrence of the 
 disease indefinitely. 
 
 How, then, should we be guided on this question of the 
 repetition, or the non-repetition, of a medicine? It is by a 
 knowledge of the agent and of its modus operandi, and not 
 the mere duration of its action. What, in fact, is a remedy? 
 It is an external agent. As in etiology, the external cause 
 does not of itself produce the disease ; so neither in therapeu- 
 tics does the medicine alone effect a cure, but it prompts the 
 organism, and gives it the necessary impulse to combat and 
 to overcome the disease. This action of the remedy once 
 obtained, we must stop it as soon as it has prompted nature 
 sufficiently, or when it has set in motion the vis medicatrix 
 naturce. 
 
 But how are we to know when the proper time has come 
 for withholding our remedies ? We have two very precise and 
 certain rules to guide us in this matter. Whenever the disease 
 is aggravated by the medicine, suspend its use ; and if the 
 aggravation is followed by an improvement in the symptoms, 
 do not return to the remedy until the improvement has ceased. 
 If, after the aggravation, the patient remains in the same con- 
 dition as at first, then you must change the remedy. 
 
46 THE MEDICAL CLINIC. 
 
 If the giving of.-the medicine causes a decided and real 
 amelioration of the patient's condition, you should suspend 
 it while the improvement continues. But should the disease 
 not appear to be sensibly modified, continue the same medi- 
 cine, or seek for one that is more appropriate. 
 
 There is no homoeopathic physician who has not observed 
 some remarkable cures obtained by the administration of a 
 few doses of a well-chosen remedy. For myself, I will cite 
 you from a number, the case of a child which came to my 
 clinic, in Rue de Verneuil, for the treatment of a large scrofu- 
 lous ulcer on the middle portion of the arm, and from which 
 he had suffered for more than a year. All kinds of old-school 
 treatment had failed. I gave him, for eight days, a potion 
 containing several globules of silicea, 30th dil., two spoonfuls 
 to be taken daily. At the end of that time, having obtained 
 a slight improvement, I prescribed nothing further, and at 
 the end of four weeks he was entirely cured. 
 
 I must add that this is not my practice in acute diseases, in 
 which, as a rule, I repeat the remedy or remedies several times 
 during the twenty-four hours. 
 
 In menstrual disorders, especially, we often find it best to give a remedy 
 during the period, and then to suspend its use until another month has come 
 around. Meanwhile, it may be advisable to give another and a very different 
 remedy, or, in very exceptional cases, not to give any medicine whatever. As a 
 rule, those remedies that are most exactly adapted to the monthly sufferings do 
 no good, and may often do harm if given in the inter-menstrual period. — L. 
 
 After this digression on the purely therapeutic domain, I 
 will return to the subject of our regular lecture, that is, to the 
 sick actually within our wards, and I will commence with the 
 case of the patient in ~No. 3, a woman who presents an inter- 
 esting example of 
 
 Menorrhagia with an Intermittent Fever. 
 
 Hamamelis had lessened the too abundant flow of the 
 menses, but the patient was much disturbed and weakened 
 
LARYNGEAL PHTHISIS. 47 
 
 by a quotidian type of fever, which returned in the evening 
 and at night, the paroxysms ending with a copious diaphoresis. 
 For this I prescribed the tarentula in the 3d trit., and from 
 the second day obtained a marked improvement, which was 
 followed on the third day by a complete cure of the fever. 
 Here was an undoubted proof of the medicinal action. 
 
 In connection with this I will cite another example, which 
 occurred last year in this hospital. The subject was also an 
 hysterical patient, with a quotidian intermittent fever. I pre- 
 scribed the sulphate of quinine for her, but without effect. 
 Here, again, I succeeded in making a cure with the tarentula. 
 
 This bit of clinical experience will be of great value to our western physi- 
 cians, who have long- been in need of a reliable remedy for menorrhagia compli- 
 cated with remittent or intermittent types of fever. We have often succeeded 
 with nitric acid, 2d dec, under similar indications. — L. 
 
 Laryngeal Phthisis. 
 
 The next patient, in No. 4, is a woman with phthisis, of 
 whom I have spoken to you before, and who has come to us 
 now for the third time. Her disease is complicated with 
 tubercles of the larynx. .Phosphorus gave slight relief, and 
 was followed by argentum in the 3d trit., which had formerly 
 been given her with apparently good result, but which now 
 has proved itself of no effect, or, at least, it has not caused 
 a medicinal aggravation. To-day, in fact, the patient com- 
 plains of very severe pains in the larynx. I have suspended 
 the remedy, and in our next lecture shall be able to tell you 
 whether we have been in this case dealing with a too strong 
 preparation of the medicine, or whether the dose was insuf- 
 ficient. 
 
 Hysteria, with Vomiting. 
 
 The next is also an hysterical patient, a girl of fourteen 
 years, who has not yet menstruated, and who comes to us 
 for the relief of a bronchitis. This patient is subject to nerv- 
 
48 THE MEDICAL CLINIC. 
 
 ous and very intractable vomiting, an affection often met with 
 in hysteria. She vomits after her supper, either immediately 
 or within an hour, or an hour and a-half. Unlike the vomit- 
 ing that arises from indigestion, and which is so painful, she 
 does not suffer at all from nausea or uneasiness, — does not 
 even grow pale. As a rule, such attacks of vomiting as this 
 girl has are very rebellious to treatment. I knew a lady who 
 was attacked with this kind of vomiting at the age of seven 
 years, at the first appearance of her menses, and at forty these 
 attacks still persisted. During all these years she had vomited 
 daily, excepting (which is remarkable) when she was pregnant. 
 Fortunately for the women afflicted in this way, they are not 
 much enfeebled by these repeated attacks, and their general 
 health is pretty good. 
 
 Here are the notes of the case under review: 
 
 Case XI. — Mile. Rose, aged fourteen years, entered the 
 hospital on the 10th of February, and left it on the 25th of 
 February. This young girl has not yet menstruated. We have 
 received her in ward 11, No. 3, in order to study the fits of 
 vomiting to which she is subject, and which are characterized 
 by a lack of pain and the absence of nausea. The attacks come 
 without premonition. I must not omit to mention that the pa- 
 tient has an hysterical mother ; nor to say that the girl herself 
 is subject to perfectly well-defined attacks of hysteria. The 
 vomiting is remittent. The epigastric region is not painful. 
 There are no signs of engorgement, nor of a tumor. In this, as 
 in the greater number of analogous cases, nux vomica, ipecac, 
 ferru7ri and bryonia have all failed, and it will probably be 
 necessary to resort to hydropathy. However, I will add that 
 if we have not been able to relieve the vomiting, we have been 
 more fortunate respecting the menses, which latter have . ap- 
 peared for the first time under the influence of pulsatilla, 12th 
 dil., and of ferrurn, 12th dil., six globules in twelve spoonfuls 
 of water, given alternately three spoonfuls each day. 
 
 The crowded condition of the hospital at this season of the 
 year makes it impossible for us longer to retain this patient in 
 our wards. 
 
GRAVE BRONCHITIS, ALIAS DOUBLE LOBULAR PNEUMONIA. 49 
 
 We have so often given temporary, and even permanent, relief, in cases 
 of intractable vomiting in hysterical women, by putting- the womb in place, that 
 we cannot forbear counseling the reader to examine such cases very carefully 
 as to the possibility that the trouble may depend upon a uterine deviation of 
 one kind or another. In two cases I have seen it associated with vaginismus; 
 and it is not very unusual as a sequel to severe and repeated cauterization of 
 the cervix-uteri. — L. 
 
 Grave Bronchitis, alias Double Lobular Pneumonia. — (Continued 
 
 from page 35.) 
 
 I wish now to speak of the happy cure of the infant which 
 was brought to ns two weeks ago, — a child of twenty-three 
 months, — and which was, at the time of its admission, at the 
 fourteenth day of a double lobular pneumonia. I do not hesi- 
 tate to declare my opinion that, but for the resources of 
 homoeopathy, this child must inevitably have died. I pre- 
 scribed for it, as is my practice in similar cases, ipecac, 12th 
 dil., and bryonia, 12th dil., to be given alternately each hour, 
 and afterward every two hours. There was a slight improve- 
 ment at the end of the first day, and that improvement has 
 steadily increased. When the inflammation and the fever 
 subsided I stopped the use of these two remedies, and gave 
 tartar emetic, in the 3d trit., which was indicated by a very 
 loose cough. To-day, gentlemen, this child is perfectly well. 
 
 Here are full notes of the case : 
 
 Case XII. — Marie Hamelin, aged twenty-three months, 
 entered the hospital, where she had a private room, on the 
 7th of February, and left on the 29th of February. 
 
 This child, born of scrofulous parents, has never had good 
 health. At the age of eight months she had an attack of 
 pneumonia, which lasted three weeks, and which left her with 
 a cough that continued for a month longer. At thirteen 
 months she had an eruptive fever, which, from what her 
 mother says of it, seems to have been the chicken-pox. 
 
 The child comes to us to-day with a capillary bronchitis, 
 which is seated in the two sides of the chest. This affection be- 
 gan suddenly on the 30th of January, and was not preceded 
 by any noticeable malaise. Two or three days before the ill- 
 4 
 
50 THE MEDICAL CLINIC. 
 
 ness the child had been exposed to the cold weather. A fre- 
 quent cough and a violent dyspnoea were, with fever, the first 
 symptoms of the disease. Before she was brought to the hos- 
 pital the child had had a small blister applied on the left side 
 of the back, at the base of the thorax, and she had also taken 
 emetics. But this treatment had done no good. Her actual 
 condition was as follows : a high fever ; pulse 140, and tem- 
 perature 104°, with considerable dyspnoea, a frequent cough 
 and a flushed face. There is a sub-crepitaut rale that extends 
 from the apex to the base of the right lung ; and the same 
 rale, but less distinct, is heard in the left lung, at the base of 
 which we note the bronchial souffle. Ipecac, 12th dil., and 
 hryonia, 12th dil., four globules in 125 grammes of water, one 
 spoonful to be taken each hour alternately. The diet is to con- 
 sist of milk. 
 
 February 10, twelfth day. The fever is somewhat less. 
 Since last evening the temperature is 102.50°, and the pulse 140. 
 The sub-crepitant rale is a little louder, the souffle persists, and 
 there is a slight diarrhoea. The same prescription. 
 
 February 11, thirteenth day. The improvement continues. 
 The temperature last evening was 101.50°. The souffle has dis- 
 appeared. The breathing is not so oppressed, and the child 
 has slept. The same treatment. 
 
 February 12, fourteenth day. Continued improvement ; 
 the rales diminish. 
 
 February 13, fifteenth day. Temp. 101.12°. The rales 
 are loud ; the child has an appetite and sleeps. Tartar emetic, 
 3d trit., twenty centigrammes in 125 grammes water, one 
 spoonful every three hours. 
 
 February 14, sixteenth day. The general condition is 
 satisfactory; the rale is greatly diminished, and the child is 
 j)layful and has some appetite. Its temperature is 100.4°. 
 
 February 16, eighteenth day. The rales cannot be heard, 
 and the child is cured. 
 
 For more than twenty years we have given chelidonium in a certain stage 
 of what has been called pulmonary catarrh, infantile pneumonia, and capillary 
 bronchitis. At first, we could not always distinguish between them at the bed- 
 side; nor are we very much wiser now. But this is certain, that the chelido- 
 nium has, in our hands, saved several little patients who had been given up to 
 die, and to whose relief we were called either after another physician or in con- 
 
ASCITES INTERCOSTAL NEURALGIA. 51 
 
 sultation. The indication for this remedy is an excess of the pulmonary secre- 
 tion, with inability to raise or dislodge it, probably through paralysis of the 
 pneumogastric. It does not seem adapted, like tartar emetic, to re-open the 
 hepatized air-cells. I always use the third dilution of the chelidonium. — L. 
 
 Ascites. 
 
 One word concerning the ascitic patient whose clinical his- 
 tory I gave you in a former lecture. Without being deceived 
 concerning the result in his case, I believe that the use of the 
 china has given him some relief. I was obliged, you remem- 
 ber, to make three successive tappings at intervals of three 
 days each. Very well ; since he took the china two weeks 
 ago, I have not been obliged to resort to the trocar again. So 
 you see, gentlemen, that, even in hopeless cases, we should 
 not abandon the pursuit. If we cannot cure the disease, we 
 may, at least, retard its progress, and give a respite to the 
 poor sufferer. And to be able to obtain even "this result will 
 afford us great satisfaction. 
 
 Intercostal Neuralgia. 
 
 In concluding this lecture, I will speak of a case of inter- 
 costal neuralgia that was incident to a slight bronchitis. The 
 pain in the side dated eight days back, when the patient 
 entered the hospital, and it was so severe as to render it 
 impossible for him to continue his work. He was cured of 
 it in three days by bryonia. The indications for this remedy 
 were, in this case, very precise, — pain in the side, increased by 
 coughing, by breathing and by motion, and relieved by lying 
 upon the affected side. In these cases bryonia is almost 
 always a certain remedy. You have already seen, and will 
 see more, examples of this kind in our service. In a similar 
 case that I treated in the city, bryonia failed, but the patient, 
 who was a young girl, did not cough at all. She was subject 
 to hemorrhoids, and could not lie on the affected side. Nux 
 vomica cured her. 
 
52 THE MEDICAL CLINIC. 
 
 In quite a number of cases, more especially in women who were inclined 
 to phthisis, we have had excellent success in curing intercostal neuralgia with 
 stannum in the third decimal trituration. The symptoms which call for this 
 remedy are violent stitches in the chest and sides, aggravated by trying to take 
 a deep breath, and even by the ordinary respiration; oppression from coughing; 
 sudden, sharp, knife-like stitches, especially in the left side of the chest. 
 
 The rhododendron, at least in our experience, has been more efficient in 
 pleurodynia than in intercostal neuralgia, with which it is so frequently con- 
 founded. My friend, Dr. D. S. Smith, has great confidence in the ranunculus 
 bulb, in intercostal neuralgia. When the neuralgia extends to the shoulders he 
 gives rhus rad., in the 30th dil. — L. 
 
 The notes of the young man's case read as follows : 
 
 Case XIII. — Henri Daoux, twenty-nine years of age, a gun- 
 maker, entered on the 18th of February, and left on the 22d of 
 February. This man has always had good health, and is not a 
 hemorrhoidal subject. He caught cold six weeks ago, and has 
 coughed since that time. The cough has not been severe 
 enough to prevent his working ; he has no fever, and has not 
 lost flesh. For the past week he has suffered from a severe 
 pain at a point in the left side, and in the dorsal region, at the 
 base of the thorax. Coughing and slight pressure increase this 
 pain. On examination we find no abnormal sound over the 
 lungs. 
 
 February 19. The chest has a normal resonance ; inspira- 
 tion and expiration are perfect ; there is a slight, dry cough. 
 One of the inferior intercostal nerves is the seat of the affection. 
 The severe pains continue and have forced him to stop work. 
 The pulse is 60 ; the appetite good. Bryonia, 3d dil. , three 
 drops in 200 grammes of water; one spoonful every three 
 hours. 
 
 February 20. The patient has slept more quietly, and suf- 
 fers less pain. The same treatment. 
 
 February 22. He left the hospital cured, and able to re- 
 sume his work. 
 
LECTURE YI. 
 
 Summary. — Hysteria, case; indications for tarentula, belladonna, hamamelis 
 and hydrotherapia: case; the hysterical delirium and belladonna. 
 
 Hysteria. 
 
 Gentlemen: At present we have three cases of hysteria 
 in our ward for women. The first case is that of the young 
 girl of whom I spoke to you last week, concerning the inter- 
 mittent fever to which she was subject, and which I cured 
 with the tarentula. 
 
 Case XI Y. — Miss Octavie Yan Yalbeck, aged twenty-two, a 
 housemaid, entered the hospital on the -29th of January and left 
 it on the 19th of March (ward 1, No. 3). This young woman 
 enjoyed good health until the month of April, 1873. At that 
 time she began to suffer from terrible headaches, the pain being 
 principally in the left temple and on a level with the sub- 
 orbital foramen. This headache is sometimes followed by an 
 interval in which she is free from pain, but it rarely lasts 
 more than two or three days. The menses are always regu- 
 lar, but the flow is too free, and the period arrives a few 
 days too soon each month. The flow lasts for from eight to 
 ten days. In the interval of the menses she has an abun- 
 dant leucorrhcea. At the period the headache is intense. 
 Since her illness the digestive organs are also affected. She 
 has little or no appetite, and during the process of digestion, 
 suffers from violent pains in the epigastrium that are often 
 followed by vomiting. 
 
 She is habitually constipated, and complains of pains in 
 the abdomen, which pains are increased by pressure. A phys- 
 ical examination of this patient disclosed, at the base of the 
 heart, a valvular murmur connected with the first sound of 
 the heart, which murmur extended along the arteries of the 
 neck, and which evidently is an ansemic souffle. 
 
 The patient has frequent nervous attacks, that are accom- 
 
54 THE MEDICAL CLINIC. 
 
 panied by sighing, choking and crying. The conjunctiva has 
 completely lost its sensibility to the touch and to pain, and 
 the integument has spots of complete anaesthesia, and of an en- 
 tire loss of sensibility to the touch. The patient recognizes 
 only one point of a compass when both of them are applied, 
 even at a distance of ten centimetres. There is also anaesthesia 
 of the isthmus of the pharynx, with a loss of the power to excite 
 a reflex nausea. 
 
 Belladonna, 12th dil., four globules in 200 grammes of 
 water, three spoonfuls to be taken daily, was prescribed for 
 her on the 12th of January. This remedy relieved the sub- 
 orbital neuralgia. Hamamelis, 1st dil., three drops in 200 
 grammes of water, one spoonful every three hours dur- 
 ing the menstrual period, had the effect of shortening its 
 duration. They are no longer so profuse, and are unaccom- 
 panied by colic. 
 
 February 12. The patient is troubled with quotidian fever, 
 that returns about nine o'clock every evening and lasts all 
 night. It is preceded by a chill, and terminates in a profuse 
 sweat. Tarentula, 3d trit., twenty centigrammes in 200 
 grammes of water; three spoonfuls daily. 
 
 February 14. The chill was neither so hard nor so long 
 as usual. 
 
 February 16. The fever has entirely disappeared. We 
 prescribed arsenicum, 3d trit., for the anaemia, which is the 
 result of the too copious menstruation, and notwithstanding the 
 taking of this remedy, the fever reappeared on the 19th of 
 February. Tarentula, 3d trit., was again successfully used. 
 The pains in the head, fever and nervousness would one 
 after another disappear under the use of belladonna, tarentula 
 and ignatia, but the relief was only temporary, and I finally 
 decided upon employing hydropathy. I ordered a cold affu- 
 sion to be taken night and morning. 
 
 February 26. The fever is entirely gone, and the patient 
 is improving beyond a doubt. Muscular exercise was pre- 
 scribed for the patient. 
 
 February 26. Menstruation occurred, but is less abundant 
 and less painful. Hamamelis, 6th dil. 
 
 March 4. Suspend the hamamelis, in order to return to 
 the cold affusion. 
 
HYSTERIA. 55 
 
 March 6. The patient has no more neuralgia. 
 
 March 9. She does not bear the affusion as well as here- 
 tofore. Wet sheets are to be used instead. 
 
 March 11. The improvement continues; the appetite is 
 returning, and with it the strength and sleep. 
 
 March 13. The patient is doing as well as possible. The 
 pharyngeal sensibility not yet having returned, we prescribed 
 the bromide of potassium in the third trituration, and this 
 medicine was continued up to the time of her leaving the 
 hospital. At this time we examined her throat again, and 
 found that the bromide had had no effect on the anaesthesia. 
 The patient, however, leaves the hospital cured of the ills for 
 the relief of which she entered. 
 
 In a case of this kind, especially at the age of this patient, 
 we should do our utmost to cure her of an affliction which 
 would not only render her, but also those about her, very 
 unhappy. For this reason I employed hydropathy, because, 
 in such cases, the good results are sometimes of a longer 
 duration than those of homoeopathy. The affusion consisted 
 of three pailfuls of water, of the temperature of the atmos- 
 phere, which were poured upon her every morning .; and later 
 this affusion was replaced by the wet-sheet-pack. 
 
 The second hysterical patient is at present in No. 3 of 
 Ward 11. She is fourteen years of age, and is subject to ner- 
 vous vomiting. I spoke to you of this case in my last lecture, 
 and told you that pulsatilla and ferritin had brought about 
 menstruation ; but that the daily vomiting still continued. 
 (See the preceding lecture). 
 
 The third of our hysterical patients has a complication 
 of troubles which renders the diagnosis at first a little diffi- 
 cult. This woman has reached the menopause. For the past 
 eight years, at each menstrual period, she has suffered intol- 
 erable pains in the abdomen and the stomach, accompanied 
 
56 THE MEDICAL CLINIC. 
 
 by vomiting, trembling, and difficult respiration, rather than by 
 real dyspnoea. It was during one of these attacks that she was 
 brought to us, and I confess that I at first thought her a victim 
 of peritonitis, or of an internal strangulation. She was deli- 
 rious all night. Her condition, when I visited her yesterday 
 morning, may be gleaned from the following history : 
 
 Case XV. — Madame Mollens, aged forty-six, entered the 
 hospital on the 23d of February, and left it on the 20th of 
 March. 
 
 This woman, who is of a robust constitution, has been sub- 
 ject to the vomiting of alimentary substances for the past seven 
 years. The vomiting is accompanied by a sensation as of a 
 ball rising from the pit of the stomach to the throat, producing 
 a feeling of suffocation. She complains also of pains in the 
 abdomen, which are increased by walking, after which she has 
 a sense of weight in the rectum, with constant and ineffectual 
 tenesmus. Her menstruation has been irregular for two years, 
 the flow at times being scanty, and again very profuse. The 
 constipation is habitual, but she has freqeunt urging to stool. 
 
 February 24. The face is flushed ; the pupils are dilated ; 
 there is vomiting and constipation ; the urine is scanty ; there 
 is a sub-delirium, with hallucinations. I prescribed belladonna, 
 6th dil., and, after taking a few spoonfuls, the vomiting ceased. 
 She became calm and rational, and had an excellent night ; 
 and to-day, as you can see, the attack has passed off entirely. 
 On account of the age of the patient, I was unwilling to make 
 a diagnosis without some confirmatory signs to corroborate my 
 opinion. I found these in the symptoms of cutaneous and 
 ocular anaesthesia and analgesia, which removed all doubt from 
 my mind. In some portions of the surface I could, with a 
 half-open compass, provoke the sensation of a single point, 
 when both points were applied to the skin. 
 
 February 25. Continued improvement ; she has had a quiet 
 night and day, but is very impressible. Tarentula, 12th dil. 
 
 February 27. The same condition and the same treatment. 
 
 March 2. The nervous attacks are much lighter, and the 
 nights more quiet. Tarentula, 12th dil. 
 
THE INCURABILITY OF CHRONIC DISEASE. 57 
 
 March 4. The improvement continues, and the stomach 
 alone seems to suffer. Ignatia, 12th dil. 
 
 This medicine was continued until the 15th, at which time 
 the vomiting and the nervous attacks, etc., had disappeared. 
 The menses had returned. We prescribed the bromide of 
 potassium in the 3d trit. Under the influence of this remedy 
 the pharyngeal sensibility returned, and the patient left the 
 hospital on the 20th of March, entirely relieved of all her 
 hysterical symptoms. Since her discharge from the hospital 
 she has several times come to the dispensary. The paroxysms 
 had returned, but less severely than at the time of her admis- 
 sion to the hospital. Ignatia, 12th dil., and lachesis, 12th dil., 
 (the latter on account of the menopause), have never failed to 
 relieve her promptly. 
 
 In the case of this patient we have been able, as you see, 
 to put an end to the paroxysms, and even to make it, on its 
 reappearance, less violent than before ; but we cannot prevent 
 its return each month. 
 
 If anything in a physician's experience could convert him to the author's 
 view that " chronic diseases are incurable," the care of a few cases of hysteria, 
 and more especially in women at the climacteric, would be very likely to have that 
 effect. In other diseases we are accustomed to wait for the menopause as a 
 limit to morbid conditions, and as bringing exemption from a host of infirmi- 
 ties; but, in hysterical subjects, it sometimes makes matters worse instead of 
 better. In the latter class of cases we have learned to place reliance upon gel- 
 semium, belladonna, macrotin and sanguinaria, given in the lower potencies. — L. 
 
 The Incurability of Chronic Disease. 
 
 To save you from disappointment in the future, let me tell 
 you that chronic diseases are incurable. Take, for example, 
 the gout. A strict hygiene, and the proper medicines, may 
 retard its development, or cause it to disappear, for the time 
 being, but the disease remains latent in the organism, ready 
 to assert itself on the slightest provocation, although powerless 
 when the exciting cause is lacking. 
 
 For the sake of illustration, take the case of a healthy 
 man who falls and sprains his ankle ; after a few days of 
 
58 THE MEDICAL CLINIC. 
 
 rest he is well again. But let the same accident happen to 
 a scrofulous person, and the result may be that he will have 
 a white swelling. In the same way you may fall asleep by 
 an open window in a railway car, and you awaken with ca- 
 tarrhal conjunctivitis, which you will be rid of in a week's 
 time ; but, with the same exposure, a scrofulous man, on the 
 contrary, runs the greatest possible risk of ulcerative keratitis. 
 
 In syphilis, which is never contracted without the inter- 
 vention of an external agent, there is a better chance of stop- 
 ping the contagion by the use of remedies which, also, are 
 external agents. It seems, indeed, that the nearer the disease 
 resembles, in its etiology, the affections that are due to external 
 causes, the more responsive it becomes to the action of remedies 
 which, I repeat, are themselves but external agents. We have an 
 example of this in the power of therapeutics over intermittent 
 fever and syphilis, and in its relative lack of efficacy in ty- 
 phus fever and in cancer. 
 
 My teacher, Kicord, says that we may blanch the venereal 
 disease, but that we cannot cure it. Despite such great au- 
 thority on this subject, I am not entirely of his opinion, for 
 I believe that syphilis can be radically cured. 
 
 In conclusion, gentlemen, I would say that when we find 
 ourselves confronted by a constitutional disorder, we should 
 treat it, if without enthusiasm, certainly without discourage- 
 ment. We may not be able to exterminate the roots of the dis- 
 ease, but we have powerful resources against its manifestations. 
 And it is a great thing, if we cannot destroy the enemy, so 
 to hold him and so to bind him as to make him practically 
 powerless. 
 
 Asthma, with. Transitory Emphysema. 
 
 I will not close this lecture without a few words in rela- 
 tion to the man in No. 1 of the ward on the second floor, 
 whose symptoms are interesting from a therapeutic point of 
 
ASTHMA, WITH TRANSITORY EMPHYSEMA. 59 
 
 view. This patient, stricken with very marked pulmonary 
 emphysema, which is characterized by a whistling and pro- 
 longed expiration, presents a peculiar symptom in a frothy 
 expectoration resembling the beaten white of an egg, without 
 a trace of thicker mucus. This expectoration being a char- 
 acteristic of arsenicum, I prescribed that remedy in the twelfth 
 dilution. The indications being perfect, I obtained, as I an- 
 ticipated, an excellent result. The expectoration has almost 
 ceased, and the symptoms, both objective and subjective, of 
 emphysema, are so much improved that I hope to see the 
 patient able to leave the hospital in a few days in perfect 
 health, at least for the present, for we must not forget that, 
 in such cases, relapses are frequent. 
 
 Case XYI. — M. Houch, eighteen years of age, entered on 
 the 25th of February, and was discharged on the 24th of March. 
 
 This patient has never had either the hemorrhoids or 
 herpes, and was never ill until 1871. At the end of the siege 
 of Paris, during which he suffered greatly, he began to cough. 
 The cough, which was not accompanied by dyspnoea, was most 
 troublesome at night. It continued for six or seven months. 
 Subsequently the respiration became impaired, and he was 
 often obliged to stop in the midst of his work. But the 
 attacks of suffocation, for which he came hither, have only 
 appeared within a year. These paroxysms occur principally 
 at night or in the morning, but are very infrequent during the 
 day. 
 
 On examination of the chest, the sonorousness is slightly 
 exaggerated. The expiration is prolonged over the whole 
 chest, but especially on the right side, with sibilant rales ; the 
 pulse is 92. The expectoration is abundant, resembling in 
 appearance the beaten white of an egg. The patient com- 
 plains of pain in the side when breathing. 
 
 February 26. Jlryonia, 12th dil. 
 
 February 27. His condition is about the same, excepting 
 that the pain in the side has disappeared, and there is great 
 suffocation. Arsenicum, 12th dil. 
 
60 THE MEDICAL CLINIC. 
 
 February 28. Less suffocation ; the expiration is not so 
 prolonged, and there are slight rales. Arsenicum, 12th dil. 
 
 March 2. The dyspnoea is much less marked, and the ex- 
 pectoration is diminished in quantity. The pain in the side 
 has reappeared. Bryonia, 3d dil. 
 
 March 4. The improvement continues ; there is very 
 slight expectoration ; the pain in the side is much less. Bry- 
 onia, 3d dil. 
 
 March 5. No pain in the side. Arsenicum, 3d trit. 
 
 March 9. The prolonged expiration has almost passed 
 away ; there is a slight suffocation ; the cough is infrequent, 
 with tickling in the throat. Jodium, 3d trit. 
 
 March 14. The taking of the jodium was followed by 
 profuse perspiration ; but the dyspnoea remaining as severe as 
 before, I returned to the arsenicum, in the third trituration. 
 This remedy was continued until he left the hospital on the 
 25th of March, cured of the emphysema. 
 
LECTUKE VII. 
 
 Summary. — Phthisis; indications for sulphur and jodium. Of the duality of 
 phthisis. Dysentery; indications for mercurius solubilis and mercurius 
 corrosivus, ipecacuanha, arsenicum, phosphorus, colocynth and secale cor- 
 nutum: case. Mild pneumonia: case. The first stage of pneumonia is 
 already one of hepatization. Ascites: case (continued). 
 
 Phthisis Pulmonalis. 
 
 Gentlemen : There are, in the hospital, at present, a num- 
 ber of consumptives, of whose clinical history I will speak to 
 you for a few moments. 
 
 In ~No. 1 of the women's ward is a patient in whom the 
 stethoscopic signs are very obscure. Fortunately these signs 
 are supplemented by a symptom which I advise you to note 
 very carefully, for it is almost pathognomic. That symptom 
 is a pain which is seated in the superior intercostal spaces, 
 and above and below the spine of the scapula. 
 
 Our patient presents this symptom on the right side ; she 
 coughs but little, and is getting better. In her case, as in 
 many others, I have prescribed the vegetable diet with suc- 
 cess. 
 
 In ~No. 2 there is a woman in whom the phthisis was pre- 
 ceded by pleurisy. She also is improving ; she gains flesh 
 and strength, and coughs but little, although there is a slight 
 elevation of her temperature at night. I have prescribed 
 sulphur for her, which is a remedy that has done me very 
 good service in tuberculosis. I give it, not only to those 
 patients who present the pathogenetic indications for it, but 
 also empirically to such as can bear it. The symptoms that 
 call for its employment are hoarseness, a dry cough, that is 
 sharp, and sometimes very severe, but not paroxysmal like 
 
62 THE MEDICAL CLINIC. . 
 
 that of drosera. There are also the symptoms in the neigh- 
 boring organs, viz., pains in the head, the chest, the abdo- 
 men, stitches in the side, and vomiting, all of which symp- 
 toms militate in favor of its employment. The cough of 
 sulphur is provoked by tickling in the throat, the same as 
 that of drosera; it is excited by rapid breathing, cold air, 
 and over-talking, like that of phosphorus. It is, perhaps, 
 unnecessary to add that, where the patient has also a cuta- 
 neous eruption, the sulphur is still more strongly indicated. 
 
 Jodium is another remedy for pulmonary consumption. 
 The development of phthisis has, in fact, been observed in 
 cases of iodism, where the cough, the purulent expectoration, 
 the hectic fever, the sweats, the oedema, the emaciation, and the 
 diarrhoea, have followed its excessive use. Jodium is also a 
 remedy for scrofula. You are familiar with its elective action 
 upon the glands, which makes it especially useful in cases of 
 scrofulous consumption. The cough that the jodium provokes 
 is short, like that of sulphur ; it is oftener loose than dry ; 
 it is accompanied by a thick mucous and puriform expectora- 
 tion, that is often streaked with blood. A tickling in the 
 throat provokes it in a number of cases ; and, lastly, aphonia 
 and the signs of laryngeal phthisis are more marked than in 
 sulphur. 
 
 Chronic Phthisis ending- in Caseous Pneumonia. 
 
 The third consumptive patient is the one who died this 
 morning. In this case the disease was chronic, forcing the 
 patient to come to us every year. She has hitherto remained 
 under treatment a few weeks each time, leaving us much 
 improved in health. This year, when she entered, you recol- 
 lect I called your attention to a symptom which gave me 
 considerable uneasiness, viz., the development of tuberculous 
 ulceration of the larynx. This ulceration caused her pain in 
 the throat, dysphagia and suffocation. Unhappily my pre- 
 
CHEONIC PHTHISIS ENDING IN CASEOUS PNEUMONIA. 63 
 
 dictions regarding her have proved true. I will say, however, 
 that she did not die of tuberculous laryngitis, but of a double 
 caseous pneumonia, which attacked her a few days ago, and 
 which gained an easy victory over her shattered organism. 
 
 Case XYII. — Mrs. Barthes, aged thirty-eight, entered the 
 hospital on the 6th of February, and died therein on the 5th 
 of March. 
 
 This is the third time this patient has come to us for relief. 
 Her disease made its first appearance three years ago. It 
 began with coughing and emaciation. The vegetable diet, 
 drosera and sulphur reduced the fever, which had twice com- 
 pelled her to enter the hospital. She had resumed her occu- 
 pation as cook, but had continued to cough and to lose .flesh. 
 Her actual symptoms were as follows : emaciation, loss of 
 strength and dyspnoea ; a dry cough, which is hoarse and 
 painful ; mucous rales, with pectoriloquy at the apex of the 
 right lung; but there is no fever. I prescribed phosphorus, 
 30th dil., 4 globules in 200 grammes of water, three spoonfuls 
 a day. This was given for the symptoms of tuberculous laryn- 
 gitis, which symptoms had for some days complicated the 
 condition of the patient. She was ordered a vegetable diet. 
 
 February 9. The phosphorus having had no effect, I sub- 
 stituted argentum, in the 3d trit., and then in the 30th dil. 
 Under the influence of this medicine the condition of the 
 larynx was sensibly improved. 
 
 February 23. She has fever ; the pulse is 96. Ausculta- 
 tion reveals nothing new. Aconite, 3d dil., one spoonful every 
 two hours. 
 
 February 25, the third day of the acute stage. She has a 
 high fever ; the pulse is 130 ; the temperature 104°, with 
 dyspnoea. The stethoscopic signs are not modified by the 
 relapse. Aconite in the mother tincture, 3 drops. 
 
 February 26, fourth day. Her condition is about the same. 
 The pulse is only 112, but the temperature is 105.44°. The 
 cough is dry and frequent. The same treatment. 
 
 February 27, fifth day. We at last find the cause of the 
 fever. The lower part of the left lung is the seat of a charac- 
 teristic bruit de souffle / at the same time the expectoration is 
 
64 THE MEDICAL CLINIC. 
 
 brownish and serous. The fever decreases ; the pulse is 112°, 
 and the temp. 103.64°. Bryonia, 4 globules in 200 grammes 
 of water, one spoonful every two hours. 
 
 February 28, sixth day. The general improvement con- 
 tinues ; the pulse is 72, and the temp. 101.84°. The souffle 
 of the left side is more intense and extended. The same treat- 
 ment. 
 
 March 1, the seventh day. There is a slight oscillation 
 in the febrile movement ; the pulse is 96, and the temp. 102. 20°. 
 The patient feels better. 
 
 March 2, eighth day. The intense fever has returned. 
 Morning, pulse 120, temp. 104° ; evening, pulse 116, temp. 
 104.36°. The right lung is invaded, and its inferior portion is 
 the seat of a very intense souffle ; with sub-crepitant rales and 
 a souffle in the left side, which was the first to be attacked. 
 The same treatment. 
 
 March 3, ninth day. The general condition is more and 
 more grave, with delirium, and great dyspnoea; both lungs 
 are involved in their inferior two-thirds. The pulse is in- 
 appreciable, the temp. 104.36°. Bryonia, 12th dil., and 
 phosphorus, 30th dil., alternately. 
 
 March 4, tenth day. The dyspnoea has increased almost to 
 suffocation. The temperature has fallen this morning to 
 103.64°. The patient died the following morning, which was 
 the eleventh day of the acute attack. 
 
 For what reasons, gentlemen, was I led to diagnosticate 
 this as a case of double caseous pneumonia? First of all, 
 because this patient was evidently tuberculous, and in my 
 opinion this particular form of pneumonia is proper to tuber- 
 culous subjects. Next, the progress of the disease, which 
 invaded both lungs, as is almost always the case in the caseous 
 form of pneumonia. Thirdly, the contrast between the gen- 
 eral improvement on the fifth, the sixth and the seventh days, 
 whilst the local condition of the left lung grew worse, and the 
 lesion invaded the right one. Again, the character of the 
 expectoration, which was serous and more or less dark, was 
 such as I had already observed in caseous pneumonia. Lastly, 
 
THE DUALITY OF PHTHISIS. 65 
 
 the absence of improvement during the critical clays, which 
 are the fourth and the seventh, as in uncomplicated pneumo- 
 nia. In this case the improvement occurred on the fifth and 
 sixth days. It is nevertheless very much to be regretted that 
 an autopsy could not be had in this case. 
 
 I cannot let this occasion pass without saying something 
 concerning the caseous form of pneumonia, and the question 
 of the duality of phthisis. We do not admit the existence of 
 a caseous pneumonia, which is to be taken, like suppuration 
 or gangrene, as a regular termination of the hepatized stage 
 of pneumonia. We understand by caseous pneumonia (and 
 if we retain this term it is because it has been generally ac- 
 cepted), a tuberculous infiltration following the inflammatory 
 process. In one word, it is not an ordinary phlegmasia that 
 terminates in caseification, but it is the pathological mode of de- 
 velopment of tuberculosis that begins with an inflammation 
 of the lungs (caseous pneumonia), or by inflammation of the 
 smaller bronchii and the vesicles (catarrhal caseous pneumonia). 
 
 The Duality of Phthisis. 
 
 We have already, in our monograph on Cellular Pathology, 
 tested the value of the arguments drawn from pure patholog- 
 ical anatomy, and which cause us to reject the theory of the 
 duality of phthisis. These arguments, confirmed by the most 
 recent histological researches, are, in substance, as follows : 
 The macroscopic and the microscopical characters of caseous 
 pneumonia, in the first stage, do not differ appreciably from 
 the macroscopic and microscopical characters of the gray 
 granulation. The only differences are in the pathological mode 
 of development, and in the seat of the lesion. 
 
 But now we wish to offer a clinical argument against the 
 duality of phthisis. If we put aside the cases of virulent 
 phthisis, of acute granulation, and the acute granulated 
 phthisis of contemporary authors, as being incontestably a 
 
6fi THE MEDICAL CLINIC. 
 
 tuberculous affection, we still have an extremely large class 
 of what are very properly called tuberculous patients. These 
 are real consumptives, because they have in the lung a lesion 
 which ulcerates and suppurates, and which is accompanied by 
 hectic fever, and a more or less rapid emaciation. In some 
 of these cases the disease has set in abruptly under the form 
 of pneumonia, or of bronchitis, but oftener it creeps on slowly 
 and insidiously. 
 
 In a small proportion of these cases the disease is not 
 hereditary, or, more strictly speaking, it cannot be proved that 
 it is inherited ; but the greater number of consumptives in- 
 herit the disease from their parents. Occasionally a cure is 
 effected ; but, alas ! rari nantes in gurgite vasto, the great 
 majority of them succumb after a struggle of a few months, 
 or, at the most, of a few years. Occasionally the disease is 
 limited to the lungs, but in the greater number of cases the 
 larynx, the intestines, the pleura, the peritoneum, the menin- 
 ges, the epididymis, etc. etc., are successively attacked. 
 
 This much we learn from the clinic. But what does the 
 fanciful pathological anatomy, that originated the theory of 
 the duality of phthisis, assert? It says, on the contrary, 
 that the caseous pneumonia, that is to say, the phthisis with- 
 out tubercles, which begins abruptly with inflammation, which 
 has no hereditary antecedents, which never affects or involves 
 the whole organism, and which is, in fact, quite curable, is much 
 more frequent than tubercular phthisis. It insists that in 
 one hundred and thirty-nine cases of phthisis there will be 
 one hundred and twenty-three which are caseous, and only 
 sixteen that are tuberculous (Jaccoud's Clinic). From which 
 it is to be inferred that the greater proportion of cases of 
 phthisis are of the caseous variety, with no hereditary antece- 
 dents ; no constitutional symptoms ; no diarrhoea, nor hoarse- 
 ness, etc.; and that they are not incurable. In other words, 
 this teaching is directly opposed to that of clinical experience. 
 
SCROFULA. 67 
 
 Among the French physicians Dr. Jaccoud is the one who 
 has defended the theory of the duality of phthisis with the great- 
 est ability. As he is distinguished among us for his knowl- 
 edge of general pathology, we will terminate this digression 
 from our subject proper by addressing him a single question 
 on the nature of phthisis : Why do certain cases of paren- 
 chymatous pneumonia and of bronchitis terminate in caseous 
 phthisis ? Evidently there is no anatomical reason that will 
 explain it, because these same diseases terminate more fre- 
 quently by resolution, or suppuration, and one of them by 
 gangrene. 
 
 There is but one answer to our question, which answer 
 is, that inflammation of the lungs and of the bronchii ter- 
 minate in caseous phthisis in subjects who are predisposed 
 to it. In order that caseification may succeed to inflammation, 
 there must have been a preexisting morbid condition. This 
 morbid condition has a name, and that name is scrofula, and 
 scrofula is, if I may use the expression, the mother of the 
 tuberculous granulation and of caseification. Therefore, pul- 
 monary phthisis, in its various forms, is always a scrofulous 
 disease, and the duality of phthisis is, consequently, a patho- 
 logical error. There are not many morbid species, but there 
 are many forms of a scrofulous affection. 
 
 Scrofula. 
 
 Scrofula, like gout or syphilis, and like all the constitu- 
 tional affections, includes a great number of morbid processes, 
 that are characterized by a class of symptoms and of lesions, 
 and by a proper evolution that constitute so many common 
 diseases, all of which are included in the greater one. This 
 is what we call the constitutional affection. Thus, beginning 
 with the most certain of them, we cite scrofulous ophthalmia, 
 cold humors, and white swellings, which are characterized by 
 a totality of symptoms, and of lesions that have developed in 
 
68 THE MEDICAL CLINIC. 
 
 their proper order. These comprise so many different dis- 
 eases ; but they are none the less inseparably bound to the 
 morbid affection, which is the scrofula. They are thus bound 
 to it by their succession, and their alternation in the same 
 person ; by their character as a family disorder ; by a certain 
 freedom from the influence of ordinary causes in their produc- 
 tion; and by their lesions, which are ulceration, caseification 
 and tuberculization. Whenever these characters can be deter- 
 mined, we have the right to say that the affection is scrofulous. 
 Very well ; now these characters are proper to tubercular 
 meningitis, to acute granulation of the lungs, to caseous 
 phthisis, and to tubercular phthisis, as well as to scrofulous 
 ophthalmia, and to white swelling. They are family diseases ; 
 all of them succeed and alternate with other affections which 
 are evidently scrofulous; they are all characterized by ulcer- 
 ation, tuberculization and caseification ; all of them are, to a 
 certain extent, independent of external causes, and all are, 
 therefore, scrofulous affections. 
 
 One word concerning the objection that one of several 
 affections, as, for example, tubercular meningitis, caseous 
 pneumonia, or acute granulation of the lungs, may attack a 
 person who has always before been in perfect health. When 
 this occurs, it illustrates the fixed form of scrofula described 
 by J. -P. Tessier, Milcent and Bazin ; and if you add that 
 white swelling and Pott's disease may occur in as spontaneous 
 a manner as caseous pneumonia, the objection is singularly 
 modified ; for if the white swelling, which is an essentially 
 scrofulous affection, may appear in a person of previous good 
 health, why may not the same happen with caseous pneu- 
 monia ? 
 
 Concerning the absence of heredity as a sign which is to 
 separate caseous from tubercular phthisis, we deny the facts 
 as they are quoted. The researches upon which they are 
 founded have been made in the hospitals, where the family , 
 
DYSENTERY. 69 
 
 history .is almost always unknown, or, at least, where the 
 knowledge regarding it is limited to the immediate relatives ; 
 and we must not forget that, in questions of hereditary en- 
 tailment, we should search back at least as far as the grand- 
 parents, if our investigations are to be of any value. And 
 such thorough research as this is acknowledged to be almost 
 always impossible in hospital practice. 
 
 Dysentery. 
 
 I come now to the treatment of another disease, of which 
 I wish to speak to you concerning a case that presents itself 
 to our observation in the hospital. You have seen in No. 5 
 of the ward for women an example of dysentery that was ■ 
 caused by contagion. It is the case of a servant who con- 
 tracted the dysentery while taking care of her mistress, who 
 was ill of that disease. You know that Trousseau considered 
 the dysentery to be one of the gravest, as well as one of 
 the most contagious, of all maladies. I think that in this 
 respect the eminent clinical teacher rather exaggerated the 
 matter, although it certainly is a serious disease, and one 
 that is deserving of the greatest care in its treatment. 
 
 The remedy which I have given this patient is the mer- 
 curius solubilis. I ordered it because the stools were small, 
 slimy, and unaccompanied by violent colic or blood ; besides, 
 it is recommended, but empirically, especially for women ; 
 but this would not have kept me from prescribing the mer- 
 ourius corrosivus, if the stools had been bloody. 
 
 I take advantage of this opportunity to tell you that the 
 benefit derived from the action of mercurius in dysentery is 
 one of the best proofs of the homoeopathic law of similars. 
 If you will study the cases of poisoning by the corrosive sub- 
 limate in Orfila or Tardieu, you will see that the acute cases 
 resemble the dysentery in every particular. In both there 
 are sharp colic ; small, slimy, bloody stools ; pain and ulcer- 
 
70 THE MEDICAL CLINIC. 
 
 ation of the anus ; and, if the poisoning is very violent, 
 there will be added to these symptoms others, such as cold- 
 ness, collapse and death, precisely as in fatal cases of dysen- 
 tery. 
 
 At the onset of this disease there is another remedy that 
 should be given, especially where there is vomiting and nausea, 
 and that is ipecac. This remedy is also indicated for the anal 
 hemorrhage. There are two other medicines, likewise, which 
 may do you great service ; the first is arsmicum, which is to 
 be given when the mercurius corrosivus proves insufficient, and 
 when your patient's strength is waning; and where there is 
 thirst, sinking, great internal heat and foetid stools, you may 
 prescribe it with effect, not Only internally, but also by injec- 
 tions of the third, and even of the second, trituration ; 20 
 centigrammes in 200 grammes of water. 
 
 * 
 
 The other remedy is phosphorus, the indications for which 
 are very similar, but which is most successful in grave cases 
 of malignant dysentery, where the patient's condition is very 
 serious. There is one symptom which particularly calls for 
 its use, and that is paralysis of the sphincter, relaxation of 
 the anus, and the prolapse of the rectum after each stool. 
 
 I will not weary you with quoting the indications for other 
 remedies, such as colocynth, which is especially called for 
 where there are green, slimy stools, with the glairy coating 
 of green bile ; nor for the secale cornutum, which is a less 
 important remedy. It is better at first not to overload the 
 memory, lest we render it unfaithful. 
 
 Case XYII. — Nathalie Adnaut, a domestic, aged twenty- 
 three years, entered the hospital on the 27th of February, and 
 left it on the 7th of March. In this case the disease was de- 
 veloped by contagion, the patient having for several days pre- 
 vious taken care of her mistress, who was ill of the dysentery. 
 
DYSENTERY. 71 
 
 The attack was preceded by a day of general discomfort and 
 feverishness. 
 
 February 27. She lias violent colic, which is accompanied 
 by frequent desire to go to stool. The discharges are fre- 
 quent, but without tenesmus or griping. The first day the 
 discharges were a little bloody, but afterward they consisted 
 almost entirely of slime. 
 
 February 28. Has had three evacuations during the night, 
 and the same number during the day. The pulse is 72, and 
 the temp. 102.20°. Mercurius sol., 6th dil., two drops. 
 
 March 1. She has had but three stools. The temperature 
 is normal. The same treatment. 
 
 March 2. 'No more evacuations. The same treatment. 
 
 March 6. The patient has had two stools, but no colic, 
 and no thirst or tenesmus. .Bismuth, 2d trit. 
 
 March 7. The discharges have ceased again, and the patient 
 leaves the hospital cured. 
 
 We have recently treated a case of dysentery, with peculiar complications, 
 that is worthy of record. The patient, a very intelligent man, aged forty years, 
 of general good health, a man of family and addicted to no excesses of any kind, 
 was seized with acute articular rheumatism. He was persuaded to send for an 
 old-style prescriber, who, it appears, attempted to carry off the disease by hyper- 
 catharsis. The poor victim afterward told me that he had had twenty-eight 
 stools in rapid succession, and that he had vomited several times besides. The 
 stools at first consisted of natural foecal matter, but finally contained nothing 
 but slime and blood. The dysentery was quite prevalent at the time (August), 
 but he had never had any symptom of this kind until after taking the drastic 
 cathartic. The tenesmus and the frequent, slimy and bloody stools had con- 
 tinued for eight days, but the rheumatism had not abated when I first saw him. 
 His sufferings were greatly aggravated at night, and by motion, and the per- 
 spiration was very copious and almost constant. 
 
 Under bryonia in the 3d dil., and mercurius sol., 3d trit., given in hourly 
 alternation, he improved steadily and both sets of symptoms gradually disap- 
 peared. He made a good recovery. 
 
 There is a form of dysentery which follows an epidemic of Asiatic cholera, 
 and which sometimes comes in the autumn, after we have had a great deal of 
 cholera morbus during the summer months, for which the veratrum alb. is 
 almost a specific in the case of adults, and the angustura for the same disease 
 in infants and young children. We had a large experience in this type of 
 dysentery in Chicago in the year 1854. — L. 
 
72 THE MEDICAL CLINIC. 
 
 Mild Pneumonia. 
 
 Before concluding this lecture, I wish to say one word to 
 you regarding a case of mild pneumonia; the patient is the 
 
 man in No. 5. 
 
 Case XIX. — M. Malmert, fifty-four years of age, a steel 
 engraver, entered our wards on the 27th of February, and left 
 us on the 9th of March. 
 
 This man is decidedly corpulent, and has never had a 
 severe illness. During the winter he has contracted a cold 
 every two or three years, which would generally last about a 
 fortnight, and which was accompanied by fever and dyspnoea. 
 About the 15th of February last he suffered repeatedly from 
 slight attacks of fever. On the 21st of the same month he was 
 seized with suffocation, which for two days had been preceded 
 by a pretty severe stitch in the side and back of the chest. 
 
 A physical examination of the patient disclosed dullness in 
 the lower third of the left chest. At this point fine crepitant 
 rales may be heard at the close of inspiration, but there is no 
 souffle. Over the remainder of the chest, and especially upon 
 the right side, there are sub-crepitant rales. The expectora- 
 tion is rusty and adhesive. 
 
 February 28. No fever ; pulse 92 ; rusty sputa ; crepitant 
 rales on the left, and sub-crepitant ditto on the right. Ipecac. 
 and bryonia. 
 
 February 29. The physical condition of the lung is the 
 same ; the sputa continue to be rusty. The same treatment. 
 
 March 1. There is no change. The temperature is 99.30°, 
 and the pulse is 92. The same treatment. 
 
 March 2. There is complete insomnia ; the cough has 
 slightly diminished ; the apyrexia is complete, excepting the 
 pulse, which was 96 in the evening and 72 in the morning. 
 The same treatment. 
 
 March 3. The expectoration is less colored ; the patient 
 has slept, and the pulse is 84. The same treatment. 
 
 March 4. The expectoration is only slightly colored, but 
 viscous ; the cough is loose and the patient sleeps. Tartar 
 emet, 3d trit., twenty centigrammes. 
 
ASCITES. 73 
 
 March 5. On examination we find crepitant rales at the 
 base of the left lung, but on the right side the rales are sub- 
 crepitant. There is no souffle. 
 
 March 6. The improvement continues ; the rales grow 
 louder and less humid. Bryonia, 12th dil. 
 
 March 9. The expectoration continues, but is less in quan- 
 tity, and the nights are good. The loud rales of bronchitis are 
 heard in the chest. The patient wants to leave the hospital. 
 The same treatment. 
 
 March 14. He left cured. 
 
 AndraVs G Unique contains seven cases of pneumonia in 
 which auscultation showed nothing but crepitant rales. The 
 same symptoms were noted, as in our patient, id est, rusty and 
 viscid expectoration ; pain in the side at the onset of the 
 attack ; noticeable dyspnoea, and a slowness in the evolution 
 of the symptoms. This is what Laennec called pneumonia in 
 the first degree, and which is characterized, anatomically, by 
 pulmonary obstruction, the second degree corresponding to 
 hepatization. 
 
 We have always protested against this error of pathological 
 anatomy, and have always taught that, although it is true that 
 the crepitant rales correspond to the first period of the inflam- 
 mation of the pulmonary tissue, nevertheless, from the first, 
 this inflammation is neither an obstruction nor a simple con- 
 gestion, but an induration, that is to say, an hepatization. 
 The last experiments of M. Cornil, on the production of the 
 crepitant rales, have demonstrated that this symptom really 
 answers to an induration of the tissue. 
 
 Ascites.— (Continued from pages 16 and 51.) 
 
 You have not forgotten our ascitic patient, in whose case, 
 as you know, I made three punctures at intervals of as many 
 days. Under the influence of china, 6th dil., this patient 
 made a steady improvement, the liquid reproducing itself very 
 slowly. His general condition improved every day, until, on 
 
74 / THE MEDICAL CLINIC. 
 
 the nights of the 24th and 25th of February, he caught a severe 
 cold through the ward being chilled. This was followed by 
 an attack of bronchitis, which developed into pulmonary tuber- 
 culosis, of which he died on the 4th instant. Here is the re- 
 mainder of the case in detail : 
 
 Case II. — February 10. The ascites appears to have been 
 arrested in its progress ; the appetite and strength have re- 
 turned, and there is no cough. China, 6th dil. 
 
 February 15. Continued improvement; the abdomen is 
 slightly swollen, but the general condition is very satisfactory. 
 China, 6th dil. 
 
 February 20. Better, with free perspiration. China, 6th dil. 
 
 February 25. In consequence of taking cold the cough has 
 returned. • There is a copious expectoration, which is thick 
 and streaked with blood. On auscultation, mucous rales may 
 be heard over the entire chest, and there is rapid sinking. 
 Ipecac, 3d dil., twenty centigrammes. 
 
 February 27. The expectoration is puriform and very 
 abundant, with dyspnoea and humid rales; the pulse is 108, 
 and the temp. 102.56°. Tartar emet., 1st trit., twenty centi- 
 grammes. 
 
 February 28. The patient is much worse, and the mucous 
 rales are very abundant in the chest. Arsenicum, 6th dil., 
 two drops. 
 
 March 3. There is no expectoration, but a quiet delirium ; 
 the pulse is 108, and the temp. 104°. Kermes' ', 1st trit., twenty 
 centigrammes. 
 
 March 4. The patient is dead. 
 
LECTUKE YIII. 
 
 Summary. — Interstitial nephritis : case. The diagnostic indications for arseni- 
 cum, phosphoric acid, belladonna, cantharis, and plumbum, in albuminuria. 
 Of certainty in therapeutics. Puerperal phthisis; great improvement; indi- 
 cations for phosphorus, sulphur, and drosera. The vegetable diet. 
 
 Interstitial Nephritis. 
 
 Gentlemen : We have, at present, in our ward for women, 
 (ward 2, room No. 3,) a patient whose case merits our attention. 
 This woman is forty-nine years of age, and has been subject to 
 a diarrhoea during the last twelve or fifteen years. Little by 
 little her constitution has given way, until now she presents all 
 the symptoms of interstitial nephritis. The case in detail is as 
 follows : 
 
 Case XX. — Mrs. Lalouette, aged forty-eight, entered the 
 hospital on the 10th of May. She is greatly emaciated ; the 
 complexion is pale and of a grayish hue, and the strength is 
 almost gone. For eight or ten years she has suffered from a 
 diarrhoea, which has resisted all kinds of old-school treatment, 
 and which, little by little, has destroyed her constitution. Not- 
 withstanding this, she has continued to work until last year, 
 when she came to be treated under the service of the lamented 
 Dr. Milcent. A short time after, she left the hospital quite 
 well, and it was this successful resort to homoeopathy in her 
 case that has brought her to us again, a year from that time. 
 Her present symptoms are, great emaciation and feebleness ; 
 loss of appetite ; excessive thirst both day and night ; the flow 
 of urine is very abundant, watery, with a specific gravity of 
 1.010, and albuminous. There is no oedema at present, but 
 at the beginning of the year her face was somewhat bloated. 
 The heart is hypertrophied, and the apex-beat is outside of the 
 line of the nipple. The radial and temporal arteries are 
 
76 THE MEDICAL CLINIC. 
 
 ossified ; the respiration is natural, and there is occasionally 
 some diarrhoea. 
 
 She reports that the thirst and the copious urination began 
 three years ago. 
 
 March 11. I prescribed arsenicum, 3d trit., twenty centi- 
 grammes in 200 grammes of water ; one spoonful every three 
 hours. 
 
 March 17. There is less thirst ; the urine not so abundant, 
 and the patient feels strong ; but still the urine has the same 
 specific gravity. 
 
 March 26. There is a general improvement ; the urine is 
 the same. Arsenicum, 1 st trit. 
 
 April 1. The patient is better ; her strength returns, slowly 
 to be sure, but she has an appetite and drinks less ; the urine 
 is less abundant, but of the same specific gravity. Phosphoric 
 acid, 3d dil., three drops. 
 
 This medicine was continued until the 15th of April, when 
 I left the patient in the care of Dr. Fredault. 
 
 You are aware, gentlemen, that besides Bright' s disease, 
 or parenchymatous nephritis, there are two other lesions of 
 the kidneys, id est, one that is called interstitial nephritis, and 
 which is characterized by a pathological development, or, in 
 the language of the day, a proliferation or hypergenesis of the 
 connective tissue of the kidney. This hypergenesis is followed 
 by atrophy of the glandular tissue, which, in the midst of the 
 morbidly exaggerated production, is compressed, and ends by 
 becoming atrophied. The other lesion to which I have re- 
 ferred is the amyloid degeneration of the kidney. This is 
 rarely found in any but scrofulous or rachitic subjects, and 
 in them only after chronic suppuration. 
 
 In the case that now claims our attention the disease is 
 interstitial nephritis, with the following symptoms : excessive 
 thirst ; the urine is very abundant, as in diabetes, with con- 
 siderable albumen in it, more especially during the last few 
 days ; absence of oedema, which, considering the length of 
 time since the disease began, excludes the idea of Bright 1 s 
 
INTERSTITIAL NEPHRITIS. 77 
 
 disease. As in almost all similar cases, we observe the co- 
 existence of hypertrophy of the heart and of ossification of 
 the arteries. 
 
 The treatment in such cases is very difficult, as it always 
 is where there is an organic lesion. However, I prescribed 
 arsenicum, which, you know, is very well indicated in albu- 
 minuria, and which, in this particular case, corresponded per- 
 fectly to the thirst, the debility and the emaciation. In fact, 
 you are aware that in all cases of chronic arsenical poisoning, 
 albumen is found to be present in the urine. When the poi- 
 soning is acute, there is not only albumen, but hemato-globuline 
 in the renal secretion. Arsenicum is, for that matter, the 
 remedy that should be called for in albuminuria. 
 
 In acute cases that are characterized by bloody urine and 
 pain in the loins, I prefer belladonna at the beginning, and 
 afterward cantharis. This last medicine is perfectly homoeo- 
 pathic, for every one knows that the application of a fly- 
 blister may cause renal congestion, accompanied by slight 
 albuminuria, by renal pains, and difficult and infrequent, 
 and sometimes bloody, urination. As for chronic nephritis, 
 I combat it with arsenimtm and plumbum. The lead prepara- 
 tions also, in cases of poisoning by them, produce a condition 
 which is very analogous to that of persons who are afflicted 
 with chronic albuminuria, for their urine is often albuminous. 
 
 Besides these remedies we venture to suggest the use of mercurius corro- 
 sivus in the third or the sixth attenuation. There is, we believe, no remedy 
 to compare with it for puerperal albuminuria, and for renal disease that has 
 been caused by the abuse of alcoholic liquors. Bsehr says, very truly, that the 
 renal symptoms in case of poisoning by the mere. corr. are almost as character- 
 istic as are its dysenteric symptoms. 
 
 Where hypertrophy of the heart coexists with interstitial nephritis, or, in- 
 deed, with either form of renal inflammation, the patient cannot improve while 
 he continues to live in the rarefied air of the mountains and of the higher alti- 
 tudes. Some of our cases have been wonderfully benefited by a change of 
 locality. In our experience, railroad men and commercial travelers are quite 
 subject to interstitial nephritis. — L. 
 
78 THE MEDICAL CLINIC. 
 
 Certainty in Therapeutics. 
 
 A . short time ago you saw me prescribe drosera to the 
 patient in No. 2 of the woman's ward, who is a consumptive. 
 This remedy corresponds to the spasmodic cough that is pro- 
 voked by a tickling in the throat, and which is accompanied 
 by vomiting. It is a precious remedy, not only for the relief 
 that it gives to the sick, but also because it serves to demon- 
 strate what I call therapeutic certainty. This term is a double 
 one, and includes the positive knowledge of the disease on 
 the one hand, and the equally positive knowledge of the cura- 
 tive agent on the other. If you are not thus doubly certain, 
 you cannot know what effects to attribute to your remedies. 
 
 Now, gentlemen, it is to Hahnemann again that we are 
 indebted for this positive knowledge of therapeutic agents, 
 for he was the true founder of the experimental Materia Med- 
 ica. Undoubtedly you will find indications of this method 
 before his time, for Pliny, in the days of the ancients, ob- 
 served the effects of aconite on a healthy man ; and Storck, 
 a long time after, followed in the same track. 
 
 But all this was only a presentiment, if I may so express 
 myself; and, if } r ou compare their crude attempts with the 
 homoeopathic formula, and the pathogeneses of the hundred 
 medicines that we owe to the almost superhuman efforts and 
 patience of Hahnemann, you will at once concede that to him 
 alone is due the honor of this therapeutic reform. 
 
 But it is not sufficient to know the positive effects of our 
 remedies. We must also know with what disease we have to 
 contend, and when this is settled we must further know what is 
 the form and the variety of the disease, for without all this our 
 statistics will be of no value. If you are treating the typhoid 
 fever, and wish to prove the effect of a remedy in shortening 
 its duration, you must note the form under which it presents 
 itself to you, for if it is left alone, the milder form of this 
 
CERTAINTY IN THERAPEUTICS. 79 
 
 disease will cure itself in from fourteen to seventeen days ; 
 or the common form in from twenty to twenty-four days ; 
 while the protracted type of this fever may run to forty el- 
 even to sixty days. 
 
 The same distinctions are necessary in cases of pneumonia, 
 which, in spite of the non-dangerous character that some of 
 your teachers have ascribed to it since they have witnessed the 
 marvelous effects of homoeopathy in its treatment, still shows 
 in the official statistics of the Paris hospitals, a mortality of 
 from twenty-live to thirty in one hundred. 
 
 When you can distinguish the morbid species, their forms 
 and varieties, their epidemic character and their medical con- 
 stitution, and when you know the positive effects of your reme- 
 dies on a healthy person, then you may claim to possess the 
 elements of this therapeutic certainty. Without this, whether 
 allopathic or homoeopathic, your experience will bear the stamp 
 of uncertainty and of deception. 
 
 Illusions and uncertainties concerning the action of reme- 
 dies form that portion of traditional therapeutics which the 
 immortal Bichat has declared in these words, and upon the 
 meaning of which, our opponents would do well to reflect : 
 
 "An incoherent assemblage of opinions, themselves inco- 
 herent, the Materia Medica is, perhaps, of all the physiological 
 sciences, the one which best portrays the caprices and whims 
 of human nature. What do I say? To a methodical mind it 
 is not a science ; it is a mass of unformed and of inexact 
 ideas; of observations that are often puerile; of illusive means; 
 of formulae that are as oddly conceived as fastidiously gathered 
 together. It is said that the practice of medicine is repulsive. 
 I say more than this, that to the mind of a reasonable man, the 
 principles of the ^greater part of our Materia Medica are irra- 
 tional. ' ' 
 
 Such, gentlemen, was the justly severe language of the cele- 
 brated teacher of whom the faculty are very proud; and it is in 
 
80 THE MEDICAL CLIiNTC. 
 
 the name of the therapeutics which he so ably cauterized, that 
 we are persecuted, when our only object has been to rescue it 
 from the chaos in which it was buried. We have not only had 
 to do battle on scientific, but also on professional, grounds. . . . 
 And these attacks have been conducted by men who know us 
 perfectly well ; men who have been our colleagues and rivals 
 in the ooncours, in the faculty and in the hospitals, and who 
 have neither had courage enough to embrace the truth, nor 
 sufficient modesty to keep silence. 
 
 Pleurisy, followed by Phthisis. — (Continued from page 34.) 
 
 The concluding history of the case of consumption that 
 was preceded by pleurisy in a lying-in woman is as follows : 
 
 Case IY. — Under the influence of arsenicum, 12th clil., the 
 general condition of this patient improved. Since the 5th of 
 February she has taken phosphorus, 30th dil. 
 
 February 11. The cough has perceptibly diminished ; the 
 fever is still high; it returns about three o'clock. The tem- 
 perature reaches 103.10° and 104°; in the morning it is 101.30°. 
 The pulse is 88. Phosphorus, 6th dil. 
 
 February 16. The cough has increased each day since giv- 
 ing the phosphorus, 6th dil.; at the same time the morning 
 temperature has raised to 102.20°. We suspect a medicinal 
 aggravation, and suspend the remedy. 
 
 February 17. She coughs less often, but the temperature 
 remains the same. 
 
 February 18. The patient improves, coughs less, is stronger, 
 and she does not realize that she has the fever, which, as you 
 know, is one of the peculiarities of hectic fever. Return to the 
 phosphorus, 30th dil. , instead of the 6th. 
 
 February 23. Continued improvement ; she coughs but 
 little, eats and sleeps well, and, despite a meagre diet, her 
 strength returns ; the temperature has fallen^ three-fourths of a 
 degree. Phosphorus, 200th dil. 
 
 February 25. The temperature is again 102.20° in the 
 morning, and in the evening 104° ; the cough is not increased. 
 I prescribed sulphur, 30th dil. 
 
PLEURISY, FOLLOWED BY PHTHISIS. 81 
 
 February 27. Notwithstanding the hectic fever, the general 
 improvement continues. The temperature varies slightly ; in 
 the morning it is 102.20°, and in the evening 103.64° ; but the 
 patient coughs much oftener. I suspend the remedy. 
 
 February 28. The cough has diminished, and we return 
 to the sulphur. 
 
 March 2. The cough has increased and is spasmodic ; it 
 is caused by a tickling in the throat. Drosera, 3d dil., three 
 times a day. 
 
 March 7. She coughs less since taking the drosera. The 
 strength, the appetite, the general condition and the flesh return 
 and are improved ; the patient no longer thinks herself ill. 
 There is still, however, an abundant expectoration and loud mu- 
 cous rales in the apex of the right lung, but more especially in 
 that of the left one. The evening temperature varies from 
 102.20° to 104°. 
 
 This patient left on the 14th of March, believing herself 
 cured. I saw her two months later. She was still feeling 
 well, but I could not make a local examination. 
 
 I wish to call your especial attention to the aggravation of 
 the cough in this case by phosphorus, 6th dil., and also by 
 sulphur, in the 30th dil. 
 
 You see, gentlemen, that even in the gravest cases, con- 
 sumption can be arrested without resorting to quinine, to alco- 
 hol, to beef-juice, or to any of the so-called tonics that have 
 so multiplied for the relief of a theoretical debility. 
 
 We very much regret that the author did not have more to say concerning^ 
 the puerperal pleurisy, for, even in private practice, we are persuaded that it is 
 more common than is generally supposed. Hervieux, after speaking of the pro- 
 fessional indifference to this subject, says, in his Traite clinique et practique des 
 Maladies Puerperales suites de couches, page 901 : " This fact is all the more re- 
 markable because, after peritonitis and phlebitis, pleurisy is one of the most im- 
 portant of all the manifestations of the puerperal poisoning, — important from 
 its danger, not less than from its frequency in certain epidemics." 
 
 This case in Dr. Jousset's clinic is typical. It illustrates one of the princi- 
 pal dangers from pleurisy in lying-in women. The class of patients which is 
 most likely to have it are those who are predisposed to phthisis, and in whom 
 the development of tubercles has been at a stand-still during gestation. Wheth- 
 6 
 
82 THE MEDICAL CLINIC. 
 
 er the drain and strain of labor have so reduced the general strength as to sup- 
 ply the conditions that favor a relapse of the pulmonary trouble, or if the revul- 
 sion from the uterus in the early puerperal state is the cause of it, we cannot 
 say. It is certain, however, that pleurisy in this class of puerperal women is 
 very much more serious than when it occurs in the idiopathic form, outside of 
 the lying-in chamber. 
 
 In such patients, pleurisy always tends toward the development of acute 
 phthisis. The latter drifts rapidly into the typhoid state, and the patient is an 
 easy victim to a galloping consumption. We are firmly of the opinion that a 
 considerable share of the cases of death reported as from, puerperal fever, and 
 from typhoid fever also, during the lying-in, are, and' have been, cases of this 
 kind. 
 
 The true prophylaxis of pleurisy, pleuro-pneumonia and phthisis in child- 
 bed is to see to it that the patient, whether in the hospital or at home, has 
 a plentiful supply of fresh air; that she has good, healthy, nourishing food, and 
 enough of it; that she is not exposed to causes that would produce a chill; and 
 that, if there is the slightest symptom of either of these affections, she has Bry- 
 onia. This remedy is especially useful about the time that the flow of milk is 
 established, or when the patient is passing through the period that is vulgarly 
 known as " milk fever. 1 ' The rhus toxicodendron seems, in general, to be bet- 
 ter adapted to puerperal inflammation of the peritoneum than to that of the 
 pleura. — L. 
 
LECTUKE IX. 
 
 Summary. — Acute articular rheumatism; indications for chininum sulph., china, 
 aconite, mercurius and bryonia. Chronic rheumatic endocarditis : case. A 
 new example of medicinal aggravation ; indications for cactus and aconite. 
 Indications for aconite, Pulsatilla and ipecac, in rubeola, and for ipecac, and 
 bryonia in the grave bronchitis of measles. Hysteria and the bromide of 
 potassium. Asthma and its treatment by iodine. Chronic aortitis: case. 
 Indications for nux vomica, bryonia and the arseniate of antimony. 
 
 Acute Articular Rheumatism. 
 
 CxiSE XXI. — Marie Maissoneur, aged twenty-four years, a 
 domestic, entered the hospital on the 17th of March, and left 
 it on the 15th of April. 
 
 A month ago this patient first felt a pain in the knee, which 
 lasted only one day. She continued to work until the 13th of 
 March, when she was seized with quick, sharp pains in the 
 knee and in the hip joint. 
 
 March 17. She has pains in the wrists and elbows, but they 
 are less severe than in the leg ; there are no hereditary ante- 
 cedents ; she has been subject to headaches for two or three 
 years. The evening temp, is 102.20° and the pulse 120. 
 
 March 18. Morning temp. 99.68°, pulse 80. The pain is 
 principally in the articulations of the legs, but there is neither 
 redness, swelling nor perspiration ; the heart-sounds are per- 
 fectly normal, but she has headache and loss of appetite. 
 Evening temp. 101.48°, pulse 88. Chininum sulph., 3d trit. 
 
 March 19. Morning temp. 100.76°, pulse 84. The hands are 
 a little swollen ; the heart continues healthy. Evening temp. 
 102.20°, pulse 92. 
 
 March 20. Morning temp. 100.4°, pulse 72. She has had 
 a good night. Chininum sulph., 3d trit. Evening temp. 
 101.48°, pulse 100. 
 
 March 21. Morning temp. 100.40°, pulse 84. Some diar- 
 rhoea, and pains in the extremities between the joints. Chini- 
 num. sulph., 2d trit. Evening temp. 101.48°, pulse 100. 
 
84 THE MEDICAL CLINIC. 
 
 March 22. Morning temp. 100.40°, pulse 84. Continue the 
 same treatment. Evening temp. 100.76°, pulse 88. 
 
 March 23. Morning temp. 101.48°, pulse 72. The patient 
 sleeps well, and suffers much less. The same remedy. Even- 
 ing temp. 100.40°, pulse 72. 
 
 March 24. Morning temp. 100.40°, pulse 68. The evening 
 temperature was the same. The patient is doing very well, 
 and from this time continued to convalesce. 
 
 March 27. The patient is up. Although the slight articular 
 pains persist, the general condition is very satisfactory. Col- 
 ehicum, 3d dil. 
 
 March 31. She has abdominal pains from over-exercise; 
 the joints are somewhat painful ; she is unable to be up very 
 long. Rhus tox., 3d dil. 
 
 April 2. Since returning to her bed the patient is much bet- 
 ter. China, 12th dil., was given, and continued until she left, 
 cured. This was on the 15th of April. 
 
 Concerning this patient, I wish to call your attention to 
 the individuality of the case, which presents two clinical pe- 
 culiarities. The first of these is the slight swelling of the 
 joints, and the second, the absence of the habitually profuse 
 sweats. You know that the progress of acute articular rheu- 
 matism is uncertain, and is not cyclical, and that it may last 
 for six weeks as well as for one week. There is no thera- 
 peutic certainty by which to judge of the promptness of its 
 cure. 
 
 If we were always careful to report only those cases in which the course 
 and duration of the disease have been modified by our treatment, it is very prob- 
 able that we should not have very much to say of our success in curing rheuma- 
 tism in any of its forms. The most that we can do is to mitigate its severity, 
 and to abort its sequela?; for in this affection, as in the eruptive fevers, the com- 
 plications and the sequelae are largely, if not entirely, under the control of our 
 remedies; and, all things considered, they really constitute the most serious and 
 troublesome parts of this painful affection. — L. 
 
 I prescribed Chininum sulph. for this case on account of 
 the remittent type of the fever, as shown by the variations 
 in the temperature and the pulse between morning and night. 
 
ACUTE ARTICULAR RHEUMATISM. 85 
 
 You observe in this case that chininum suljph. succeeded 
 very well, and that our patient was convalescent on the sev- 
 enth day of the treatment, which was the ninth or the tenth 
 day of the disease. This convalescence, which in rheumatic 
 patients is so perilous, was passed by her with but very little 
 trouble. However, she walked a little too much in the ward, 
 and I was obliged to send her to bed again. China effected 
 the cure, and the patient left the hospital after a stay of less 
 than a month. I do not hesitate to claim that in the dura- 
 tion of the disease, as well as in the convalescence thereof, 
 this case may certainly be considered a success. 
 
 The chininum sulph. is the remedy that I habitually pre- 
 scribe for acute articular rheumatism, and it corresponds as 
 china does to articular jpains with swelling and redness, and 
 above all, to an intermittent or remittent type of the accom- 
 panying fever. 
 
 When this fever is very intense and continuous, the pulse 
 full and strong, the face red, the thirst very great, and the 
 patient anxious, aconite is the principal remedy. 
 
 Mercurius is best indicated by profuse sweats, paleness of 
 the face, and the aggravation of the pain during the night. 
 
 Bryonia is frequently employed by homoeopaths in the 
 treatment of acute articular rheumatism, with inflammation 
 of the larger or of the smaller joints, with a pale or red 
 swelling, moderate fever, and aggravation of the pain by the 
 least movement. 
 
 China affects the same parts as the chininum sulphuricum. 
 You have seen me prescribe it for this patient when the fever 
 had completely disappeared. This is the time for its adminis- 
 tration in acute articular rheumatism. You will often see me 
 prescribe it for the arthritic gout. 
 
86 THE MEDICAL CLINIC. 
 
 Chronic Rheumatic Endocarditis. 
 
 Case XXII. — Louise Pommier, thirty-eight years of age, 
 entered the hospital on the 9th of May, and left it on the 
 18th of the same month. 
 
 This girl, who has a wretched constitution, came to us com- 
 plaining of palpitation and suffocation. She has never had 
 good health, and, during her infancy, had symptoms of 
 scrofula. 
 
 From the time that her menses were established, she has 
 had leucorrhcea in the intervals between the periods, and 
 symptoms of chlorosis, id est, headache, dizziness and palpi- 
 tation. 
 
 Ten years ago she had an attack of general rheumatism. 
 After that attack, and since that time, she has had very decided 
 palpitation of the heart. Paroxysms of suffocation and of 
 choking have made it impossible for her to do any hard work. 
 She has never had a cough, and the physical examination of 
 the lungs gave a negative result. 
 
 Her present condition is as follows: She has palpitation on 
 the least motion, and a very sharp pain at the apex of the 
 heart. There is roughness with the first sound of the heart ; a 
 very decided purring tremor at its apex, and the organ is de- 
 cidedly hypertrophied. 
 
 On questioning the patient, we learned that the palpitation 
 and the pains which she had had about the heart before the 
 attack of rheumatism, and which were due to the chlorosis, had 
 been considerably increased by the rheumatism. 
 
 The diagnosis is very easy. There is insufficiency of the 
 mitral valve, which is a sequel to the rheumatic endocarditis, 
 and a compensating hypertrophy. 
 
 May 9. Cactus grand., 1st dil., ten drops in 200 grammes 
 of water ; one spoonful every three hours, with an ordinary diet. 
 
 May 11. The patient complains of insomnia, and of sharper 
 pains in the heart. No prescription. 
 
 May 12. She is improving. We resume the cactus, 1st dil., 
 but four drops only, instead of ten. 
 
 May 13. The aggravation is the same as with the ten drops. 
 We suspend all medicine for forty-eight hours. Improvement 
 
CHRONIC RHEUMATIC ENDOCARDITIS. 87 
 
 followed, with a better night, and a diminution of the pains, 
 the palpitation, and of the suffocation. 
 
 May 16. Resume the cactus, 1st dil., four drops. 
 
 May 18. There is no perceptible aggravation, but, on the 
 whole, the condition of the patient is about the same that it 
 was a week ago. We prescribed aconite, 1st dil., and after- 
 ward the 30th dil. This last potency calmed the pains and the 
 palpitation ; the purring tremor disappeared ; the souffle per- 
 sists, but is less obvious, and the patient left the hospital much 
 improved. 
 
 The absence of all the signs of the cardiac cachexia, not- 
 withstanding the gravity and duration of this lesion, makes this 
 case a very interesting one. This woman is really thin and 
 anaemic, but she was so before she had the rheumatism, and 
 owes the relative immunity from which she has already profited 
 to the compensating hypertrophy of the heart. This hyper- 
 trophy has made the arterial pressure equal to the venous 
 pressure. But the day on which this equilibrium is lost, the 
 cachexia will make its onset. 
 
 You will readily understand that the treatment of this case 
 is very difficult. A valvular lesion of ten years' duration does 
 not offer a chance for a very brilliant success in therapeutics. 
 All that can be done is to try and relieve the general condition 
 of the patient, to wrestle with the valvular lesion, and so to 
 delay the development of the cachectic stage. As for curing 
 the organic trouble, we need not think of it. 
 
 I prescribed the cactus grandijlora, which is strongly indi- 
 cated in affections of the heart of a rheumatic nature ; and 
 here we have another case of medicinal aggravation from the 
 effect of this same remedy. From the first day that she took 
 it, the patient suffered from palpitation and insomnia. We 
 suspended the remedy, and she improved. In two days more 
 we prescribed it again, and with the same result. I thought it 
 best, however, to persist with the cactus, and have, therefore, 
 
88 THE MEDICAL CLINIC. 
 
 given it until within the last few days, when it was replaced 
 by aconite, which is a powerful regulator in cardiac affections. 
 As a matter of fact, I have experimented upon rabbits with the 
 aconite, and have found that by the injection of the lower po- 
 tencies, I almost always caused lesions of the mitral valve. 
 
 The Remedies in Rubeola. 
 
 Regarding the treatment of the young man who has the 
 measles in the common form, and who to-day enters upon the 
 convalescent period of that cyclical disorder, without having 
 presented any other symptoms than a few attacks of bleeding 
 at the nose and a slight diarrhoea, I wish to say a few words 
 concerning the treatment. In such cases it is my habit to pre- 
 scribe aconite^ and to continue its use as long as there are no 
 complications. Fever, thirst and redness of the skin are its 
 principal indications, and I usually prescribe it in doses of a 
 few drops of the 3d dil. put into 200 grammes of water, one 
 spoonful to be taken every three hours. 
 
 Pulsatilla would be preferable in cases where there is otal- 
 gia and no thirst. When the epistaxis is very profuse and 
 recurrent, the tampon may be necessary, but I believe that you 
 can almost always stop the bleeding with ipecac. Finally, 
 gentlemen, you are aware of the serious nature of capillary 
 bronchitis, that is incident to this disease, which is called ru- 
 beolous pneumonia, and which Trousseau considered as fre- 
 . quently fatal ; but, since I began to use homoeopathic remedies, 
 and that is a long time ago, I have yet to meet with a failure 
 in these cases. Our treatment is really heroic. It consists in 
 the employment of two remedies, viz., ipecac, and oryonia al- 
 ternately every two hours. I always give them in the 12th 
 dil. I will not say that this method is infallible, but I do in- 
 sist that it is remarkably successful. 
 
 Remembering' that cuprum aceticum is one of the very best remedies for 
 symptoms growing out of a repercussion of the eruption in measles, we have 
 
THE BROMIDE OF POTASSIUM IN HYSTERIA. 89 
 
 been in the habit for some years of prescribing it, in bad cases, as a prophylactic 
 of this very condition. We begin with it on the second day of the eruptive 
 stage, and repeat it about three times daily in alternation with whatever rem- 
 edy is indicated for the incidental symptoms. Our preference is for the 6th 
 dil. — L. 
 
 The Bromide of Potassium in Hysteria. 
 
 The two hysterical patients in JSTos. 3 and 8 of the women's 
 ward will leave the hospital in a few days. I have given them 
 of late the bromide of potassium, which presents, in its patho- 
 genetic effects, the absence of reflex nausea, when the finger is 
 introduced into the pharynx, a symptom that most hysterical 
 patients are certain to have. In one of these women (No. 8) 
 the use of the bromide in the 3d trit. stopped, at least for the 
 time being, the reflex nausea, which fact affords another illus- 
 tration of the law of similars. 
 
 Asthma. 
 
 Our asthmatic patients are less numerous than formerly. 
 The woman in No. 6, who had transitory emphysema, has been 
 cured by arsenicwm. The man in No. 1 of the men's ward, 
 who was also ill with a transitory emphysema, and whose sputa 
 were frothy and like the beaten white of an egg, indicating arseni- 
 eum, has also been cured, as you know, by that remedy. In 
 order to hasten his cure I gave him jodium, but without any 
 marked result, and we therefore resumed the arsenicum. My 
 reason for prescribing the jodium in this case was because 
 Trousseau had observed that patients to whom he had given it 
 had a prolonged and sibilant respiration which he attributed 
 to iodism ; and I thought that if it caused these symptoms, it 
 should also cure them. Since, however, having read Rilliet 
 over again, I can find no notice of such a result. The remark 
 of Trousseau should, for the present at least, be accepted with 
 some reservation. We must wait until further research. has 
 settled the question. 
 
 It is only just to say, in this connection, that an American 
 
90 THE MEDICAL CLINIC. 
 
 quack and a French pharmaceutist, M. Aubre, have warmly 
 praised the value of the iodide of potassium in large doses in 
 the treatment of asthma. This remedy has been unsuccessful, 
 so far as I have seen and read of it, as all medicines must be 
 for the employment of which we have no positive indications. 
 
 Gout — Chronic Aortitis — Emphysema — Hemorrhoids. 
 
 Our next patient will need to remain for a longer time in 
 the hospital. 
 
 Case XXIII. — Mrs. Kenaudin, aged seventy years, en- 
 tered on the 9th of March and left on the 4th of April. 
 
 This woman has had good health. She has borne eight 
 children, and her confinements have never been followed by 
 any of the puerperal diseases. 
 
 About seven years ago she commenced to have pains in 
 the right side of the base of the chest, and breathing became 
 less easy and free than natural. For three or four years past 
 she has had hemorrhoids, and the loss of blood, which was 
 sometimes very profuse, brought relief. 
 
 In 1872 she had an attack of acute bronchitis which kept 
 her in bed for Hve months. At that time the dyspnoea, of 
 which she had already complained, became more intense ; the 
 fits of suffocation, that were much more frequent in winter than 
 in summer, came very often, but did not last long ; she had 
 some palpitation ; she is habitually constipated, and the bowels 
 are never moved except by enemata. 
 
 Present condition: The patient has suffered for the last 
 eight days from a pain in the right side of the chest. Since 
 this began she has coughed and raised a great deal. On exam- 
 ination of the chest we find the signs of a transitory emphyse- 
 ma, — exaggerated sonorousness and prolonged expiration, ac- 
 companied on both sides by moist rales. 
 
 There are no abnormal cardiac sounds, but there is a very 
 marked arching of the chest in front of the sternum {voussure 
 presternal). There is a dullness that extends from the right of 
 the sternum on a level with the aorta, and which measures 
 nearly six centimetres. With the second aortic sound, there is 
 
GOUT CHRONIC AORTITIS EMPHYSEMA, ETC. 91 
 
 a little murmur ; the radial arteries are ossified, and therefore 
 it is not difficult to diagnosticate aortitis with ossification and 
 dilatation of the aorta. The nights are restless. The sphygmo- 
 graphic tracing corresponds with the physical signs ; the ascend- 
 ing line is vertical, the horizontal one is very pronounced, and 
 the descending trace is a little oblique, with slight dicrotism. 
 
 Tkace No. 6. 
 
 This woman complains most of the hemorrhoids, which 
 bleed and are very painful, and of a terrible constipation. 
 Nux vomica, 12th dil., six drops in 200 grammes of water ; one 
 spoonful to be given her every three hours. 
 
 March 12. The patient complains a great deal. Arseni- 
 cum, 12th dil., in the same manner, and an injection of cold 
 water. 
 
 March 14. The nights are better ; the oppression is dimin- 
 ished, but the hemorrhoidal pains continue. Nux vomica, 30th 
 dil., four globules in 125 grammes of water; three spoonfuls dur- 
 ing the day. 
 
 March 18. The hemorrhoidal suffering has lessened within 
 twenty-four hours, and to-day the pains are almost entirely 
 gone. Ipecac, 3d trit., was prescribed for the catarrhal expec- 
 toration. 
 
 March 21 . The habitual pain in the right shoulder is more 
 intense ; the expectoration is less free. Bryonia, 3d dil. 
 
 March 23. This morning there are signs of gouty arthritis 
 in the fingers of the right hand, and in the right shoulder. 
 China, 12th dil., six globules in twelve spoonfuls of water; 
 three doses a day. 
 
 March 26. The pain has greatly lessened. We prescribe 
 the arseniate of antimony, 2d trit. , twenty centigrammes in 200 
 grammes of water ; one spoonful every three hours. 
 
 March 31. Great improvement ; the patient scarcely coughs 
 at all ; the nights are good, and she breathes well, but the pain 
 in the right side persists. Bryonia, 3d dil. 
 
92 THE MEDICAL CLINIC. 
 
 The improvement continued, and the patient left the hos- 
 pital on the 4th of April, in a fair condition of health. 
 
 In this case, the existence of the hemorrhoidal tumors com- 
 plicating the emphysema, led me to prescribe nux vomica. 
 The 12th dil., which I first prescribed, had but little effect, and 
 as she complained of violent pains in the anus, I ordered the 
 same remedy in the 30th dil., which was followed by a prompt 
 and decided improvement. She does not suffer any more from 
 the hemorrhoids; but, unfortunately, the fits of suffocation con- 
 tinue to recur, and she has symptoms of chronic aortitis, a 
 disease which, up to this time, has not been very carefully 
 studied, and the characteristic signs of which are those of dis- 
 ease of the heart, with an absence of the physical signs of 
 a lesion of its orifices. Our patient shows an increase of the 
 transverse dullness over the aorta, which now measures between 
 six and seven centimetres, instead of three and a half. 
 
 The radial arteries show evident signs of ossification ; the 
 nights are restless, and the oppression is very marked ; and the 
 sphygmographic tracing shows the characteristic horizontal 
 line of aortitis. In such cases vou will frequentlv observe the 
 breathlessness, the cough and the dysphagia, as well as the 
 albuminuria and the oedema, that are so common in cardiac 
 affections. 
 
 We shall return to the subject of chronic aortitis in a subse- 
 quent lecture. 
 
 See the last part of Lecture XI, for a remarkably interesting and practical 
 discussion of the subject of chronic aortitis, illustrated with several cases. — L. 
 
LECTUKE X. 
 
 Summary. — Simple ulcer of the stomach, case; indications for nux vomica, 
 arsenicum and argentum nitricum. Pneumonia of the apex of the lung, 
 case; bryonia, phosphorus and tartar emetic; treatment of pneumonia. 
 History of the introduction of homoeopathy into the Paris hospitals; Tessier 
 and his enemies; the report and the favorable statistics of M. Davaine. The 
 Expectant and the homoeopathic treatment of pneumonia. Sciatica, case ; 
 indications for bryonia, rhus toxicodendron, colocynthis, arsenicum, bella- 
 donna and chamomilla, mix vomica, sulphur and veratrum. The common 
 form of phthisis, case; indications for bryonia and drosera. On the choice 
 of the attenuation. 
 
 Simple Ulcer of the Stomach.. 
 
 Gentlemen : The following is the history of a patient who 
 for many years has been subject to attacks of vomiting : 
 
 Case XXI Y. — M. Martin, a mason, aged thirty-seven years, 
 entered our ward on the 25th of March. 
 
 This man, who, during his infancy, was subject to epistaxis, 
 was taken ill about three years ago. After two months of dys- 
 pepsia he began to reject his food. Sometimes vomiting would 
 occur immediately after eating, and again not for five or six 
 hours after his meals, but it was always preceded by a violent 
 colic. He usually vomited every second day, but occasionally 
 he would have an interval of a fortnight, during which he 
 would have no attack. He tried the milk diet at the Hospital 
 la Pitie for two months, but without effect. 
 
 On pressure, the patient complains of pain below the 
 xiphhoid cartilage ; but examination with the hand does not 
 disclose any tumor in the epigastric region. There is no pain 
 in the corresponding portion of the vertebral column. 
 
 March 26. Nux vomica, 30th dil., four globules in 125 
 grammes of water, three spoonfuls during the day. 
 
 March 27. There was vomiting last night. The same 
 treatment. 
 
94 THE MEDICAL CLINIC. 
 
 March 28. No vomiting. The same treatment. 
 
 March 29. Vomiting. Nux vomica, 3d clil. 
 
 March 30. Vomiting last night, Arsenicum, met.. 6th dil. 
 
 March 31. Vomiting. Arsenicum, met., 12th dil. 
 
 April 1. The patient is not so weak, and has not vomited. 
 Arsenicum, met., 3d trit. , and an almost exclusive animal diet. 
 
 April 2. ~No vomiting. The same treatment. 
 
 April 3. Slight vomiting. Arsenicum, met., 2d trit. 
 
 April 4. No vomiting. The same treatment. 
 
 April 5. Excessive vomiting. Arsenicum, met., 1st trit. 
 
 April 6. Slight vomiting. The same treatment. 
 
 April 7. No vomiting. 
 
 April 8. No vomiting. 
 
 April 9. Last evening the patient vomited a little several 
 times. His general condition is, however, much improved 
 since he entered the hospital, and he has now passed fifty-six 
 hours without vomiting. 
 
 April 11. He vomited again last night, The same treat- 
 ment, 
 
 April 12. Argentum Nitricum, 3d trit. 
 
 April 13. No vomiting. The same treatment. 
 
 April 14. No vomiting. 
 
 I wish to call your attention to the fact that this patient 
 is of a hemorrhoidal constitution. He has had the epistaxis, 
 which is common in persons who have this peculiar clyscra- 
 sia. Moreover, he has not lost his appetite, which is a neg- 
 ative symptom that is of very great importance in an or- 
 ganic affection of the stomach. On direct examination, we 
 find neither the dilatation with sonorousness that is present 
 in pyloric affections, nor the circumscribed dullness that ex- 
 ists where there is a gastric tumor, nor does palpation dis- 
 cover any such tumor. 
 
 It is very doubtful if, in the whole range of our medical literature, there is 
 a more expressive paragraph than this, or one that carries more of meaning in 
 regard to the differential diagnosis of the class of cases to which it refers. The 
 hints contained therein are of the utmost importance wherever they can be 
 used ; but they are especially significant in the recognition and treatment of 
 
PNEUMONIA AT THE APEX OF THE LUNG. 95 
 
 reflex disorders of the stomach in women. We have treated several cases of 
 so-called ulceration of the stomach, in which, for the lack of this kind of teach- 
 ing", the most egregious blunders had been made in diagnosis. One of them 
 was declared to be a perforating ulcer of the stomach, and the patient had been 
 given up to die. In each and all of them, however, there was a mild form of 
 metritis, with prolapsus uteri, which soon yielded to appropriate treatment. — L. 
 
 The disease has lasted three years without being followed 
 by a cachexia. In brief, therefore, I believe we may give our 
 diagnosis of this case as one of simple ulcer of the stomach. 
 
 Of this simple ulcer, you know, there are two forms, one 
 of which is hemorrhagic, while in the other the loss of blood 
 is more rare. The fatal termination may come quickly in 
 either of them. Indeed, the ulceration of a vessel in the coats 
 of the stomach will sometimes, be followed by a mortal hem- 
 atemesis, and at other times it will produce a perforation that 
 is followed by peritonitis. This latter mode of termination 
 occurs twelve times in one hundred on the average. 
 
 I began the treatment with nux vomica^ it being indi- 
 cated by the vomiting of food and of acid matters, by the 
 pains, and by its adaptation to the constipation, and also to 
 the hemorrhoidal diathesis. I prescribed it in the 30th dil., 
 because I have often observed the aggravation produced 
 by this remedy in gastric affections. This attenuation not 
 producing any result, I descended the posological ladder, 
 and then I tried arsenicum, and finally the argentum nitri- 
 cum, which have caused a slight amelioration of the symp- 
 toms. 
 
 Pneumonia at the Apex of the Lung. 
 
 I have a few words to say to you of the patient who 
 died the day before yesterday of pneumonia. 
 
 Case XX Y. — Mrs. Goris, aged fifty years, entered the 
 women's ward on the 20th of March, and died on the 24th of 
 March. 
 
 This woman has suffered greatly of late. She was badly 
 
96 THE MEDICAL CLINIC. 
 
 nourished, and being obliged to work to earn her living, she 
 has, she tells ns, been losing her strength for some months 
 past. 
 
 She still menstruates, and her periods are regular. 
 
 In the intervals between them she has suffered from leu- 
 corrhoea for the last fifteen months. 
 
 March 11. Without premonitory symptoms, and without 
 any known cause, the disease set in with a violent chill, which 
 was followed by a continuous fever. Afterward she had a 
 headache, a pain in the right side under the nipple, and some 
 cough. These were the first symptoms of the attack. The 
 disease was not understood, and she was treated with aco- 
 nite up to the day of her admission to the hospital. She came 
 to us in a very dangerous condition. Her symptoms at that 
 time were oppression, a frequent cough, the tongue was dry 
 and covered with a thick coating, and there were patches of 
 muguet on the cheek and upon the veil of the palate. The 
 expectoration is viscous, transparent and greenish. There is 
 a souffle and bronchophony in the fossae above and below the 
 clavicle. 
 
 The face has a most anxious expression ; her strength 
 is very much exhausted ; the pulse, which is 116, is soft and 
 small, and the temperature is 104°. 
 
 March 21, the eighth day of the disease and the first day 
 of the treatment. She had a wretched night. There is excess- 
 ive dyspnoea, noisy respiration; the tongue is dry, with great 
 thirst, and scanty expectoration of a yellowish and adhesive 
 mucus. The pulse is 104, and the temp. 103.28°. Bryonia, 
 12th clil., six globules in 200 grammes of water, one spoonful 
 to be taken every two hours. 
 
 Evening. There is oppression and delirium, with arrest of 
 the expectoration. The pulse is 120, and the temp. 103.64°. 
 Phosphorus, 12th clil., six globules in twelve spoonfuls of 
 water ; one spoonful every two hours. 
 
 March 22, being the ninth day of the disease and the second 
 day of the treatment. After taking the phosphorus the patient 
 began to expectorate ; otherwise the night has been very bad, 
 with great unrest, considerable dyspnoea, a general perspira- 
 tion, and the tongue is a little less dry. The two last symp- 
 
PNEUMONIA AT THE APEX OF THE LUNG. 97 
 
 toms* which are comparatively good, lose their value in the 
 presence of the others ; the urine is pale ; the pectoral lesion 
 extends from the apex of the lung downward. The pulse is 
 108, the temp. 101.84°, or nearly two degrees lower than it was 
 at the same hour yesterday. Phosphorus, 12th dil., was con- 
 tinued. The patient is to be nourished with milk and with 
 broth. At evening the pulse was 124, the temp. 102.92°. By 
 mistake, ipecac, 1st dil., was given to the patient instead of 
 continuing the phosphorus. 
 
 March 23, or the tenth day of the disease and the third 
 day of the treatment. The fever is still diminishing ; the 
 pulse is 108, and the temp. 100.40°, or more than a degree 
 less than it was yesterday at the same hour ; but the patient 
 has been delirious during the night, and the dyspncea is as 
 bad as ever. The expectoration has almost ceased. Tartar 
 emetic, 3d trit., twenty centigrammes in 200 grammes of water, 
 one spoonful every two hours. 
 
 Evening. The fever, which is higher than this morning, is 
 less intense than it was last evening ; it follows a descending 
 scale. The pulse is 104; the temp. 102.20°. The general 
 condition is very serious ; the tongue is dry ; the lips are black ; 
 the pulse is very feeble ; the urine is pale, and the ulceration 
 of the mouth is more extensive. Resume the phosphorus, 12th 
 dil. 
 
 March 24. The eleventh dav of her illness, and the fourth 
 day of the treatment. The fever is not so high as it was last 
 evening, but it is higher than it was yesterday morning. She 
 passed a terrible night, with excessive dyspnoea, a feeble pulse, 
 and a progressive debility and prostration. The evening pulse 
 was 108, the temp. 99.5°, with collapse, anxiety, agitation, a 
 very dry tongue, and a complete arrest of the expectoration. 
 Tartar emetic, 1st trit., and wine. She died during the night. 
 
 You observe, gentlemen, the singular thermometrical vari- 
 ations in this case. You have seen, from the detailed account, 
 that the temperature diminished regularly, which would have 
 been a favorable sign if, at the same time, the dyspnoea and 
 the prostration had not constantly increased. More than this, 
 although it seems almost incredible, we know that the diag- 
 
98 THE MEDICAL CLINIC. 
 
 nosis of pneumonia was not made by the physician who saw 
 this patient seven days before she came into the hospital. 
 In general, I do not find fault with those errors of diagnosis 
 which the difficulty of the case will explain ; but there are 
 certain things and certain signs which to ignore is unpardon- 
 able. A disease that makes its onset with a chill, with fever, 
 with pain in the side, and a cough, suggests pneumonia at 
 once, and should be treated as such while waiting for the 
 stethoscopic signs to corroborate the diagnosis. Notwith- 
 standing it has been said that pneumonia presents no steth- 
 oscopic signs in old people, I believe that by a proper and 
 careful examination they are to be found. It was so in the 
 case of this poor woman, for on auscultation of the right cla- 
 vicular fossae we heard a decided though feeble bronchial souffle. 
 But we must not forget that the apex of the lungs expands 
 much less than the inferior lobes, which, of course, makes 
 these sounds weaker than elsewhere. 
 
 In this case my prognosis was from the first very grave. 
 There were two unfavorable signs : firstly, the decline of the 
 temperature whilst there was an aggravation of the general 
 symptoms, — a state of things which revealed the ataxic char- 
 acter of the disease ; and secondly, the color of the urine, 
 which was pale and without deposit, while in pneumonia it 
 should be red, and sometimes even the color of blood. There 
 was also great oppression and prostration ; the tongue was 
 dry ; and finally the respiration at times was rattling, which 
 is a very bad symptom, and which indicates great weakness 
 •of the bronchial muscles. 
 
 A propos of this case, I have something to say of the ther- 
 apeutics of pneumonia. Tessier formulated a treatment for 
 this disease which to-day is classical. It consists in the ad- 
 ministration of hryonia during the day, and of phosphorus 
 during the night. By the aid of these two remedies the mor- 
 tality in his hospital service was only three in forty-two cases, 
 
PNEUMONIA AT THE APEX OF THE LUNO. 99 
 
 and these three deaths included those of two patients who 
 entered the hospital in a dying condition. 
 
 The symptoms that afford the best indications for bryonia 
 are the pain and the stitch in the side. Phosphorus corresponds 
 more accurately to the dark brown coating of the tongue, to 
 its dry condition, and also to the typhoid state or appear- 
 ance of the patient. 
 
 While we are on this subject, I think it will be profitable 
 to give you the History of Homoeopathy in Paris. In 1848, 
 Tessier, who was then a physician of the Sainte Marguerite 
 Hospital, which is now the Sainte Eugenie, agreed with 
 two other physicians of the same hospital, Drs. Yalleix and 
 Marrotte, to test the homoeopathic treatment in pneumonia. 
 When it was discovered that the patients were cured in great 
 numbers by this treatment, those who at first had recom- 
 mended and tried the experiment, rejected it ; and not con- 
 tent with flying from the light themselves, denounced Tessier 
 to the Director of ;t Public Assistance " for having introduced 
 charlatanism into the hospitals. M. Davaine, who was at 
 that time Director, responded to this denunciation by an ex- 
 amination of the subject, which lasted for three years, and 
 which considered the case of every patient in the three ser- 
 vices, or divisions of that hospital. At the end of the three 
 years the superiority of the homoeopathic treatment was shown 
 not only in curing, but in shortening the duration of the 
 disease, in a manner so conclusive, that the Director of "Pub- 
 lic Assistance" could not but encourage the experiments of 
 Tessier, the results of which were so full of promise, as he 
 loyally said, not only to the sick, but also to science. 
 
 I will read you the exact statistics afforded by this exam- 
 ination, and certified to by M. Davaine himself a short time 
 before his death. 
 
 During the years 1849, 1850 and 1851, there were treated 
 
100 THE MEDICAL CLINIC. 
 
 by allopathy (Drs. Marrotte and Valleix), 3,724 cases, of which 
 411 were fatal, which shows a mortality of 11.3 per cent. 
 
 During the same period there were treated by homoeopathy 
 (Tessier), 4,663 cases, of which 339 were fatal, making a mor- 
 tality of 8.55 per cent, showing a difference of 3 per cent in 
 favor of homoeopathy. 
 
 Besides, as the number of beds was practically the same 
 in the two services (100 beds under Tessier, and 99 under 
 Marrotte and Valleix), and as there were three hundred more 
 cases treated in the homoeopathic service than in the allopathic, 
 the duration of the disease must have been shorter in the former 
 than it was in the latter. 
 
 You understand, gentlemen, that such a result was scan- 
 dalous, and that some sort of answer must be made to the 
 facts offered, and to the cures that were obtained by bryonia 
 and phosphorus ! Valleix was the first to attempt this. He 
 said that the diagnosis of the cases published by Tessier was 
 erroneous, and that he had been treating capillary bronchitis 
 for pneumonia. This was not only silly but stupid. It was 
 silly, because no one doubted the truth of Tessier' s diagnosis, 
 or of his experience ; and stupid, because capillary bronchitis 
 is a more serious disease than pneumonia. This argument, 
 therefore, returned upon its author, and the first reply to 
 Tessier' s statements was not echoed very loudly. 
 
 At about the same time the hospitals of Vienna furnished 
 even more serious evidence of the truth of homoeopathy. 
 It was there, indeed, that the expectant method was openly 
 practiced, and that Dietl extolled its use in pneumonia. 
 
 In the first year the results were certainly not unfavorable, 
 for the mortality was only 7.4 per cent. In the second year 
 it increased to 9.2 per cent, and the third year to 21.2 per 
 cent. Borde, in 1855, had a mortality of 22 per cent; Schmidt, 
 of 23 per cent ; and, finally, Brandes, at Copenhagen, one of 
 31 per cent. Adding these figures together we find there was 
 an average mortality from this method of 18.8 per cent. 
 
SCIATICA. 101 
 
 In Paris, Tessier's statistics showed a mortality of not quite 
 6 per cent ; while the Leopolstadt Homoeopathic Hospital had 
 a loss of only 5 per cent. 
 
 More than this, gentlemen, outside of statistics you may 
 rest assured that the progress of the disease is not the same 
 when treated by the expectant method as when treated by 
 homoeopathy. In the former the disease, after running its 
 course, terminates abruptly with defervescence, while, on the 
 contrary, this symptom is very rare in the latter, where the 
 improvement is gradual and constant, and the symptoms grow 
 lighter day by day. 
 
 Moreover, there is this difference also, that when the dis- 
 ease has been left to itself, although from the ninth to the 
 eleventh day, the fever has stopped, the physical signs may 
 persist until the twenty-fifth or even the thirtieth day ; where- 
 as, under the homoeopathic system, the stethoscopic signs will 
 disappear after eight days of treatment. 
 
 Sciatica. 
 
 After this digression we return to our patients, and I will 
 speak to you directly of the man who is suffering from sciatica, 
 and whom you may have seen lying upon his sound side. 
 
 Case XXVI. — M. Large, forty years of age, entered on 
 the 18th of March. He is not hemorrhoidal, and has had 
 neither herpes nor syphilis. He was never ill until about the 
 10th of March. 
 
 On the 16th of March the pain became so violent that he 
 was obliged to stop work. He had a burning pain in the thigh, 
 which extended to the leg, following the course of the sciatic 
 nerve. Pressure between the great trochanter and the sciatic 
 eminence is extremely painful. The pain is continuous, and is 
 aggravated by movement, but it is not more severe at night 
 than during the day ; it loses itself in the leg, where it causes 
 a sensation of cold in the calf of the leg especially ; there 
 is also insomnia, loss of appetite, and constipation. 
 
102 THE MEDICAL CLINIC. 
 
 March 18. Rhus tox., 3d clil., three drops in 200 grammes 
 of water ; one spoonful to be taken every three hours. 
 
 March 19. The patient begins to improve. The same treat- 
 ment. 
 
 March 20. The improvement continues. The same treat- 
 ment. 
 
 March 21. He complains of severe constipation. To have 
 an enema, with the same treatment. 
 
 March 22. He had a copious stool, and has been able to 
 sleep a little. The same treatment. 
 
 March 23. Continued improvement. 
 
 March 24. The patient is able to lie for a short time on 
 the affected side. The same treatment. 
 
 March 25. The improvement continues. Rhus tox., 3d 
 dil. 
 
 March 27. The patient gets up and walks easily. His 
 nights are very good. 
 
 March 30. In consequence of a slight imprudence, the 
 pains have returned. Sulphur, 30th dil., four globules in 125 
 grammes of water ; three spoonfuls a day. 
 
 April 3. The pains do not lessen. Rhus tox., 3d dil. 
 
 April 6. The thigh only is painful. Rhus tox., 1st dil. 
 
 This remedy was continued until the 15th of April, at 
 which time the patient scarcely suffers at all, and is able to 
 walk. 
 
 Now, the pain has left its first location, which was in the 
 thigh and the hip, and has gone to the lower part of the leg, 
 where there is still a sensation of cold. From the beginning 
 of the treatment the case has constantly improved. 
 
 The remedies usually given for sciatica are, Rhus tox., bry- 
 onia, chamomilla, belladonna, colocynth, sulphur, plumbum, 
 veratrum. and nux vomica. 
 
 Bryonia and rhus tox. have several indications in common, 
 but the first is especially useful if the pain is increased by mo- 
 tion, and lessened when the patient lies upon the affected side. 
 The second, on the contrary, is indicated where the pain is 
 increased by repose, or by lying upon the diseased side. It is 
 
SCIATICA. 103 
 
 also useful when there is a sensation of tingling, or of cold in 
 the affected part. We prescribed the rhus tox. for our patient, 
 because of the sensation of numbness and cold, and also be- 
 cause of the increase of pain when he would lie upon the 
 affected side. I once cured a patient who had suffered from 
 sciatica with atrophy of the limb, for eighteen months, with 
 bryonia, 2d dil. 
 
 At the end of one week the improvement was very obvious, 
 and the patient was well in a few weeks. In six weeks I 
 also cured a case of chronic sciatica, which dated from a 
 year, by plumbum. In this case the patient was a gentleman 
 who had been treated by many old-school physicians, each of 
 whom had failed to relieve him. Among these physicians 
 was Beau, the anatomical draughtsman, and author, with Bon- 
 amv and Broca, of an atlas which has become classical. 
 
 The symptoms that correspond to arsenicum are great pain, 
 which increases at night, and a sensation of burning. Colo- 
 cynth is called for when the pain is constrictive in character, 
 and when there is a sensation as of an iron band around the 
 hip ; but I have not found it a reliable remedy. 
 
 Colocynth is not by any means a specific for sciatica, but, in exceptional 
 cases, more especially where the pains are of a shooting and cutting kind, that 
 run like lightning from the hip to the knee, or even to the heel; and where they 
 come on, or are worse at night, and from motion; where they affect the right 
 side more than the left; and when they occur in one who is subject to neuralgia 
 elsewhere, it is very useful. Only recently I gave one dose of colocynth, 2d dil. r 
 to a very dear friend, whose attack of sciatica was sudden and very severe, and 
 who, in former years, had suffered prodigiously from it. The relief was com- 
 plete, and almost instantaneous. — L. 
 
 When there is a very sharp pain, with restlessness and con- 
 tinual complaint, you will do well to give ehamomilla and bel- 
 ladonna alternately. The distinctive characteristic which calls 
 for the latter is a sharp pain on the slightest touch. Sulphur 
 is successful in cases of chronic sciatica — particularly when 
 the patient is hemorrhoidal. One of the symptoms indicating 
 
104 THE MEDICAL CLINIC. 
 
 this remedy is the increase of the pain at night from the 
 warmth of the bed. Nux vomica is also strongly indicated in 
 cases where the patient is hemorrhoidal. 
 
 My friend, Dr. Cretin, uses the veratmcm very often. He 
 giyes it in the tincture, and with excellent results. The symp- 
 toms which, according to the Materia Medica, indicate the 
 veratrum, are extremely violent pain, with nervous irritability ; 
 pains like electric flashes, and tingling pains, occurring princi- 
 pally at night, or about three or four o'clock in the morning. 
 
 In one very protracted case, where the suffering was confined to the left leg, 
 and the pain had resisted many remedies, I found the ledum palustre, 3d dil., of 
 great service. The pain descended from the hip along the posterior surface of 
 the thigh; was aggravated by the touch, and by the warmth of the bed; there 
 was swelling of the leg and foot; the leg felt cooler than its fellow, and the sole 
 of the foot was very sensitive. 
 
 A very interesting collection of cures of sciatica by various remedies, includ- 
 ing arnica, bryonia, cocculus, ignatia, mercurius, rhus tox., sepia, stapkysagria, 
 sulphur, etc., may be found in Hoyne's Clinical Therapeutics. — L. 
 
 The Common Form of Phthisis. 
 
 In conclusion, I wish to speak to you of the unfortunate 
 consumptive in Ko. 2 of the men's ward. He has the symp- 
 tom so common in tuberculous cases, of a tickling in the 
 throat which provokes vomiting. This symtom I have arrested 
 in nintv-seven out of one hundred cases, bv drosera.* In the 
 present case I prescribed it in the third, and afterward in the 
 twelfth, dilution, but without succeeding in checking the spas- 
 modic cough. I then gave it in the mother tincture, and in 
 twenty-four hours the vomiting had stopped. The case of this 
 poor patient, who is doomed to face death very soon, is an in- 
 teresting one, because it affords an opportunity for studying the 
 real effects of our homoeopathic remedies. He has, like most 
 consumptives, the frequent pains in the side that we can cut 
 short with bryonia. But unfortunately, although in such cases 
 
 * These cases were published in the Transactions of the Homoeopathic Con- 
 gress of Paris. 
 
THE COMMON FORM OF PHTHISIS. 105 
 
 we may relieve the symptoms, it is not possible to attack the 
 disease at its root. Still, if we may not always cure it, we can 
 at least relieve it, and that is what we are trying to do in the 
 present case. 
 
 In connection with the prescription of drosera for this pa- 
 tient, I cannot let the occasion pass without reminding you of a 
 precept in therapeutics, which is generally admitted to be true, 
 but which is very often neglected in the practice, viz : that 
 when a remedy has been carefully selected, it should not be 
 hastily changed ; but the proper attenuation for the particular 
 case should be sought for, without regard to our prejudice. 
 For example : In the case of this patient, drosera was indicated 
 by the experimental Materia Medica, and also by clinical 
 experience, and we could, therefore, depend upon a thera- 
 peutic result with certainty. I accordingly persevered in the 
 use of the drosera, and because the third dilution, which I 
 habitually prescribe, was not effectual, I gave the twelfth. 
 This also failing, I resorted to the mother tincture, which 
 was successful. 
 
 The detailed account of this case is as follows : 
 
 Case XXYII. — M. Leblanc, aged thirty-seven years, en- 
 tered the hospital on the 7th of March. 
 
 The bad effects of living in a dark and illy-ventilated 
 room are well shown in the case of this patient, who, born 
 of strong parents, has always had good health heretofore. 
 For the last four years he has occupied a room that was 
 situated in a court into which the fresh air seldom penetrates. 
 
 In July, 1873, he had a dry cough, which was also fre- 
 quent, and which provoked vomiting. About the month of 
 December he had hemoptysis. He has become greatly ema- 
 ciated, and has lost his strength. 
 
 On examination of the chest, loud humid rales are heard 
 in the apex of the right lung, and over the remainder of 
 the chest there are the rales of bronchitis. He also has a 
 pain in the side. Bryonia, 3d dil., three drops in 200 
 
106 THE MEDICAL CLINIC. 
 
 grammes of water, one spoonful to be taken every three 
 hours. He is also to have the vegetable diet. 
 
 March 10. The cough is less frequent; there is a slight 
 expectoration ; the pain in the side has disappeared ; there 
 is slight vomiting after the cough. Brosera, 3d dil. 
 
 March 11. The pain in the side has returned ; there 
 are night sweats, but the patient coughs less. Bryonia, 3d 
 dil. 
 
 March 12. The pain in the side persists ; there is the 
 same general condition. Bryonia, 6th dil. 
 
 March 13. The pain in the side is gone. The same 
 treatment. 
 
 March 16. The cough is better, but still produces vom- 
 iting. Brosera, 3d dil. 
 
 March 18. The vomiting continues. Brosera, 12th dil. 
 
 March 19. The same condition. Brosera, in the mother 
 tincture, three drops. 
 
 March 20. ~No more vomiting ; has had a very good 
 night, and but little cough. The same treatment. 
 
 March 26. His condition is unchanged. There is no 
 vomiting. Arsenicum, 3d trit. 
 
 March 28. The same. Kermes\ 1st trit. 
 
 April 6. The patient's condition is very satisfactory, and 
 he wishes to leave the hospital. Phosphorus, 12th dil. 
 
 April 10. The pain in the side has returned. Bryonia, 
 3d dil. This pain afterward disappeared, and the same rem- 
 edy was continued until April 15. 
 
 The influence of bryonia over the pain in the side, and 
 of clrosera over the spasmodic cough and the vomiting of 
 the food, was very marked and evident in this case. 
 
LECTURE XI. 
 
 Summary. — Typhoid fever; indications for arsenicum. Phthisis and chlorosis; 
 indications for oryonia and sepia. Of the use of iron in phthisis. Sea-baths 
 in ditto. Chronic aortitis; the common and the painful forms of angina 
 pectoris; description of chronic aortitis; cases — angina pectoris ; case. 
 
 Typhoid Fever, alias Acute Phthisis. 
 
 Gentlemen : The diagnosis of the case in No. 4 of ward 
 11 is somewhat difficult. The woman's symptoms are: fever, 
 which has lasted for twelve days, with morning remissions and 
 evening exacerbations, the morning temperature being 101.84°, 
 and the evening temp. 104°; debility, bronchitis and some stu- 
 por, which symptoms certainly resemble those of typhoid fever. 
 But there is another morbid condition which so strikingly 
 resembles this disease, that the most skillful physicians have 
 hesitated in its diagnosis. I allude to the acute, or galloping 
 phthisis of Trousseau, which may present itself in two forms. 
 In one of these forms of phthisis the affection is very like 
 capillary bronchitis, because the dyspnoea is so very marked ; 
 the other is of a typhoid type, which may be, and has often 
 been, mistaken for typhoid fever. 
 
 The case of our patient is all the more perplexing, because 
 the abdominal symptoms are lacking entirely. On account of 
 the adynamia, and the duration and the violence of the fever, 
 the prognosis in these cases is always very grave. 
 
 I prescribed arsenicum in a low trituration, which appeared 
 to me to be indicated by the pale face, the prostration, the 
 sleeplessness with great agitation, and the intense thirst, which 
 are pathogenetic symptoms of arsenicum. As to alimentation, 
 I try to preserve a proper medium, giving such strengthening 
 
108 THE MEDICAL CLINIC. 
 
 food as the feebleness of the patient, and the duration of her 
 disease, require, and at the same time that which is not so sub- 
 stantial as to increase the fever. I will speak of this case again 
 in our next lecture. 
 
 Phthisis and Chlorosis. 
 
 In No. 1 of this same ward for women, there was, you 
 recollect, a patient who presented the symptoms of two dis- 
 eases, which are frequently observed in the same person, viz, 
 phthisis and chlorosis. This woman, who has coughed for a 
 long time, has in fact a pretty well-marked dullness in the right 
 side. Upon auscultation, the expiration was found to be harsh 
 and prolonged, and there was also bronchophony. At the 
 same time she suffered from neuralgia in the superior inter- 
 costal spaces. The leucorrhcea, breathlessness, and a carotid 
 souffle, show a well-defined state of chlorosis existing independ- 
 ently, I believe, of the phthisis. 
 
 I first prescribed bryonia, which was indicated by the pain 
 in the first intercostal spaces. I did not put her on the vege- 
 table diet, as is my custom in consumptive cases, the chlorosis 
 being a clear and well-defined counter-indication for such an 
 aliment ; but I prescribed a more nourishing diet instead. 
 
 The improvement of the respiration being prompt, I stopped 
 the use of bryonia and prescribed sepia, which was imperatively 
 called for by the leucorrhcea. Ought we, gentlemen, in similar 
 cases, to make use of the heroic remedies ? I certainly do not 
 pretend to deny that iron is the principal remedy in chlorosis, 
 but I do consider it a very dangerous one when consumption 
 makes its onset, and is complicated with the insidious symp- 
 toms of chlorosis. And in this opinion I am happy to have the 
 indorsement of one of our most illustrious teachers, Trousseau, 
 who reproached himself during the last years of his teaching, 
 for the freedom with which he had prescribed iron during 
 the first period of his medical practice. He confessed this with 
 
PHTHISIS AND CHLOROSIS. 109 
 
 the sincerity of one who deserves to be great as a medical 
 authority, and whose reputation will not be damaged by his 
 early mistakes ; for he charged himself with the death of sev- 
 eral women in whom consumption was the consequence of the 
 use of iron, given for the cure of a real, or of a suspected, 
 chlorosis. 
 
 The celebrated Dr. Graves, of Dublin, once expressed a wish that the sen- 
 tence, "He fed fevers, 11 might be engraved on his tombstone. Trousseau 
 and Graves were great friends, as well as great teachers in the department of 
 Clinical Medicine. And in view of the fact just cited by our author, we have 
 sometimes thought that an equally creditable and suggestive epitaph might be 
 written for Trousseau : He Proscribed Iron in Tuberculosis.— L. 
 
 Independent of clinical experience, the physiological action 
 of iron is sufficient to put us on our guard. We know that it 
 congests the lung, produces a dry and frequent cough, and 
 sometimes, also, hemoptysis, and therefore, that it should 
 never be given except in homoeopathic doses to a patient 
 in whose case the existence of tubercles is even suspected. 
 
 In the case of this patient I prescribed the acetate of iron 
 in the 1st trit., for two reasons, namely, first, because she 
 has not coughed for two weeks, and because, by careful 
 auscultation I do not find that there has been any advance- 
 ment of the pulmonary lesion for the last six weeks. The 
 second reason is, that her social condition does not permit 
 of her taking the treatment that I should greatly prefer for 
 her — I mean the fresh air, exercise and sea-bathing. I in- 
 tend, however, to watch her very carefully, and shall sus- 
 pend the use of the remedy the moment there are signs of 
 an aggravation. 
 
 It may surprise you to hear me speak of sea-bathing in 
 connection with consumption. Our great Laennec had un- 
 bounded confidence in the sea-air for the cure of phthisis. 
 He sent these patients to the seaside, and had sea-weeds 
 placed in the consumptive wards of the hospital. Of late, 
 
110 THE MEDICAL CLINIC. 
 
 there has been a reaction against this order of things. It 
 has been shown, in a certain number of cases, that the sea- 
 air was unfavorable, and the doctors, like Luther's drunken 
 countryman on horseback, who fell on the right side when 
 lifted up on the left, have proscribed sea-bathing and sea- 
 air in the treatment of tuberculosis with the same unanim- 
 ity and enthusiasm with which they formerly advised their 
 employment. 
 
 However, this question should depend, not upon fashion, 
 nor upon caprice, but upon the real indications. Consump- 
 tives with hemoptysis, or with fever, should avoid the salt 
 water, while those who are not thus affected mav derive 
 benefit from a sojourn on the southern coast of Brittany or 
 somewhere along the Gulf of Gascony. Not only the sea- 
 air, but short baths of, say, from five to ten minutes' dura- 
 tion, taken with moderation and care, will prove beneficial. 
 
 It is a great mistake to suppose that one climate, or one set of surroundings, 
 will be the best for any class of invalids whatever. The most careful rules, and 
 the most encouraging analyses of wind and weather, of dryness and moisture, 
 of heat and cold, of soil and water, are worth but little unless the patient's or- 
 ganism is en rapport with the " health resort, ' ' wherever it may be. We pre- 
 fer to choose a climate, just as we would a diet, for a sick person, id est, to suit 
 his tastes and idiosyncrasies, and, as nearly as possible, to make his experience 
 the rule for its continuance or for its rejection. — L. 
 
 Chronic Aortitis. 
 
 An old woman, gouty and hemorrhoidal, in No. 1, ward 
 2, furnishes me an opportunity of speaking to you of chronic 
 aortitis. You have heard me several times, both in the 
 wards and at the consultations, make a diagnosis of chronic 
 aortitis. I am aware that such a term may have appeared 
 strange, and it is better that I should give you some in- 
 formation concerning this affection; for all, or a great part, 
 of that which you may find in contemporary medical litera- 
 ture is erroneous. The history of inflammation of the aorta 
 
CHRONIC AORTITIS. Ill 
 
 is very brief. Up to the time of Bizot, nothing but theo- 
 ries regarding the inflammation of the internal membrane 
 of the aorta and of the arteries existed. Pinel, of whom 
 they tried to make a great authority, and who was really 
 but the caricature of a philosopher, had founded angiotenic 
 fever upon the existence of acute inflammation of the ar- 
 teries, but this inflammation was and is an hypothesis, and 
 we have, therefore, nothing to do with it now. 
 
 This angiotenic fever was a name offered by Pinel as a substitute for the in- 
 flammatory fever of Huxham and Stoll, the synocha of Cullen and Hoffman, and 
 the continuous but non-putrid fever of Boerhaave. — L. 
 
 Bizot published an account of three cases, which he called 
 acute aortitis. In these cases the disease was characterized 
 by intense and continued fever, an increasing dyspnoea, and 
 oedema. At the autopsy, one could distinguish inflamma- 
 tory redness, and pseudo-membranous deposits were found on 
 the surface of the lining membrane of the artery. In one 
 of the cases an atrophy of the kidneys cast a doubt upon the 
 value of Bizot' s reports. 
 
 At this time (1833) Bright' s disease was but little known 
 in France, and the kidneys of patients troubled with attacks 
 of aortitis were very superficially examined. In Bizot's cases 
 it is, therefore, difficult to separate that which belongs to aorti- 
 tis from that which belongs to parenchymatous nephritis, or 
 possibly to interstitial nephritis. 
 
 In 1859 Tessier traced, in I? Art Medical, the prominent 
 features of chronic aortitis. This description was founded 
 upon the cases, including the autopsies, of two men, who were 
 equally distinguished in their several ways — Dupuytren and 
 Saint Arnaud. Thanks to the silence which envelops and 
 tries to stifle all works that come from the pen of a disciple 
 of Hahnemann, this production has remained without an echo, 
 but has not been without an effect ; for it is impossible not to 
 
112 THE MEDICAL CLINIC. 
 
 recognize in many points the influence of J. -P. Tessier in the 
 writings of Peters, on the painful form of chronic aortitis or 
 angina pectoris. It was a singular destiny, that of this man, 
 whom they would consign to oblivion because he placed the 
 truths of therapeutics above the prejudices of his professional 
 neighbors ; above his own interests, and above all personal 
 considerations, but whose influence is felt at every step in 
 the progress of contemporary medicine. * 
 
 Chronic aortitis occurs in two forms, one of which is ex- 
 tremely painful, and which, for a long time, has been known 
 as angina of the thorax, or angina pectoris. The other form, 
 which is almost painless, is little known, notwithstanding its 
 frequency. The latter is what I call the common form of 
 chronic aortitis. 
 
 Between these two forms there are intermediate cases, in 
 which you will find the rudiments, or echoes of angina pectoris. 
 These cases are frequently met with in practice, and you have 
 seen several of them in our hospital. 
 
 Chronic aortitis is generally found in persons between forty 
 and fifty years of age. In every case that I have seen there 
 were unmistakable symptoms of gout, and especially of hemor- 
 rhoids. The abuse of coffee, tobacco, and, above all, of alcohol, 
 in some form, have been noticed by all authors as ' ' occasional 
 causes" of thoracic angina, and of ossification of the aorta. 
 In other words, you will find these etiological conditions to 
 have existed in nearly all cases of chronic aortitis. Finding 
 that the same morbid conditions and the same causes that 
 determine organic affections of the heart are present, we 
 observe that it is not infrequent to discover that the same 
 person may have a chronic inflammation of the aorta, coin- 
 cidently, with a chronic inflammation of the endocardium. 
 The cardo-aortitis is a frequent affection, and it is often difficult 
 
 * See UArt Medical for January and March, 1874 ; article, Angine de Poitrine. 
 
CHRONIC AORTITIS. 113 
 
 to tell which of these lesions preceded the other. Moreover, 
 they may coexist. 
 
 In the case of Count B., aortitis had continued in an un- 
 complicated form for more than a year. The heart, which was 
 examined each day by the consulting physicians and by myself T 
 presented absolutely no abnormal sounds ; but near the termi- 
 nation of the disease, or about three months before his death, 
 we discovered a perfectly well-defined mitral insufficiency. 
 
 Endocarditis may become complicated with chronic aortitis, 
 as aortic inflammation often is complicated with endocarditis, 
 and cardo-aortitis is a frequent affection. The subject of Case 
 III, who was attacked with rheumatic endo-pericarditis, had, 
 for some time, signs of intercurrent aortitis, as shown by the 
 sphygmographic tracings, in which we found the range that is. 
 characteristic of the aortitis. 
 
 Not having any morbid specimens of it to show you, I will 
 not dwell upon the pathological anatomy of chronic aortitis. 
 This part of the subject, for that matter, is better understood 
 than the history of its symptoms. Broussais has shown that 
 the bony and cartilaginous deposits, as well as the atheromata 
 of the aorta, are the product of a chronic inflammation ; and 
 Virchow, by histological examination, has confirmed the opin- 
 ion of Broussais. 
 
 The autopsy of Dupuytren may serve as a type of the lesions 
 of chronic aortitis: "The heart was hypertrophied, but its in- 
 ternal membrane was healthy. The valves, right and left, were 
 flexible, mobile, and well-formed ; and the orifices to which 
 they were adapted were perfectly free. . . . The internal sur- 
 face of the aorta and of the large arteries, which originally was 
 a little rough, is slightly rugous, with small yellow points and 
 patches scattered over it, — these patches being fibrous, or 
 fibro-cartilaginous, but not yet bony or calcareous. The walls 
 of the arteries were thick, as though hypertrophied like the 
 heart itself." (See LArt Medical, t. x, p. 419). 
 
114 THE MEDICAL CLINIC. 
 
 Thus, as demonstrated by the autopsy, the heart of Dupuy- 
 tren was perfectly healthy, notwithstanding he died of dysp- 
 noea, and with the oedema of the cardiac cachexia. Recollect 
 this, gentlemen, and when you find a patient having all the 
 rational signs of an affection of the heart, but in whom, by 
 attentive auscultation, the integrity of the cardiac orifices is 
 made evident, think at once of chronic aortitis, and a careful 
 examination will often give you a certain diagnosis. 
 
 And what is there astonishing in this resemblance between 
 the symptoms of aortitis and those of chronic carditis ? Is it 
 not the immediate effect of chronic inflammation that there 
 should be a loss of elasticity in the arterial tunics, and, conse- 
 quently, a narrowing from defective dilatation? You remem- 
 ber, in your physiology, that the channels of the human 
 body, such as the trachea for conducting the air, the urethra 
 -and the bile ducts for the escape of the excretions, and the 
 channels for the blood, like the aorta, are all essentially di- 
 latable, and that they do dilate every time they perform their 
 functions. But when there is chronic or acute inflammation in 
 these channels, they become, wherever they are diseased, non- 
 dilatable tubes. In default of dilatation, there is narrowing ; 
 whence, in trachitis, we have dyspnoea ; in angiocholitis, the 
 more or less complete retention of the bile ; of the urine in 
 urethritis ; and in aortitis, the symptoms of aortic contraction. 
 
 But when the disease is more advanced the lesion becomes 
 more complicated ; the wall of the artery is attacked in its 
 whole thickness, and loses its physiological properties. Awhile 
 ago it was its dilatability only that was impaired ; now, its elas- 
 ticity is more or less lost, and the walls, to a certain extent 
 only, yield to the pressure of the blood-current. From this 
 ■comes the consecutive dilatation of the aorta, and all of its 
 morbid consequences. 
 
 In the normal state, the expansible and elastic aorta gives 
 way to the flow of blood, and then reacts upon itself, — a con- 
 
CHRONIC AORTITIS. 115 
 
 dition that is eminently favorable to the circulation. But when 
 the arterial wall is attacked in all of its coats, it becomes an 
 almost inert tube, incapable of yielding to the sanguinary 
 wave, and incapable also of contracting after it, or of assist- 
 ing the progress of the blood-column, from which come, very 
 soon, the disorders analogous to those produced by the con- 
 traction and insufficiency of the aortic valves, viz : the diminu- 
 tion of arterial pressure, the increase of venous pressure, albu- 
 minuria, oedema, dropsy, and all the signs of a cachexia that 
 depends upon a failure of hematosis and of nutrition. Whence 
 the sphygmographic signs that are so characteristic of chronic 
 aortitis, the level tracing and absence of dicrotism, due to the 
 diminution and loss of the action of the elasticity of the aorta 
 in the circulation of the blood. 
 
 The disease always commences with dyspnoea. This dysp- 
 noea, which is very moderate in a state of rest, is soon accom- 
 panied by paroxysms that frighten and depress the patient. 
 They are brought on by exercise or emotion, and are more 
 frequent after eating. In the case of one lady, the first 
 paroxysm occurred while dancing. In general, these patients 
 suffer less when the stomach is empty, and are almost always 
 most oppressed after dinner. 
 
 In the case of Count B , of whom I have spoken to 
 
 you, the attacks of dyspnoea occurred in the night, like those 
 of asthma. 
 
 This dyspnoea is sometimes associated with a catarrh, which 
 is not very serious ; but from the beginning these patients lose 
 strength rapidly, and their nights are often troubled by dreams, 
 nightmare and unrest. 
 
 The progress of the disease is more or less rapid, but it 
 is never really arrested ; the habitual dyspnoea becomes more 
 pronounced day by day, and then follow the terrible paroxysms, 
 causing fear of death by suffocation or by syncope. These 
 paroxysms are in fact characteristic of the cardiac dyspnoea ; 
 
116 THE MEDICAL CLINIC. 
 
 the pulse is accelerated, and at the same time it grows smaller, 
 and finally disappears ; the skin is cold, and bathed with a 
 cold sweat ; the face is pale, with most pronounced syncope. 
 In some cases there is 'an entire loss of consciousness during 
 the worst paroxysms. The expiration is habitually convulsive 
 during the paroxysms, as in asthma. Some patients relieve 
 themselves decidedly by exaggerating this expiration into a 
 prolonged and plaintive moaning cry. 
 
 In the cases of M. Beaur and of Mrs. Broq, the detailed 
 accounts of which I have given, you, the diaphragm was seized 
 by clonic convulsions, producing a sub-costal throbbing, which 
 was worse on the left than on the right side. A strong press- 
 ure, which prevented the throbbing in the sides, relieved 
 them very much. 
 
 Some patients are subject, at intervals, to a silent dyspnoea, 
 which is characterized by an extremely slow and prolonged 
 inspiration, that is made with the mouth widely opened. The 
 loss of strength, and the anaemia make incessant progress ; 
 the appetite is retained for a greater or less length of time, 
 but many patients will not eat, from the fear of bringing on 
 the attacks of dyspnoea. 
 
 Sleep becomes more and more troubled, and the albumi- 
 nuria appears very promptly. 
 
 I have known patients to go for months, and even for 
 years, without developing a cachexia, in spite of habitual al- 
 buminuria and some paroxysms, with considerable time be- 
 tween them, of cardiac dyspnoea. The Duchess of is an 
 
 example of this (see Case XXXI), but in most cases the 
 presence of albumen in the urine denotes the advent of the 
 cachexia. 
 
 The Cachexia. — (Edema is usually the first symptom. It 
 increases more or less rapidly, or more or less slowly ; but it 
 increases, reaching the scrotum and the loins. It makes its 
 appearance also in the superior extremities and in the face ; 
 
CHRONIC AORTITIS. 117 
 
 the appetite diminishes and disappears, and, if the patient 
 be forced to eat, when the stomach is no longer able to digest 
 food, vomiting or diarrhoea ensues. Insomnia now becomes 
 a cruel evil, an enemy that is more terrible than thrist or 
 hunger. "It is a lamentable sight, that of a victim to this form 
 of the disease. "No sooner is he in his bed than he springs 
 from it precipitately, rushes about his chamber as though 
 insane ; sits down and then gets up again ; he is afraid of 
 the heat, because it increases his dyspnoea ; afraid of the cold, 
 because of his dropsy. Around the patient all the anxious 
 family are also awake, each one trying to find a comfortable 
 position for him : this one for his feet, that one for his head ; 
 one for his back and another for his arms ; and yet another 
 for his loins and his hips. And so the whole night passes 
 in these fruitless attempts to make him comfortable" (J. -P. 
 Tessier, VArt Medical, t. x, p. 413). 
 
 M. Beaur presented a type of this kind of insomnia. 
 
 The delirium and stupor appear in the very last stage. 
 I have often observed a delirium with symptoms approaching 
 those of insanity. 
 
 During the last weeks of the disease the fits of suffocation 
 usually disappear. In some cases, even the dyspnoea is so 
 relieved that the patient and his friends begin to hope for 
 his recovery. 
 
 The death, which follows, results from different mechanical 
 causes. It is most frequently occasioned by the accidents 
 which are usually observed at the termination of cardiac affec- 
 tions. The great anasarca, the oedema of the lungs and of 
 the brain, produce a slow asphyxia, which kills the patient 
 after an agony which is most painful to those about him, for 
 he himself is almost unconscious. 
 
 The symptoms of albuminuria, and of the different varie- 
 ties of ursemia that succeed it, often modify the death by 
 asphyxia, and then the patient passes into a state of coma. 
 
118 THE MEDICAL CLINIC. 
 
 The convulsive symptoms must be very rare, for I have never 
 seen them. Sometimes death comes by syncope, as in angina 
 pectoris. 
 
 The inflammation of the endangium extends more or less 
 rapidly until it gains the external sheath of the aorta ; some 
 of the painful symptoms of thoracic angina follow, and death, 
 by syncope, results when the cardiac plexus is involved in 
 the inflammatory process. 
 
 For the sake of convenience in the description, I have 
 deferred speaking of the accessory symptoms until now. These 
 symptoms are none the less important because, if not well 
 understood, they may impair the diagnosis. 
 
 Some patients suffer greatly from difficulty of deglutition 
 (see the case of Madame, the duchess of P.) This difficulty 
 compares perfectly, in its character and symptoms, with that 
 which accompanies aneurism of the arch of the aorta. In 
 both cases this dysphagia is of the paralytic form, and arises 
 either from pneumo-gastric compression, or from the extension 
 of the inflammation to this nerve. You know that the muscles 
 of the oesophagus are supplied by the nerves which come from 
 the pneumo-gastric. 
 
 I have sometimes observed a pain in the throat, with con- 
 striction. This pain is extremely persistent, troubling the 
 patient, who begs his physician to cure him of an angina, 
 which absolutely does not exist. 
 
 The extension of the inflammation of the endangium to 
 the external tunic of the aorta produces, when it attacks the 
 nerves that surround these vessels, certain special symptoms, 
 which give the patient a peculiar expression of the face. 
 First of these are the pains which radiate in different direc- 
 tions, as along the jaws to the neck, the shoulders and the 
 epigastrium. The cases in which the pains are slight form 
 a connecting link between the common variety of chronic 
 aortitis and angina pectoris. Painful spots may frequently 
 
CHRONIC AORTITIS. 119 
 
 be found by pressure upon the first bone of the sternum, and 
 in the superior intercostal spaces. The spasms of the dia- 
 phragm, and the pains along the scalenus muscle, may be ex- 
 plained by the inflammation of the phrenic nerves ; just as 
 the peculiar character of the expiration, noted in many cases, 
 shows an excitation of the pneumo-gastric by the extension 
 of the inflammation. 
 
 Let us return to the physical signs which permit us to 
 make a precise diagnosis in chronic aortitis : 
 
 1st. There is often a sub-sternal pain, that is increased 
 by pressure upon the first joint of the sternum, and also in 
 the neighboring intercostal spaces. 
 
 2d. There is, but not always, a dull sound on percus- 
 sion over the aorta, which dullness predominates habitually 
 on the right side of the sternum, between the right border 
 of this bone and the sterno-clavicular articulation. 
 
 3d. In the onset, the aortic sounds have seemed to us 
 to be more distinct ; later they became dull ; and sometimes 
 there was a veritable bruit de souffle. 
 
 4th. The pulse is generally small and feeble, but it may 
 be irregular, as it was in the case of Madame Broq, but, on 
 examination with the sphygmograph, it always shows the fea- 
 ture which Marey attributes to senile atheroma. This symp- 
 tom has never failed us. We shall show you several drawings 
 in which it may be ' seen. 
 
 Finally, the superficial arteries are often ossified, and some 
 patients present the senile circle of the cornea. 
 
 Case XXYIII. — Mr. B., whose present age is fifty-two, is 
 a man of vigorous constitution. His mother was gouty, and 
 he has himself been subject to periodical headaches, that recur 
 about once a month. He has for a long time used tobacco 
 to excess, drinks wine and coifee freely, and is a high liver. 
 His occupation is sedentary. 
 
120 THE MEDICAL CLINIC. 
 
 At about the age of forty lie suffered from hemoptysis, 
 for which trouble he was sent to the Pyrenees. Several years 
 later I saw this patient for the first time, and, upon examina- 
 tion, was unable to find any lesion, either pulmonary or car- 
 diac, connected with this hemorrhage. 
 
 Mr. B. has complained of his throat for a long time ; he 
 suffers from dryness, with strangulation, pain in swallowing, 
 and incessant coughing from the throat ; the voice is nasal. 
 A local examination of the throat showed a general redness, 
 a very irregular swelling of the tonsils, and some granula- 
 tions in the pharynx. However, in 1870 and 1871 his general 
 health was sufficiently good to permit him, in spite of his age 
 (forty-nine), to serve in the marching battalions of the National 
 Guard. From 1872 his breathing became difficult, and his 
 dyspnoea was always connected with his sore throat. 
 
 Toward the commencement of the year 1873, tormented by 
 the idea of chronic angina, he consulted a specialist, whose 
 diagnosis was ancemia, and who advised a resort to hydropa- 
 thy. This treatment induced certain cerebral symptoms ; a 
 congestion of the retina of the right eye, with diminution of 
 sight ; a certain difficulty of speech, and a noticeable failing 
 of the intellectual faculties. By my advice, he stopped this 
 treatment and took belladonna, which gave him some relief. 
 
 On the 12th of May, 1873, Mr. B. had his first attack of 
 suffocation. The paroxysm lasted one ftbur and a-half, and 
 was very alarming. One of our college professors was con- 
 sulted, and he attributed the paroxysm and the habitual dysp- 
 noea to an imperfectly developed angina pectoris of a gouty 
 nature. On auscultation, he found that the sounds of the 
 heart were very tumultuous, especially at the orifice of the 
 aorta, which led him to admit the existence of a parchment- 
 like condition of the endocardium and of the endangium. 
 
 From this time, I had no doubt that the disease was chronic 
 aortitis. The habitual dyspnoea, the attacks of suffocation, 
 
CHRONIC AORTITIS. 121 
 
 which were frequently repeated, the commencing anaemia, the 
 absence of the signs which characterize the lesions of the 
 cardiac orifice, and the absence of the usual pains of angina 
 pectoris, made it impossible to hesitate regarding a diagno- 
 sis that was soon to be confirmed by the character of the 
 dyspnoea, the restless insomnia, the presence of albumen in 
 the urine, the oedema, the dullness in the aortic region, and 
 the succession of all the symptoms which characterize the 
 cardiac cachexia, without any of the signs of a lesion of the 
 cardiac orifices. 
 
 Pilules of arsenic were prescribed by the physician to 
 whom my patient had applied, but notwithstanding their use 
 the spasms of suffocation were frequent. Nux vomica, in the 
 30th dil., which was prescribed on the 4th of June, stopped 
 the paroxysms for some time. The patient, who was in the 
 country, passed several days at the sea-side ; then he spent a 
 season at Royat, and returned much relieved, although he 
 had one violent attack after an immersion in the waters of 
 Royat. 
 
 During the autumn he was comparatively better, but the 
 dyspnoea continued to return, and he was obliged to walk, 
 and especially to go up-stairs, with the greatest care, as he 
 always felt himself at such times on the verge of an attack. 
 
 The severe paroxysms of suffocation returned in the month 
 of December, and in consequence of his having called another 
 physician during one of these spasms, and then remaining un- 
 der his care, I lost sight of him for some weeks. 
 
 About February, 1874, I was recalled, and then his condi- 
 tion was as follows : The complexion is yellow and cachectic ; 
 there is swelling of the face ; oedema of the legs ; the urine 
 is albuminous ; there is complete insomnia, accompanied by 
 an unrest that causes him to rise, to change his position, and 
 to walk and talk incessantly, and there is dyspnoea with spas- 
 modic efforts at respiration, and a moaning cry. The dyspnoea 
 
122 THE MEDICAL CLINIC. 
 
 is worse at intervals, and is accompanied by a throbbing in 
 the side that is quite perceptible to view, and which is caused 
 by the convulsive action of the diaphragm. From time to 
 time these attacks were accompanied by faintness, and a threat- 
 ened syncope. The pulse is small and feeble, varies from 
 88 to 112, and gives a characteristic sphygmographic trace, 
 a straight ascending line, a very marked level one, and a 
 descending line that is very oblique without dicrotism. 
 
 Trace No. 7. 
 
 The patient is, therefore, in the cachectic stage, and his. 
 condition becomes worse progressively. He is unable to lie 
 down. The insomnia and suffocation are agonizing, and they 
 pursue him to his arm-chair ; and for several weeks his wife, 
 his son, and the nurse, were exhausted in useless attempts to 
 make him more comfortable. Overpowered by fatigue, he is 
 scarcely asleep when he awakens suffocating, and anxious, until 
 at length he is afraid to sleep, and resists it with all his 
 strength, imploring those about him not to let him fall asleep 
 again. It seems as though respiration could not go on auto- 
 matically, but needed a voluntary effort to make it complete. 
 The nights pass in this unceasing struggle, the patient rising, 
 changing his chair, tries to eat, talks a great deal, and after 
 a time becomes delirious. • His days are a little more tranquil. 
 
 Aconite and spigelia, in the mother tincture, and in the 6th 
 dil., relieved the violent attacks of suffocation, but were power- 
 less against the habitual dyspnoea, and the increasing cachexia. 
 It was the same with the cactus grandiflora, lachesis, digitalis, 
 and secale cornutum. The arseniate of antimony, in the form 
 of granules, — advised by Doctor Cretin, — was productive of 
 
CHRONIC AORTITIS. 123 
 
 calmer nights and several hours' sleep ; but this remedy soon 
 lost its power, and when I resumed its use after a suspension 
 of several days, it was ineffectual. 
 
 At the end of April the insomnia returned. The patient 
 no longer suffers from suffocation, but the dyspnoea, which has 
 become habitual, is intense at times. The oedema has made 
 great progress. The patient is delirious every night. His 
 speech is so embarrassed that it is very difficult to understand 
 him. The appetite is gone, and his physical strength is so 
 reduced that he cannot take a step. At this juncture I pre- 
 scribed carho vegetabilis, 12th dil., which gave him a little quiet; 
 but it was cuprum, 12th dil., that produced a veritable revolu- 
 tion in our patient's case. The dyspnoea ceased, the appetite 
 and the sleep returned, and at the same time the pulse, which 
 had been between 96 and 120, fell to 80, and also became less 
 feeble. 
 
 At the end of two weeks his strength had increased con- 
 siderably ; the unrest and anxiety had disappeared ; he spoke 
 distinctly ; could walk a little, and believed himself convales- 
 cent. But this improvement was not lasting ; his strength 
 failed again ; the oedema increased ; the somnolence became 
 more and more pronounced, and the patient finally passed 
 away quietly without a return of the dyspnoea or of the agita- 
 tion, which had marked the beginning of the cachexia. 
 
 Case XXIX. — Mrs. B , aged forty-five years, still has 
 
 her menses. This patient is hemorrhoidal, and has had several 
 attacks of bilious colic. In November, of 1872, more than a 
 year ago, she was seized with an attack of dyspnoea while 
 dancing after dinner. The paroxysm was short, and it ap- 
 parently left her in good health, but there was a return of 
 it at brief intervals, sometimes when walking fast, or on 
 mounting the stairs. These paroxysms finally became very 
 frequent, and were accompanied by an habitual dyspnoea. Eat- 
 
124 THE MEDICAL CLINIC. 
 
 ing had more and more influence in causing a return of these 
 paroxysms, and when we saw the patient at the end of Feb- 
 ruary, 1874, she had not dared to eat solid food for more than 
 a month, each attempt at doing so provoking an attack of 
 dyspnoea. 
 
 At the same time that the dyspnoea became habitual the 
 strength failed ; the anaemia became more and more pro- 
 nounced, and the appetite was completely lost. The opinions 
 of the physicians who were consulted before I was called 
 varied, for some of them thought the disease to be seated in 
 the heart, although they could not discover any abnormal 
 murmurs ; others considered it a nervous affection. 
 
 The Present Condition. — The patient is lying, or rather 
 sitting, in bed, and bolstered up by numerous pillows. She 
 is extremely pale, with the yellowish tint common to cardiac 
 affections ; there is oedema of the eyelids ; the respiration, 
 which is manifestly accelerated when the patient is in repose, 
 becomes a perfect breathlessness when she tries to speak ; with 
 oedema of the inferior members ; the urine contains albumen. 
 She experiences a feeling of constriction, and of distress in 
 the epigastrium, which is not absolutely painful. For the 
 reason that the eating of solid food induces a paroxysm, she 
 takes for nourishment but a single cup of coffee and a little 
 broth each day. These spasms are characterized by dyspnoea, 
 which is really orthopncea, with throbbing in the epigastrium 
 that raise the abdomen violently, and which are apparently 
 caused by the convulsions of the diaphragm. The pulse be- 
 comes small, obscure, and disappears. There is prolonged 
 lipothymia, with cold sweats. The paroxysms, which are so 
 terrible for the patient and so frightful to those about her, 
 come at irregular intervals, several days apart, but are sure 
 to be provoked by eating solid food, and by unusual exercise 
 or emotions. The sleep is agitated, and sometimes she does 
 not sleep at all at night. There is some degree of somnolence 
 during the day. 
 
CHRONIC AORTITIS. 125 
 
 The heart is large, but auscultation does not show any 
 abnormal sounds either at its apex or at its base. The aortic 
 dullness measures six centimetres ; the aortic sounds are in- 
 tense, and the sphygmographic trace shows the ascending line 
 very short and oblique, the level one, followed almost without 
 transition by a descending line that is oblique, almost straight, 
 and without dicrotism. The pulse is very irrregular. 
 
 Trace No. 8. 
 
 The pulse, which usually was feeble and irregular, varied 
 from 90 to 100. 
 
 Aconite and arsenicum were successively administered in 
 various potencies ; the tincture of the former, and triturations 
 of the latter, and dilutions also from the 6th to the 30th, all 
 of which were powerless to modify the morbid condition. 
 
 The oedema and feebleness increased daily. The patient 
 had alternations of excitation and somnolence. But a short 
 time after the persevering use of carbo mgetabilis, in from the 
 6th to the 30th dil., the attacks of suifocation ceased, and did 
 not return. 
 
 Toward the middle of March the symptoms of uraemia 
 appeared abruptly ; there was a considerable weakness of 
 vision, especially in the left eye ; aphasia, characterized by the 
 impossibility of finding the proper word, and the use of words 
 belonging to no language at all ; divagation and irritability. 
 These symptoms were much relieved through the influence of 
 belladonna. 
 
 The sphygmographic trace, made at this time, shows signs 
 of asystolie. The urine continues albuminous. The oedema 
 of the superior extremities has become very excessive. The ap- 
 
126 THE MEDICAL CLINIC. 
 
 petite has completely failed, and at different times she has had 
 attacks of nausea and vomiting, and some diarrhoea. Ipecac. 
 caused these symptoms to disappear, but the debility and the 
 oedema are worse each day. She is delirious, lucid and som- 
 nolent alternately. 
 
 The patient finally died in the month of April, having 
 been perfectly rational for several days previous. It is to be 
 remarked that for several weeks she had not had a paroxysm 
 of suffocation, and that the habitual dyspnoea was greatly 
 lessened. 
 
 Case XXX. — Madame de R., aged thirty-six years, of 
 gouty parentage, has suffered from arthritic pains and hem- 
 orrhoids. Some years ago she drank tea to great excess to 
 arrest an embonpoint. This patient has been through preg- 
 nancy several times, the first being followed by phlegmasia 
 alba dolens, which left behind an incurable oedema of the left 
 leg. She has for eighteen months been subject to a slight 
 want of breath, and during the summer of 1873 her physician, 
 struck by her palor and her bloated condition, examined her 
 urine, which he found contained a considerable quantity of 
 albumen. 
 
 The first attack of suffocation occurred in July, 1873, at 
 Pouliguen, on the coast ; it came on during the night, and was 
 occasioned by the going out of the oil-lamp. She attributed it 
 more to the darkness than to the odor of the burnt oil. The 
 second paroxysm occurred a few weeks later, and was neither 
 violent nor of long duration. It was not so with the attack of 
 the 22d of November, which lasted between ten and eleven 
 hours. This came on about ten or eleven o'clock, after the 
 patient had gone to bed, and after a day during which the 
 asthmatic breathing had been very bad. This paroxysm was 
 so violent that the patient lost consciousness. She had scarcely 
 time to call for help and throw herself down near an open 
 
CHRONIC AORTITIS. 127 
 
 window, when she sank unconsciously in the arms of her hus- 
 band. The respiration was apparently suspended ; the mouth 
 was wide open ; the face pale and cyanotic ; the lips were 
 blue ; the eyes were fixed ; the pulse was regular, feeble and 
 hard. The patient was bled, after which the breathing became 
 slower, and consciousness returned. She expectorated a 
 frothy, bloody substance, and upon auscultation very fine sub- 
 crepitant rales were detected. The night following was quiet, 
 and the patient recovered rapidly. This was, therefore, a well 
 marked attack of pulmonary congestion. 
 
 In February, 1874, the third attack was occasioned by 
 mental excitement, and was similar to the first. The physi- 
 cians who cared for her found no signs of cardiac affection, 
 and their diagnosis was aortitis, with an extension of the 
 inflammation to the pneumo-gastric, and consequent disorder 
 of this nerve. 
 
 Actual Condition. — The patient suffers from habitual dysp- 
 noea, characterized by a slight increase of the symptoms, and 
 spasmodic expiration. She is pale and anaemic ; the mucous 
 membranes are almost colorless ; the vascular souffles are ob- 
 vious, and oedema has commenced in the legs and in the 
 hands ; she has thirst ; the urine is sometimes very abundant 
 and pale, and sometimes darker and less in quantity than 
 natural, containing albumen generally, though not always, and 
 in variable quantities. The urine, however, takes the charac- 
 teristic odor from the use of asparagus. There is but little 
 appetite and great debility. The menses still appear regularly. 
 The patient is subject to terrible attacks of suffocation, which 
 come at irregular intervals, several days apart, and at any 
 hour in the day. 
 
 She sleeps very poorly, sometimes passing the entire night 
 in an arm-chair, because she breathes more easily, and dreads 
 the spasms of suffocation. After sleeping a short time, 
 perhaps a quarter or half an hour, she awakens in such agony 
 
128 THE MEDICAL CLINIC. 
 
 that she is afraid to go to sleep again, and struggles against 
 the inclination to do so. When she cannot sleep, which is 
 oftener the case, she is extremely agitated, and one position 
 is as uncomfortable as another. 
 
 Two weeks ago she took cold while driving in an open car- 
 riage, which resulted in an attack of pleurisy, limited to the 
 inferior third of the left pleura. This pleurisy is still far from 
 being entirely cured. Auscultation and percussion of the lung 
 revealed no lesion ; there is no pulmonary emphysema, a fact 
 which causes us to reject the idea of asthma, notwithstanding 
 the expiration is, as we have said, sometimes spasmodic and 
 very difficult. 
 
 The heart presents no abnormal murmurs ; both of its 
 sounds are distinct, but a little harsh in tone. The apex of 
 the heart beats in the line of the nipple. The aorta pre- 
 sents a transverse dullness of four and a half centimetres. The 
 aortic sounds are dull. The pulse is frequent, but so small and 
 so feeble that it is impossible to take the sphygmographic 
 trace of it. 
 
 Under the influence of carlo vegetabilis, 30th dil. , and then 
 of arsenicum, 12th dil., the dyspnoea was greatly relieved; the 
 nights became more calm ; the effusion was reabsorbed, and 
 the appetite returned ; but the oedema and the albuminuria in- 
 creased constantly. Following a fresh cold, which was charge- 
 able to the coolness of the weather, the pleurisy was lighted up 
 again, the dullness increased to three fingers' breadth, with 
 absence of the respiratory murmur, which is replaced by an 
 abnormal souffle. Oantharis, 3d dil., and bryonia, 3d dil, were 
 of little benefit, and at the end of thirty-six hours I was obliged, 
 on account of the dyspnoea, to return to carbo vegetabilis, 12th 
 dil., which speedily relieved this symptom. During the day I 
 gave several spoonfuls of cantharis, 3d dil. Under the influ- 
 ence of this treatment the effusion decreased again. 
 
CHRONIC AORTITIS. 129 
 
 During this relapse of the pleurisy, the pulse was raised, 
 and varied from 104 to 116, growing stronger also, meanwhile. 
 
 A complication of pultaceous angina occurred during this 
 febrile relapse. I treated it locally by painting it with glycer- 
 ine and mercurius cor., 1st dil. (twenty grammes of glycerine 
 to twenty drops of the mercurius cor., 1st dil.) 
 
 We took advantage of the slight improvement in the pa- 
 tient's condition, caused by this treatment, to send her back 
 to her family, where she died a month after, with considerable 
 anasarca. 
 
 The premature appearance of the albuminuria, the variable- 
 ness of its proportions, and even its non-existence occasionally; 
 the thirst, and the quantity of urine, which was often large, 
 caused it to resemble a case of interstitial nephritis. 
 
 For, is not interstitial nephritis always associated with an 
 arterial affection and ossification of the arteries, and is it not 
 often, like chronic aortitis, a gouty affection ? 
 
 Case XXXI. — Madame de , the Duchess of , is a 
 
 woman of forty-eight years, and of a fine constitution. Heart 
 diseases are hereditary in her family, and she has herself shown 
 symptoms of gout. Subsequent to a labor, 22 years ago, the 
 menses became deranged and she was attacked with phlebitis, 
 which left her with oedema of both legs. Her disease com- 
 menced by oppression of breath when walking, in 1871, or 
 about three years ago. It was at first observable only when 
 climbing the stairs, but it progressed steadily and was attrib- 
 uted to anaemia. Joined to this suffering there soon ap- 
 peared another, and a characteristic symptom, which still ex- 
 ists, viz : great difficulty in the deglutition of solids. Be- 
 sides this, the patient is subject to palpitation. 
 
 Her condition is shown in the following symptoms : 
 There is an habitual breathlessness which makes walk- 
 ing very painful ; she lias palpitation, and a short, dry, 
 9 
 
130 THE MEDICAL CLINIC. 
 
 laryngeal cough, and choking while eating ; the pulse is 
 regular, small and frequent, varying from 96 to 104, and 
 there is a considerable quantity of albumen in the urine. 
 
 A short time after this the patient was seized, when 
 about to retire, with a violent fit of suffocation, which lasted 
 for several hours, and which greatly alarmed her family. I 
 found her the next morning much more oppressed than usual, 
 very anxious, and with a pulse of 120. Aconite, in the mother 
 tincture, twenty drops in 200 grammes of water, one spoonful 
 every two hours, gave her relief. 
 
 A careful examination showed her condition to be as fol- 
 lows : There is no lesion of the lungs ; the heart-sounds 
 are well marked, and normal ; the aortic dullness extends 
 over a little more than four centimetres, and this dullness 
 is more pronounced at the left of the sternum ; there are 
 no murmurs in the vessels. The pulse, examined by the 
 sphygmograph, gives the ascending line as perpendicular, 
 the level very marked and the descending line very oblique, 
 with noticeable dicrotism. 
 
 Trace No. 9. 
 
 The results of this examination being confirmed by one 
 of our most distinguished hospital physicians, I no longer 
 hesitated in my diagnosis of chronic aortitis. 
 
 Fifteen days later this patient had another terrible at- 
 tack of suffocation, but since then, thanks to an almost 
 absolute state of repose, and the use of digitalis, of lachesis 
 and of aconite, these paroxysms have not returned ; the 
 cough has left ; the asthmatic breathing is lessened, and 
 the pulse has fallen to 84 ; but the continued presence of 
 
CHRONIC AORTITIS WITH ANGINA PECTORIS. 131 
 
 albumen in the urine, and the persistence of the dysphagia 
 clearly show that the disease is not cured. 
 
 The details which follow will illustrate to you the anal- 
 ogies and the differences between the common form of chronic 
 aortitis and the painful form, or angina pectoris. 
 
 Chronic Aortitis with Angina Pectoris. v 
 
 Case XXXII. — Mr. Etienne, sixty-one years of age, en- 
 tered the hospital on the 26th of January, and left it on the 
 31st of January. 
 
 This man has never had a serious illness, excepting an at- 
 tack of cramps of the stomach, which occurred five years ago, 
 and which lasted about a fortnight. His health had been good 
 up to the month of October, 1873. At that time his appetite 
 began to fail, and his sleep, hitherto always calm, to be inter- 
 rupted by pains in the pit of the stomach and. in the legs. 
 These pains ascended to the side of the chest, producing vio- 
 lent dyspnoea, and forcing the patient to get up. 
 
 The paroxysms were very frequent at night, but he rarely 
 suffered during the day. A physical examination of the patient 
 showed no morbid sounds in the vessels of the neck, but on 
 the level of the aorta a harsh sound was perceptible by aus- 
 cultation. By percussion, we found a dullness which was much 
 greater than normal. The movement of the heart is irregular, 
 but there is no souffle either at its apex or its base. 
 
 January 26. Nux vomica, 12th dil. 
 
 January 27. The paroxysms have recurred, but they are 
 very short and very frequent. The same treatment. 
 
 January 28. No improvement. We find that the arteries 
 are ossified. The sounds' of the heart are dull. The same 
 treatment. 
 
 January 29. Slight improvement ; the attacks have been 
 less frequent, and the night a satisfactory one. Nux vomica, 
 12th dil. 
 
 January 30. The patient wants to leave, being, in fact, but 
 slightly improved. He died at his home a few days after. 
 
132 THE MEDICAL CLINIC. 
 
 Case XXXIII. — Mrs. Duplessis, aged forty-nine years, 
 entered on the 1st of April, and left on the 3d of April. 
 
 The general health of this patient has been good. Her 
 menses were established at the age of seventeen, and ceased 
 at forty-two. She has had hemorrhoids for the past fifteen 
 years, which at times are very painful. The affection for 
 which she has come to ns is of a year's duration, but long 
 before she had felt a formication in the region of the left 
 scapula. This present illness began with a constant pain 
 in the back, which was so severe as to cause her to stop 
 sometimes in the midst of her work. She says that it 
 seemed to her as though some creatures were gnawing her 
 flesh. 
 
 For two or three months she complained of fits of suffo- 
 cation which were of short duration, and which came on 
 generally while she was walking. 
 
 Since that time, also, she has suffered from sub-sternal 
 pain and a numbness in the left arm, which extended to 
 the fingers. 
 
 An examination of the patient reveals an absence of ab- 
 normal aortic dullness, a souffle in both carotids, and absence 
 of the aortic valvular click, which is replaced by dull mur- 
 murs. 
 
 There is a pain at the top of the sternum, which is in- 
 creased by pressure, and especially by walking ; pain in 
 the diaphragm, that is also excited by pressure on the level 
 of the left scalenus muscle ; habitual dyspnoea, and in- 
 somnia. The patient is often obliged to stop while walk- 
 ing, on account of the sub-sternal pain, which extends in 
 the form of numbness to the left arm. The sphygmograph 
 gives a pulse that is pretty regular ; the ascending branch 
 is short and a little oblique ; the level line very marked 
 at certain pulsations, and the descending line long and 
 oblique, with very feeble undulation. This patient only 
 
CHRONIC AORTITIS WITH ANGINA PECTORIS. 133 
 
 came to the hospital for examination. She was prescribed 
 for regularly at the dispensary. Spigelia, in the mother 
 tincture, almost entirely stopped the sub-sternal pains. 
 
 Among the cases of chronic aortitis that I have seen in 
 the consultations, and which I have received into our wards 
 simply to make an examination of the pulse, is that of 
 Mrs. Clery, aged sixty-five, and who occupied ~No. 3 of 
 the second ward, from the 21st to the 24th of January. 
 This woman bears the appearance of advanced age ; she 
 is hemorrhoidal ; the cornea presents the senile circle ; the 
 superficial arteries are ossified ; the sphygmograph showed 
 the typical level tracing ; the state of the heart is normal. 
 She complained especially of dyspnoea and of insomnia, 
 and was treated by arsenicum, 12th dil., and did not re- 
 turn to the consultations. 
 
 Mr. Cartier, aged sixty-five. He has dyspnoea and sub- 
 sternal pains, which radiate to the epigastrium ; insomnia, 
 and ossification of the superficial arteries. The sphygmo- 
 graphic trace is characteristic. Spigelia, 3d and 6th dils., 
 gave great relief to the pains and the oppression. 
 
LECTURE XII. 
 
 Summary. — Typhoid fever, case. Asthma, case; indications for bryonta. 
 Asthma and trifacial neuralgia, case. £)n the choice of the attenuation. 
 
 Typhoid Fever. 
 
 Gentlemen : A week ago you may have seen in our wards 
 a woman for whom, and with some reservations, I made the 
 diagnosis of typhoid fever. I told you that I had but faint 
 hopes of her recovery. My fears have been realized in her 
 death, which occurred two days ago. The temperature of this 
 patient increased constantly; there was a complete absence of 
 alvine discharges and of urine, both of which are very bad 
 prognostic signs. The remedies that I used in this case were 
 arsenicum, carbo-vegetabilis, and, as a last resort, stramonium, 
 in the third dilution. The medicines were alike ineffectual in 
 retarding the progress of the disease. 
 
 Case XXXI Y. — Mrs. Charpentier, aged thirty-five, entered 
 on the 1st of April, and died on the 6th of April. 
 
 This patient came to us on the twelfth day of her illness, 
 which commenced, as we learned from her relatives, with 
 headache and vomiting. There was no epistaxis. The stools 
 were frequent, but they had been provoked by a purgative 
 given during the first days of the disease ; from that time there 
 has been constipation. The patient was completely prostrated. 
 She complains of headache, and says that since she has been 
 ill she does not hear distinctly. 
 
 The abdomen is sensitive, especially in the right iliac fossa, 
 but there are no spots on the skin. The pulse is frequent and 
 small; the tongue whitish, a little red at the tip and on the 
 sides. An examination of the chest reveals nothing. No 
 rales are to be heard, although there is dyspnoea and a frequent 
 cough. 
 
ASTHMA. 135 
 
 April 1. Evening temp. 104°, pulse 120. 
 
 April 2. Morning temp. 101.8°, pulse 120. Arsenicum 
 met. in the 3d trit. Evening temp. 104.36°, pulse 120. 
 
 April 3. Morning temp. 104°, pulse 120. Carbo-vegeta- 
 bilis, 12th dil. Evening temp. 104.72°, pulse 128. 
 
 April 4. Morning temp. 103.28°, pulse 116. Stramonium, 
 3d dil. Evening temp. 104.36°, pulse 128. 
 
 April 5. Morning temp. 102.56°, pulse 120. Stramonium, 
 3d dil. Evening temp. 105.44°, pulse 136. 
 
 April 6. Morning temp. 102.20°, pulse 128. Stramonium, 
 in the mother tincture, one drop. Evening temp. 106.88°, 
 pulse 168. Death. 
 
 From the 2d to the 6th of April, the prostration and 
 adynamia increased. The patient has had no alvine evacua- 
 tions at all, and during the last days no urinary discharge ; 
 not because of retention of the urine, but from absence of the 
 secretion. She is agitated and delirious, particularly at night ; 
 the face is pale, and there is considerable emaciation. 
 
 Asthma. 
 
 The patient in ~No. 3 is a woman, ill with transitory em- 
 physema and asthma. Her case, although of slight interest 
 from a pathological point of view, is of great therapeutic im- 
 portance. You recollect that this patient left us some time 
 ago, after having been treated with arsenicum, and that when 
 she left she showed, upon auscultation, that there were no 
 remaining symptoms of emphysema. She returned to us in 
 a few days with a most violent attack, for which we again 
 prescribed arsenicum. She was again relieved, although she 
 complained of a constant difficulty in breathing. We then 
 gave her cuprum, which seemed indicated by another attack, 
 and which was accompanied with vomiting, but we completely 
 failed to relieve her. I then made a more thorough exam- 
 ination of her symptoms, and found that she suffered from 
 a pain in her side, which was increased by respiration. I 
 
136 THE MEDICAL CLINIC. 
 
 prescribed bryonia, under the influence of whicli remedy she is 
 being rapidly cured. 
 
 This indication for bryonia in asthma is not really a clas- 
 sical one. Hahnemann names asthma as being within the 
 sphere of bryonia, but in the history of the remedy he gives 
 few homoeopathic symptoms of this affection. Jahr mentions 
 more of them, as difficult respiration, the need of a deep in- 
 spiration, constriction of the chest, and anxious breathing. I 
 find bryonia strongly indicated in asthma when it is accom- 
 panied by vomiting and pain in the side. In fact, a goodly 
 number of homoeopathic physicians are in the habit of using 
 it in similar cases, and with decided benefit. Here are the 
 full notes of this patient's case. 
 
 Case XXX Y. — Mrs. Rouel, aged forty-six years, entered 
 the hospital, for the first time, on the 4th of March, and left 
 on the 19th of March, and reentered on the 21st of March. 
 
 This patient has neither suffered from hemorrhoids, cu- 
 taneous diseases, nor from articular gout. For a long time 
 she has been subject to pains in the stomach with cramps. 
 She has had bronchitis quite frequently for three years, and 
 since the 1st of January last has suffered from attacks of suf- 
 focation with oppression, which often oblige her to rest. She 
 adds that from that time she has heard a whistling sound 
 in her chest ; but the fits of a suffocating dyspnoea, which 
 are as apt to come during the day as at night, are the cause 
 of her coming to the hospital. These paroxysms are usually 
 of short duration. 
 
 The examination of the chest, on her entrance, showed 
 the whole left side to be the seat of sibilant rales ; there is 
 a prolonged and very emphatic expiration, which is really 
 double. She has been in the hospital since yesterday, but 
 as we have not yet seen her during the paroxysm, we have 
 not made a prescription. 
 
ASTHMA. 137 
 
 March 5. The paroxysms have not returned. No remedy. 
 
 March 6. No paroxysms ; frothy expectoration ; the ex- 
 piration is very prolonged, and the whistling more marked 
 than it was yesterday. Arsenicum, 3d trit., twenty centi- 
 grammes in 200 grammes of water, one spoonful every two 
 hours. 
 
 March 7. Improvement ; there was less suffocation during 
 the night. The same treatment. 
 
 March 9. The rales have considerably diminished ; the pro- 
 longed expiration is not heard except in the apex of the left 
 lung. The same treatment. 
 
 March 11. The suffocation has almost disappeared. The 
 same treatment. 
 
 March 12. The emphysema has disappeared. 
 
 March 13. There is still slight suffocation. Arsenicum, 
 2d trit. 
 
 March 14. No suffocation. Same treatment. 
 
 March 16. The patient is cured, and leaves the hospital. 
 
 From the day of her leaving us the attacks of suffoca- 
 tion recommenced. On the night of the 16th she had a 
 severe dyspnoea, which prevented her from sleeping, but she 
 has had no paroxysm nor cough. The day of the 17th was 
 not bad, but during the night the suffocation returned and 
 was more severe than the night before. 
 
 March 19. The patient continues to grow worse, and re- 
 enters the hospital on the 21st. 
 
 March 22. She has had four successive paroxysms this 
 afternoon. These paroxysms present this especial character- 
 istic, that they are accompanied by stiffness of the limbs and 
 a loss of consciousness, with cyanosis of the face. Each par- 
 oxysm terminates with a profuse sweat. On examination of 
 the chest, we find whistling respiration, prolonged expiration, 
 and moist rales on both sides of the chest. Arsenicum, 3d trit. 
 
 March 24. The rales have diminished ; the expiration is a 
 little less prolonged, and there is less suffocation. 
 
 March 25. She has an abundant expectoration ; great im- 
 provement. Arsenicum, 2d trit. 
 
138 THE MEDICAL CLINIC. 
 
 March 26. Less expectoration and suffocation. Arsenicum, 
 2cl trit. 
 
 March 28. The patient had a high fever last evening, and 
 we feared another paroxysm ; the pulse was 120, and the tem- 
 perature increased to 102.5°. These symptoms grew rapidly 
 better. The same treatment. 
 
 April 1. The same condition, but no diminution of the 
 dyspnoea. Cuprum, 6th dil. 
 
 April 2. No fever in the evening, but the night was very 
 bad. 
 
 April 3. There is very great dyspnoea, with frequent 
 cough, and the signs of emphysema persist on the right side. 
 Last evening the pulse was 120, and the temp. 102.74°. She 
 vomited several times during the night, and had pains in the 
 side when she coughed. Bryonia, 3d dil. 
 
 April 4. No fever last evening, and there is almost no suf- 
 focation. 
 
 By auscultation, it was difficult to find traces of emphysema, 
 and there is almost no prolonged expiration. 
 
 Convalescence was established, and she left us on the 9th 
 of April. 
 
 No. 3, of ward 2, is also occupied by a woman, whose 
 paroxysms of asthma alternate with trifacial neuralgia. Arsen- 
 icum cured the asthmatic paroxysms ; nux vomica, and then 
 belladonna, have been given for the neuralgia, which is princi- 
 pally seated in the branches of the sub-orbital nerve. 
 
 Case XXX YI. — Mrs. Casal, forty-five years of age, en- 
 tered the wards on the 30th of March, and left on the 14th of 
 April. 
 
 This patient still menstruates regularly. For five years she 
 has had hemorrhoids, and when these began she first noticed 
 that she lost some blood at stool. 
 
 Nine years ago she was attacked with bronchitis, which was 
 brought on by a cold, and followed by a cough that lasted two 
 years. This cough, which was loose, and as frequent in sum- 
 mer as in winter, did not at first impede a free respiration. 
 
 The attacks of suffocation, of which she complains, began 
 
ASTHMA. 139 
 
 six or seven years ago. The paroxysms occurred every eight 
 or ten days, as often in summer as in winter, and were usually 
 of short duration. 
 
 During these paroxysms her body would be bathed in a cold 
 sweat. She retained her appetite up to the time of the fit, 
 which is always preceded by dryness of the nose, although 
 ordinarily, when the patient is well, the nose secretes a great 
 deal of mucus. 
 
 Auscultation and percussion showed the existence of a uni- 
 versal transitory emphysema ; the expiration is prolonged and 
 whistling, and the sonorousness- of the thorax is increased. 
 
 This woman is subject to neuralgia of the sub-orbital 
 branches of the right trifacial nerve, and this neuralgia alter- 
 nates with the paroxysms of asthma. 
 
 March 31. Arsenicum, 3d trft., twenty centigrammes in 
 200 grammes water. Three spoonfuls daily. 
 
 April 6. The patient is better in respect to the paroxysms 
 of suffocation, but the neuralgia is worse. Nux vomica, 3d trit. 
 
 April 9. The neuralgia persists. I prescribed belladonna, 
 3d dil. The patient, frightened by the admission of a case of 
 erysipelas of the face, asks to leave the hospital. 
 
 I will call your attention to two other cases of asthma, in 
 order to familiarize you with the treatment of this disease. 
 The first is a case that was cured by ipecac, in the third trit- 
 uration, followed by arsenicum in the same potency. 
 
 A point that has not been made by the author is, that in cases like this 
 it is sometimes a very delicate and difficult thing to bring the patient safely 
 through the climacteric period. For, with a strong liability to asthmatic affec- 
 tions existing at this time, the critical age often increases the difficulty instead 
 of curing it by limitation. The prognosis in a woman who is forty-five years of 
 age, and who still continues to menstruate, should be very guarded. It is for- 
 tunate, however, for women at the menopause, that asthma is twice as common 
 with men as it is with women at any time of life. — L. 
 
 Case XXXYII. — Mrs. Hedoin, thirty-five years of age, 
 entered on the 6th of April and left on the 19th of April. 
 
 This patient has never had hemorrhoids nor any cutaneous 
 disease. She has been troubled in her respiration for the past 
 
140 THE MEDICAL CLINIC. 
 
 eighteen months. For that time, also, the menstruation has 
 been very irregular, the flow slight and accompanied by pains 
 in the region of the loins. 
 
 The attacks of suffocation, of which she complains, have 
 been more severe and frequent since she had the bronchitis last 
 December. 
 
 The paroxysms of dyspnoea come usually at night, and the 
 days are generally calm. The sputa are sometimes streaked 
 with blood. On auscultation, whistling rales both on inspira- 
 tion and expiration may be heard. The expiration is pro- 
 longed. Percussion shows an increased resonance in the lower 
 part of the lungs. 
 
 April 7. Ipecac, 3d dil., every three hours. 
 
 April 8. The night has been very good ; the patient has 
 coughed but little ; there is less oppression, and on examina- 
 tion we find the rales diminished. The same treatment. 
 
 April 11. The cough has diminished considerably ; she 
 complains of pains in the abdomen, and has a slight diarrhoea. 
 Arsenicum, 3d trit., three times daily. 
 
 April 13. No more enteralgia, but she has slight leucor- 
 rhcea. Sepia, 3d trit., three spoonfuls a day. 
 
 April 15. The patient is greatly improved, and leaves the 
 hospital a few days later with no signs of emphysema. 
 
 In the case that follows we owe the cure of our patient to 
 the combined effect of hryonia and ipecac. Ipecac, alone, in 
 the third trituration, was given for three days without effect. 
 A few days later, it is true that ipecac, arrested a return of 
 the paroxysms in twenty-four hours, but then it was given 
 in the first dilution. 
 
 Case XXXYIII. — Mrs. Arnoult, fifty-nine years of age, a 
 domestic, entered on the 7th of February, and left on the 4th 
 of March. 
 
 This woman has formerly had good health, and menstru- 
 ated up to the age of fifty-seven, since which time she has had 
 a dry cough, that is more frequent at night than during the 
 day, and that is always preceded by tickling in the throat. 
 
ASTHMA. 141 
 
 She also suffers from paroxysms of suffocation, which are more 
 frequent in summer than in winter. 
 
 February 9. On examination of the lungs, percussion re- 
 veals a sonorousness over the whole chest. By auscultation, 
 we find a very prolonged expiration in the upper third, and 
 diminution of the vesicular murmur in the lower two-thirds. 
 These signs are more strongly marked on the right side. The 
 chest, therefore, presents all the symptoms of the two varieties 
 of emphysema — the transitory and the confirmed emphysema. 
 
 The patient has attacks of asthma several times during the 
 night, but there is no fever. Ipecac, 3d trit., twenty centi- 
 grammes in 200 grammes of water, one spoonful every three 
 hours. 
 
 February 10. The oppression continues as great as before. 
 
 February 11. Her condition is the same. The same treat- 
 ment. 
 
 February 12. The oppression continues. The right side, 
 which was less involved in the emphysema, is now attacked, 
 and loud rales are heard in the left side. Ipecac, 3d trit., thirty 
 centigrammes. 
 
 February 13. The expectoration, which was scanty, has 
 become very abundant, and is that of bronchitis. There are 
 moist rales throughout the chest. Ipecac, 3d dil., and Bryonia, 
 3d dil., alternately. One spoonful every two hours. 
 
 February 14. The dyspnoea is much less severe. The same 
 treatment. 
 
 February 16. Great improvement in the local and general 
 state of the patient. Arsenicum, 3d trit., three times a day. 
 
 February 17. The paroxysms have ceased; there is much 
 less expectoration. The same' treatment. 
 
 February 18. Continued improvement. 
 
 February 19. Same condition. Arseniate of antimony, 2d 
 trit., three times a day. 
 
 February 20. There is a considerable diminution of the 
 cough. 
 
 February 24. The patient has had another paroxysm. 
 Ipecac, 1st trit. 
 
 February 25. The paroxysms have not returned. Nux 
 vomica, 3d trit. 
 
142 THE MEDICAL CLINIC. 
 
 The improvement was very rapid and uninterrupted until 
 the patient left the hospital, which was on the 4th of March. 
 
 This was a case of what we should call post- climacteric asthma, and the 
 remedy that we have found most useful for it is the sanguinaria canadensis, in 
 the third or the sixth attenuation* Apart from the general indication furnished 
 in diseases affecting the bronchial tubes at and after the change of life, this 
 remedy is called for in case of severe dyspnoea, with a teasing, hacking cough, 
 with dryness in the throat, and an inclination to take a deep inspiration during 
 the paroxysm. 
 
 In a few cases of this form of asthma we have found the apis mellijica, 3d 
 trit., of great service. It has a wider range of use at the menopause than is 
 generally supposed. The symptoms upon which we have prescribed it, after a 
 careful diagnosis of the case, are inability to lie on the left side; hurried and 
 difficult breathing, with a feeling of suffocation, fever and headache, and an 
 aggravation of the cough by lying down, or by sleeping. In one case these 
 symptoms were post-puerperal, and were accompanied by swelling and pain in 
 the right ovary, and tenderness over the uterine region. — L. 
 
 Of the Choice of the Attenuation. 
 
 Apropos of these cases, gentlemen, I wish to say a word to 
 you regarding the choice of the attenuation. I shall not speak 
 now of palliative medication, nor of those cases in which the 
 physician desires to obtain the physiological effects of a remedy, 
 as, for example, where it may he necessary to produce vomit- 
 ing, or purgation, in order to evacuate a poison, or to stimu- 
 late the uterus to contract in aid of delivery. In such very 
 simple cases, every one knows that a dose must be given which 
 is in accordance with the eifect that we wish to obtain, and 
 that, in such cases, the dose has long been settled by general 
 experience. 
 
 The question that concerns us at present is a much more 
 difficult one, id est, to determine the dose in the homoeopathic 
 treatment. 
 
 We might say, as in the time of Hartmann, that this is an 
 arbitrary matter, and that it is optional with the physician, 
 and that each doctor must be governed by his own experience, 
 in order to be able to justify such very opposite precepts. 
 
OF THE CHOICE OF THE ATTENUATION. 143 
 
 Some have taught the giving of high dilutions in chronic 
 diseases, reserving the lower ones for the treatment of acute 
 affections.* 
 
 This precept is much too absolute to be true, as may be 
 shown by citing the use of arsenic in chronic diarrhoea, of iion 
 in chlorosis, of mercury and the iodide of potassium in syphilis, 
 all of which are given in strong doses for chronic diseases. Some 
 physicians are in the habit of prescribing the mineral reme- 
 dies in the higher potencies, as the 30th dilution, for ex- 
 ample, and the vegetable remedies in from the sixth to the 
 twelfth potencies. You have observed that this pretended 
 rule is successfully broken by us every day. 
 
 Other physicians have contended, and with more show of 
 reason, that substances which, of themselves, are inert, such 
 as carbo-vegetabilis, silicea and lycopodium, need extreme trit- 
 uration and dilution, in order to develop their curative prop- 
 erties, and that in consequence, the higher dilutions, from the 
 twelfth upward, are preferable for these substances. 
 
 There are yet others who accept, as pure gold, the theory 
 of dynamizaticn, and who, believing firmly that each new 
 dilution develops an additional power in the remedy, con- 
 clude that it has no limit. The believers in this theory have 
 left the 30th dilution, which Hahnemann was accustomed to 
 use, far behind, and they have successively adopted the 60th, 
 100th, 1000th and 1500th. With no rule to guide them, these 
 physicians have reached the 40000th dilution, and have indorsed 
 the action of the contact potencies, id est, it suffices for them 
 that one globule, saturated with a medicinal substance, be 
 placed in contact with some inert and unmedicated globules, 
 for the latter to acquire, in a high degree, this medicinal power ! 
 
 * Mure, of Geneva. 
 
144 THE MEDICAL CLINIC. 
 
 Certainly the greatest enemies of homoeopathy are not in 
 the old school ; and we may well say, with Hartmann, that 
 since the death of Hahnemann these ideas have been pushed 
 to the very limit of extravagance. 
 
 Clinical experience they reply to us is, you say, your only 
 rule for determining the dose and the strength of your reme- 
 dies ; but clinical experience has proved the effect of remedies 
 in the highest and most extreme dilutions, and has fully justi- 
 fied what you call extravagance. 
 
 If clinical experience had so pronounced in their favor, I 
 should submit to its sovereign decision, because there is no 
 absolute certainty in therapeutics, and, consequently, no science 
 apart from the bed-side. 
 
 But what the partisans of extremely high dilutions call 
 clinical experience, is limited to the most shameless and utterly 
 truthless affirmations, or to the publication of cases without 
 a diagnosis, and without even sufficient details to make it pos- 
 sible to examine them, and, for the most part, so ridiculous 
 that the Homoeopathic Society of Paris would not permit their 
 publication. 
 
 Do we, then, intend to fix the 30th dilution as the extreme 
 limit of the action of a remedy ? Certainly we have no right 
 to fix any such limit. But we do protest that none should 
 venture very far on this perilous ground, except he be a true 
 clinical physician, and, I will add, unless he is gifted with 
 enough good sense and discernment to keep clear of all illu- 
 sions. 
 
 In the face of such an extravagance as this, it is not as- 
 tonishing that a great many physicians have adopted the use 
 of ponderous doses in their practice, — doses that approach the 
 mother tincture, such as the first, second and third dilutions. 
 Shall we say, as some do, that the important thing in the 
 homoeopathic treatment is the choice of the remedy, and 
 that the attenuation is of little account? 
 
OF THE CHOICE OF THE ATTENUATION. 145 
 
 This would be a convenient way of getting out of the dif- 
 ficulty, but it would not solve the question. To cite only 
 those examples which you cannot have forgotten, the hemor- 
 rhoidal patient to whom you remember we gave nux vomica, 
 12th trit., without effect, and who was afterward greatly re- 
 lieved by nux vomica, 30th trit. (Case XXIII), and the pa- 
 tient with phthisis, with whom you recollect drosera failed 
 in the third and twelfth dilutions, but was entirely successful 
 when given in the mother tincture (Case XXYII). 
 
 In each of these cases the medicine was well chosen, but 
 it was effective of good only when it was given in the dose 
 that was most appropriate to each particular case. The po- 
 tency is, therefore, of great importance. 
 
 If no one has already made an unvarying rule for deter- 
 mining the choice of the attenuation, it must be because such 
 a rule is not yet possible, and because we do not yet pos- 
 sess the necessary evidence for the solution of this very dif- 
 ficult question. It seems to me that there is no better way 
 of helping to settle this question than by summing up the 
 facts, which are known to be unquestionable. For example : 
 
 1st. The efficacy of different potencies of the same medi- 
 cine varies with the diseases in the treatment of which they 
 are indicated ; thus, quinine should be used when indicated 
 by the totality of the symptoms in the treatment of inter- 
 mittent fevers and of chronic diarrhoea. The potency that 
 is most successful, and which is consequently the most strongly 
 indicated, in intermittent fever is the strong one. On the 
 contrary, that which is most efficacious in the treatment of 
 chronic diarrhoea is of a medium dilution, or, say, the sixth 
 to the twelfth dilution. 
 
 2d. In the treatment of the same disease the attenuations 
 vary with the different remedies ; for example, in the treat- 
 ment of intermittent fever, if quinine is indicated, it should 
 10 
 
146 THE MEDICAL CLINIC. 
 
 be given in strong doses ; but when mix vomica or arsenicum 
 are indicated, the higher dilutions, from the twelfth to the 
 thirtieth, are of greater benefit. 
 
 From these two undoubted facts we may, therefore, con- 
 clude that neither the nature of the remedy nor the kind of 
 the disease can serve as the basis for the choice of the po- 
 tencies, inasmuch as the most appropriate doses vary with 
 the diseases and with the remedies. 
 
 The faculty of feeling the influence of external causes, 
 and consequently that of a medicine, which is nothing else, 
 and which is a foreign agent to the organism, varies with 
 each person, and this individual susceptibility, this idiosyn- 
 crasy, is the cause of the necessary variation of the attenua- 
 tions. This element of uncertainty is a part of the very na- 
 ture of man ; we cannot, therefore, hope to eliminate it, but 
 must accept the fact that there is always something unknown 
 in this question of the dose and the potency, and that the 
 answer differs with the individual. 
 
 There is another modifying element that sometimes influences our success, 
 or our failure, with the medium and the higher attenuations especially. Whether 
 it is the faith of the doctor, or the faith that the patient has in him, that causes 
 him to succeed with an exclusive potency where others would fail with it, we 
 cannot say; but it is morally certain that some unrecognized influence of this 
 kind, which never came from the pharmacy, or from the medicine case, puts a 
 peculiar emphasis upon much of our experience without getting the proper 
 credit for it. If the scales were balanced, we should find that in many cases, 
 and sometimes in whole communities, the physician's manner and the patient's 
 confidence and impressibility have quite as much to do with the cure as the 
 mere choice of the attenuation after the remedy had been selected. This fact, 
 which is a matter of daily observation, makes it impossible for the members of 
 our school of practice ever to agree upon the comparative efficacy of any range 
 or class of potencies whatever. Taking all the conditions and circumstances 
 into account, each one must settle this question for himself. — L. 
 
 But what should be the course of the practitioner in the 
 presence of such a difficulty? For those remedies which 
 are known, and for the use of which we possess positive 
 
OF THE CHOICE OF THE ATTENUATION. 147 
 
 clinical indications, we should employ the dose that expe- 
 rience has settled upon. If this fails, whilst the remedy is 
 suited to the particular case, we should change the dilu- 
 tion instead of changing the remedy. 
 
 When a medicine is not well understood, and the choice of 
 the potency has not been determined by clinical experience, 
 it is best to commence with the lower potencies, because the 
 positive indications for the newer remedies not being well 
 denned, the chance for an appreciable effect is greater from 
 them. For in general, the more strictly homoeopathic the 
 indication, the less the need for the stronger dose. 
 
 Those of our readers who desire to have the latest views of Dr. Jousset (for 
 he is a progressive man) upon this subject, will find them in the Transactions 
 of the International Homoeopathic Congress, held in Paris, in August, 1878, 
 page 15 et seg. — L. 
 
LECTUKE XIII. 
 
 Summary. — Croup; indications for tracheotomy ; case. The cure of phthisis ; 
 case; the vegetable diet in phthisis. Rule for the choice of remedies. In- 
 dividualization. 
 
 Croup. 
 
 Gentlemen : I will first call your attention to the patient 
 who has successfully passed through the operation of trache- 
 otomy for the croup. The case is as follows : 
 
 Case XXX. — Brassard, a butcher boy of fifteen and a-half 
 years, entered the hospital on the 8th of April. 
 
 We learn from the patient, and from the relative who 
 brought him to us, that his ill-health began three months 
 ago with a dry cough, which at times was accomjDanied by an 
 expectoration that was streaked with blood. His general 
 health remained good, and the boy continued his occupation 
 until the 25th of March. At this time the disease passed into 
 the acute stage. There was a continuous fever, and the patient 
 was confined to his bed or room with dyspnoea, a painful cough, 
 hoarseness and emaciation. The boy adds that eight days ago 
 he expectorated a bit of false membrane, a fact the impor- 
 tance of which we did not at first appreciate. 
 
 April 9. He has a high fever. Last evening the tempera- 
 ture was 102.20°, and the pulse 100. There is complete apho- 
 nia, with a dull, hoarse and painful cough ; dyspnoea, which is 
 worse in paroxysms. During these paroxysms, both inspiration 
 and expiration are whistling ; but when the patient is calm, the 
 respiration is calm and quiet. There is no perceptible oedema 
 of the folds of arytheno-epiglottis. On auscultation, we find the 
 respiratory murmur obscure, and an echoing of the laryngeal 
 sounds ; some scattered sibilant rales ; the relative dullness at 
 the apex of the right lung ; the fever is lower than it was 
 last evening; the temp, is 100.76°, and the pulse 96. Phos- 
 
croup. 149 
 
 jphorus, 12th dil., six globules in 200 grammes of water, and 
 one spoonful every two hours. 
 
 April 10. Last evening the temperature was only 101.12°, 
 and the pulse 100. This morning the fever is much higher, 
 the temperature being 102.92°, and the pulse 112. The patient 
 is red, perspires profusely, and the dyspnoea is worse. Aconite 
 in the mother tincture, twenty drops in 200 grammes of water, 
 one spoonful every two hours. 
 
 April 11. The fever has subsided since last evening ; the 
 temp, is 102.56°, and the pulse 108. This morning the temper- 
 ature is again lower, being 101.84°, although the. pulse has in- 
 creased to 112. The patient is much calmer, and the dyspnoea 
 less. The same treatment. Toward noon the dyspnoea in- 
 creased very much, and the patient has had fits of suffocation, 
 during which the face became purple. Tracheotomy was de- 
 cided upon, and the operation was performed by Dr. J. -P. Tes- 
 sier, assisted by Dr. Guerin and by the interne, M. Scheffer. 
 
 April 12. Morning. The patient is much relieved ; he has 
 thrown up three false membranes through the canula. The 
 respiration is still rapid; the temp, is 102.20°, and the pulse 
 116. He takes bryonia, 12th dil.; with milk for drink and for 
 nourishment. 
 
 Evening. Increased fever; temp. 103.28°, the pulse 140; 
 the dyspnoea is more pronounced, and there is great restless- 
 ness. Cyanide of mercury, 2d trit., twenty centigrammes in 
 200 grammes of water, one spoonful every hour. 
 
 April 13. Improved ; the fever has decreased ; the temp. 
 is 102.56°, and the pulse 120. Evening. Temp. 102.20°, pulse 
 124. The patient has no appetite yet, although he drinks milk, 
 some drops of which pass through the canula. The same 
 treatment. 
 
 April 14. He slept last night, the fever decreasing. Morn- 
 ing temp. 100.76°; evening temp. 101.12°; the pulse in the 
 morning was 112, and in the evening 108. The respiration 
 is easy, and the patient expectorates mucus freely by the canula. 
 He still takes milk. The canula is changed. The same treat- 
 ment. 
 
 April 15. He is convalescent ; the fever is entirely gone. 
 Morning temp. 98.96°, pulse 88; slight increase in some of 
 
150 THE MEDICAL CLINIC. 
 
 the symptoms. Evening temp. 100.76°, the pulse, on the con- 
 trary, dropped to 84. The patient sleeps well, has a little 
 appetite, is cheerful, and breathes easily. The same treatment. 
 I left the patient at this time in the care of Dr. Fredault. 
 The febrile movement stopped entirely on the 16th, and the 
 temperature fell to 99.32°. The canula was removed a few 
 days later, and the cure was complete in a short time. 
 
 The erroneous statements made by the relatives of this 
 patient, concerning the onset of the disease, which they fixed 
 at three months previous to his coming to us, his age, and 
 the absence of false membranes in the pharynx, misled us 
 for a short time in our diagnosis. However, the aphonia, the 
 hoarse, dull and painful cough, the dyspnoea, coming in 
 paroxysms, with the symptoms on inspiration, made it im- 
 possible for us to doubt the seat of the lesion. Beyond a 
 doubt, the affection was laryngeal. The laryngeal whistling 
 during expiration, as well as during inspiration ; the absence 
 of oedema of the folds of the glottis, that was perceptible to 
 the touch, excludes the possibility of the affection that is im- 
 properly styled oedema of the glottis. I confess that I did not 
 think of croup in a patient who was fifteen years old, where 
 there was no diphtheria of the pharynx, and where the disease 
 had already lasted for three months. This last circumstance 
 caused me to make the diagnosis of acute tuberculosis of the 
 larynx. 
 
 In the progress of this disease, I could not but admire the 
 precept of Hippocrates: u An error in diagnosis is sometimes 
 the fault of the physician, often of the patient, and oftener 
 still of those about him." 
 
 In this case I was, beyond a doubt, the victim of the error 
 ab astantibus, and the three months' duration, which was falsely 
 attributed to a disease that had begun but a few days before, 
 had totally changed the aspect and signification of the patho- 
 logical picture. 
 
THE VEGETABLE DIET IN PHTHISIS. 151 
 
 In no single respect is the author's sincerity and merit more pronounced 
 than in this frank avowal of an error in diagnosis. We can trust him to the 
 verge of the incredible if he tells the truth when he has blundered. Every 
 man, woman and child, who drives a horse and carriage down the street, thinks 
 himself or herself capable of doing it more skillfully and adroitly than anybody 
 else; and almost every doctor, who prescribes for a patient, supposes himself or 
 herself to be equally skilled, and quite as infallible in the art of diagnosis. — L. 
 
 The dyspnoea, increasing hourly, with threatened asphyxia, 
 were the clearly constituted indications for tracheotomy. There 
 was, as expressed by Galen, i ' the evident necessity of a fixed 
 course of action," and Dr. Tessier, in whose charge I had 
 placed the patient, did not hesitate to act. 
 
 The effect of the cyanide of mercury, prescribed after 
 the operation, was eminently favorable in arresting the prog- 
 ress of the disease, and in contributing to its cure. As for 
 the tracheotomy, it removed but one cause of the disease ; 
 and here we repeat what we wrote in 1844 (in the Archives de 
 Medecine), while we were yet an interne of the Hojpital des 
 JEnfants : "Tracheotomy does not comprise the whole treat- 
 ment for croup, as Trousseau teaches, but the treatment of 
 one cause of the disease only — suffocation from obliteration 
 of the larynx. This operation is indicated whenever the par- 
 oxysms of dyspnoea increase regularly, threatening the patient 
 with death by asphyxia." 
 
 The Vegetable Diet in Phthisis.* 
 
 In No. 1 of the first ward is a very interesting case as re- 
 gards the influence of the vegetable diet in phthisis. Here 
 is an abridged history of the case : 
 
 Case XXXI. — Francoise Degage, aged twenty-eight years, 
 entered the hospital on the 2d of April, and left on the 14th 
 of April. 
 
 Ten years ago this patient was prescribed for at the dispen- 
 sary in Rue de Verneuil, and now she enters our hospital for 
 
 * We have styled this the Vegetable Diet, for lack of a better name. — L. 
 
152 THE MEDICAL CLINIC. 
 
 the third time. At its beginning, ten years ago, her disease 
 presented all the symptoms of phthisis, — incessant cough, 
 emaciation, hemoptysis and fever, with night-sweats and mu- 
 cous rales at the apices of the lungs. 
 
 She has been on the vegetable diet, almost without in- 
 terruption, for several years, and has greatly improved. 
 
 April 3. Her present symptoms are : a comparative dull- 
 ness in the apex of each lung, but particularly of the right one ; 
 moist rales, but which are very rare in the apices of the lungs ; 
 the expiration is long, and whistling in both lungs ; dyspnoea ; 
 frequent cough ; mucous expectoration, but she has some ap- 
 petite and strength. Phosphorus, 12th dil. 
 
 April 5. Having no result from the phosphorus, I pre- 
 scribed ipecac, 12th dil., and oryonia, 12th dil. 
 
 April 10. Great improvement in the cough and the dysp- 
 noea. The menses appear unexpectedly, and are accompanied 
 by diarrhoea. 
 
 April 14. She left the hospital greatly improved. 
 
 When this patient came to the dispensary, in the Rue de Yer- 
 neuil, now some six years ago, she presented all the character- 
 istic signs of phthisis, with softening of the tubercles of the 
 apices of the lungs. The same positive signs are to be found 
 there to-day, — dullness of the apex of each lung, but especially 
 of the right one, and some mucous rales in the same location ; 
 but the other portions of the lungs show the certain signs 
 of emphysema in the prolonged and whistling expiration. 
 There are, therefore, two lesions, of which the latter, or the 
 emphysema, seems to have completely arrested the progress 
 of the former, or the tuberculosis. 
 
 At the same time that we observed this fortunate develop- 
 ment of the lesion, the patient began to gain flesh, her 
 strength returned, and she entirely lost the appearance of a 
 consumptive, which she had at the beginning. For six years 
 she has lived almost entirely on a vegetable diet, and it is 
 chiefly to this diet that we must refer the favorable change 
 in her condition. 
 
THE VEGETABLE DIET IN PHTHISIS. 153 
 
 Eight years ago I commenced to prescribe the vegetable 
 regimen for phthisis. I borrowed this practice, which may be 
 found, for that matter, at different epochs in medical tradition, 
 from an old physician, Dr. Brunner, who had made a great 
 study of urology. This regimen consists in withholding all 
 meats and wines from consumptives. The aliment, which 
 appears to us the most appropriate in phthisis, consists of 
 farinaceous articles and milk, soups of all kinds, broths, purees, 
 all vegetables, including salads, all fruits, and eggs. Certain 
 fish, and shell-fish also, afford a sufficient variety for a diet, 
 which must, in some cases, be taken for years. The difficulty 
 of getting good milk in some of the large cities, and the dis- 
 taste that many adults have for it, caused me, almost from the 
 first of my prescribing this diet, to replace it by meat-broth, 
 from which the grease must be carefully removed. With this 
 addition, the patient bears this diet much better than without 
 it. 
 
 I have found no bad effect from permitting such patients 
 
 as cannot content themselves with water at their meals, to 
 drink beer instead. In this I except, of course, the English 
 beer, which contains entirely too much alcohol. I also per- 
 mit the use of coffee and tea where they have no bad effect 
 on the cough, and the patient is accustomed to their use, and 
 where they constitute, as we call it now-a-days, an economical 
 remedy. 
 
 I return to the contra-indications of the vegetable diet in 
 the treatment of phthisis, so that such of you as may pre- 
 scribe it on my recommendation may not be disappointed. 
 In the cachectic stage, which is characterized by hectic fever, 
 colliquative discharges and increasing inability to quit the 
 bed, the vegetable diet is positively contra-indicated, and its 
 use will only precipitate the death of the patient. 
 
 In the early period this regimen is well borne, and, pro- 
 
154 THE MEDICAL CLINIC. 
 
 viding the patient can easily digest the materials that compose 
 this diet, is of great service ; but a bad digestion, acidity, and, 
 above all, a diarrhoea, constitute a decided contra-indication for 
 its use. In these latter cases this diet should not, however, 
 be entirely abandoned, for often by giving the patient meat 
 three times a week, and a little wine at each meal, we may 
 arrange a diet that will be easily borne, and from which ex- 
 cellent results may be obtained. This is the line of conduct 
 that we followed in Case No. IV. 
 
 A certain proportion of patients will not conform to the 
 vegetable diet, either because it is distasteful to them, or, 
 more frequently, on account of their prejudice against it. In 
 the former case, we should tax our ingenuity to find such 
 food as will suit the taste of the patient ; in the latter, it 
 is best to say very decidedly that we will not, under such cir- 
 cumstances, take the responsibility of the result. But it is 
 above all in the very commencement of phthisis that the 
 vegetable regimen is of the greatest benefit. We have col- 
 lected a large number of cases in proof of this view, — cases, 
 for example, in which the patient has coughed only a few 
 months, and where there is already an observable emacia- 
 tion, a slight difficulty of breathing, and sometimes hemop- 
 tysis and dullness, with dry rattling at the apex of the lung. 
 These symptoms often disappear after a few weeks of this 
 particular regimen. You have seen a marked illustration of 
 this in Case ~No. V. 
 
 When the patients are getting better, they should not 
 return at once to an ordinary diet. If the disease is in its 
 early stage, I do not permit either wine or meat until the 
 cough has entirely ceased. I then allow meat three times 
 a week, once each day, and if the improvement is not de- 
 layed by this, I allow the patient to return to his usual bill 
 
THE VEGETABLE DIET IN PHTHISIS. 155 
 
 of fare, charging him not to abuse the use of meat or of 
 wine, and to drop them both if the cough reappears. 
 
 In the more fully developed stage, where the diet must 
 continue for years, I am less severe ; and when the cough 
 is very much better, the nights are good, and the patient 
 gains flesh, I allow meat three times a week, but once on 
 each day ; to be replaced by the stricter regimen whenever 
 it produces an aggravation of the symptoms. Patients bear 
 this diet very well, even while they are at work. 
 
 I will detail some of the symptoms that I have observed 
 in patients with phthisis when they have been placed upon 
 this meagre diet. During the first two weeks they complain 
 of loss of strength, and this complaint, although it is partially 
 due to imagination, has been too often made not to have some 
 truth in it. At the same time, it is exceptional, if the patient 
 does not find an improvement in his sleep, and that the cough 
 is less frequent, with a general sense of relief, which comes 
 from the subsidence of the febrile movement. This relief 
 will encourage him to continue the diet, and at the end of 
 three weeks there is a very evident improvement in the pa- 
 tient's condition. Shortly after, if the regimen be continued, 
 the emaciation is arrested, and then the patient begins to gain 
 flesh. This last phenomenon is the certain sign of the 
 successful resort to the vegetable diet in the treatment of 
 phthisis. 
 
 But how does this diet act? The farinaceous substances 
 and the milk, which form its basis, are recognized by all 
 hygienists as the elements that increase the flesh. The vegeta- 
 ble diet is, therefore, essentially a fattening diet ; now a tuber- 
 culous patient, who gains flesh, is certainly one who is improv- 
 ing, and it is, therefore, not surprising that the vegetable diet 
 should be useful in such cases. But, we repeat, it is impera- 
 
156 THE MEDICAL CLINIC. 
 
 tive that the diet should agree with, and be grateful to, the 
 organism. This rigid diet would not be proper in case of 
 inanition, for in such a case it is necessary, in order to produce 
 the desired effect, that the patient should absorb a considerable 
 amount of substantial food. 
 
 The prejudices that generally exist in medicine, upon the 
 etiology of phthisis, contribute very greatly toward preventing 
 physicians from using the diet that we have advised in the 
 treatment of this disease. That tuberculosis is the result of 
 an enfeeblement of the organism, is a proposition which is 
 generally accepted as an axiom, and which has its corollary 
 in the affirmation that a strong animal, and a no less strong 
 alcoholic diet, is the best prophylactic of pulmonary phthisis. 
 
 This etiology, which we dispute, rests not only upon theo- 
 retical ideas, which are badly elaborated, but also upon certain 
 well-known facts, from which certain inferences have been 
 drawn that do not belong to them. Thus the disease is often 
 caused by a too prolonged lactation, by venereal excesses, by 
 living in dark and badly ventilated rooms, or by great grief; 
 and in such cases it is impossible to say that tuberculosis is 
 the result of an enfeeblement of the organism. If the pre- 
 disposition to pulmonary phthisis did not already exist, all of 
 the occasional causes just enumerated could not produce it; 
 while, on the contrary, we know that it appears in persons 
 who are predisposed to it in spite of the most fortifying ali- 
 ment. 
 
 We cannot forget that phthisis, like other tuberculous affec- 
 tions, numbers among its victims, in the wealthy classes, those 
 young subjects who are well nourished, and in whom there 
 is no cause for enfeeblement. Indeed it is especially dur- 
 ing youth, the age in which the vitality is strongest, that 
 phthisis is the most frequent. Recent researches have demon- 
 strated that the blood of a sufferer from phthisis is, at the 
 
ON THE CHOICE OF REMEDIES. 157 
 
 beginning of the disease, very rich in globules, while, on the 
 other hand, chlorosis is an affection with which phthisis has 
 no necessary connection. 
 
 The tendency to classify all diseases into sthenic and 
 asthenic is a systematic idea which only results in mislead- 
 ing the physician, and in causing him to lose sight of a 
 more exact etiology. My own observations, which, it is 
 true, are imperfect, have shown me that phthisis is ex- 
 tremely rare among the religious sects, where, according to 
 the rules of the order, they abstain almost entirely from 
 meat ; and this is the case, notwithstanding the fatigues of 
 teaching or of preaching, and the living of this class in the 
 large cities. Phthisis is, on the contrary, to be found, but 
 too frequently, in seminaries and among those religious teach- 
 ers who are not restricted to the vegetable diet. 
 
 The working class in cities who eat meat twice a day, 
 and who abuse the use of alcoholic drinks, furnish a large 
 proportion of the deaths from pulmonary phthisis. 
 
 Facts, therefore, lead us to conclude that the use of meats 
 and wines, far from preventing this form of phthisis, seem 
 rather to incline the patient to it, since the greater number 
 of its victims are persons who use such food most freely, 
 while such as abstain from it are almost exempt from that 
 disease. 
 
 On the Choice of Remedies. 
 
 Before closing this lecture I have something more to say 
 to you of the rules which should guide us in the choice of 
 a remedy. 
 
 The formula similia similibus expresses, as we have often 
 said, the law of positive indications in the treatment of dis- 
 ease ; but it must be interpreted in its largest sense, and it 
 must also be confirmed by clinical experience. The formula 
 employed by Hahnemann and the first homoeopaths, is this : 
 
158 THE MEDICAL CLINIC. 
 
 " Give the medicine which is indicated by the totality of the 
 symptoms." This formula is incomplete, for you can readily 
 understand that the ulceration of Peyer's patches, pulmonary 
 hepatization and pleuritic eifusion are morbid phenomena, 
 which are at least as important as febrile heat, thirst, cough 
 and diarrhoea. However, the early homoeopathic physicians 
 did not include these morbid processes in their picture of 
 similia, because these are lesions, and the formula expressly 
 says the totality of the symptoms. These lesions, for that 
 matter, are not apparent, and cannot be known except by 
 diagnosis, and diagnosis was a secondary affair with the first 
 practitioners of the homoeopathic school. 
 
 We should, therefore, complete the formula cited above, 
 and say that the remedy is indicated by the totality of the 
 sy?nptoms and of the lesions. 
 
 But this is not all, for there are diseases in which indi- 
 cations may be drawn, not only from the totality of the 
 symptoms and of the lesions, but also from the course of 
 the disease. For example, intermittent fevers, and all the 
 diseases which accidentally assume an intermittent type, re- 
 quire those remedies which respond to this type, the most 
 prominent of which is quinine, then arsenic, nux vomica and 
 many others. 
 
 We suggest, therefore, that the law of similars should 
 be formulated thus : Administer the remedy which corre- 
 sponds to the totality of the symptoms, the lesions, and 
 to the course of the disease, or, in other words, to the dis- 
 ease in its totality. Thus, without believing in specifics, and 
 without teaching that for each morbid affection there is a 
 corresponding treatment, or an especial remedy, which would 
 be false, we insist upon it that there is no reliable and sat- 
 isfactory therapeutics apart from the diagnosis of the mor- 
 
ON THE CHOICE OF REMEDIES. 159 
 
 "bid condition. It is in fact this diagnosis .which shows us 
 not only the symptoms, but the lesions and the progress of 
 the disease, but which gives the physician a true view of 
 the totality of the morbid phenomena. Without this diag- 
 nostic ability the doctor is like a nurse who sees only the 
 most conspicuous of the symptoms in a given case ; he can 
 have no idea of their connection or of their rank or order. 
 You have had in our clinic two examples in which serious 
 trouble had resulted from the lack of a proper diagnosis. The 
 first of these, you recollect, was the case of the old woman 
 who entered the hospital on the ninth day, of an unrecog- 
 nized pneumonia, and who died a few days after coming to 
 us. In the case of this patient no diagnosis had been made, 
 and the aconite, which was indicated by the violence of the 
 fever and the agitation of the patient, was continued for 
 eight days without modifying the disease. 
 
 The importance of the diagnosis in this case was very 
 great, for it would have added to the totality of the external 
 symptoms, the emphatic development of the pulmonary le- 
 sions, which call for bryonia and phosphorus. 
 
 More recently still, you have seen us hesitate with regard to 
 an obscure case of croup, and seen us prescribe phosphorus and 
 aconite on purely symptomatic indications, and without effect ; 
 whereas the bromine, bryonia and especially the cyanide of 
 mercury which were indicated by the diphtheritic lesions might 
 have been, if given in season, alone sufficient to cure the 
 patient. 
 
 In a case that came to us from Baltimore, the patient had been ill for four 
 years, or since the birth of her last child. Her condition was really deplorable. 
 The menses were regular, but scanty ; there was much intra-pelvic pain and dis- 
 tress; spinal irritation, and sleeplessness, with a complete loss of appetite. Men- 
 tally she was on the verge of insanity; nothing on earth interested her; her 
 lovely child, her sister, her friends, society, the church, were very distasteful ; 
 she could not read or think with any diversion or satisfaction, and she became 
 •emaciated and wretched. She had had treatment from both and all schools of 
 practice, had worn pessaries, and passed through the purgatory of leeching and 
 
160 THE MEDICAL CLINIC. 
 
 blistering, starvation and hydropathy, without being benefited in the least.. 
 Locally there was an extensive abrasion of the cervix uteri, to which I applied 
 the oleaginous collodion. She was of a rheumatic diathesis, which, with the 
 character of the suffering and of the mental symptoms, indicated macrotin. She 
 was given this remedy in the third decimal trituration. In a short time she be- 
 gan to improve, and in a few weeks was quite well again. She took no other 
 remedy. Two years have now passed and there has been no return of the old 
 troubles. She has gained in flesh, is rosy and hearty, and the centre of attrac- 
 tion for a large circle of friends. — L. 
 
 On "Individualization." 
 
 Our brother physicians have reproached us for not "individ- 
 ualizing " in the choice of our remedies. Let us see what is 
 to be understood by the term individualization in therapeutics, 
 and to what extent on this point we fall under the lash of our 
 critics. 
 
 The extreme homoeopaths mean by "individualization," to 
 attach no value to diagnostics (people generally attach little 
 value to that of which they are ignorant), and they seek the 
 proper remedy only through the guidance of certain symptoms 
 proper to each individual case that they have to treat. Thus, 
 they prescribe carbo vegetabilis for a patient who is affected with 
 a cerebral tumor, simply because he expressed the need of fan- 
 ning himself; or they give nitric acid to another who has an- 
 gina pectoris, because he is relieved by riding in a carriage ; 
 or chamomilla for the croup, because the child is easier when it 
 is carried about in the arms. There are those who consider 
 this the highest order of therapeutics. 
 
 For ourselves, we declare that we will have nothing to do 
 with this kind of individualization ; and that we will not con- 
 sent so to degrade the system of therapeutics that was raised so 
 high by Hahnemann himself. I know that by this method 
 some chance successes have been obtained, but it has been at 
 the cost of disasters that we never can fully realize. 
 
 As we view it, individualization is the searching out of all 
 the peculiarities which the case of the patient whom we have 
 
ON kk INDIVIDUALIZATION. 161 
 
 to treat presents. We say the patient, and not the disease', and 
 herein we are to be distinguished from those who use specifics, 
 and who pretend to have a ready-made treatment for each dis- 
 ease, and who literally cure diseases by their names. We do 
 not treat pleurisy, pneumonia, cholera, etc. , but we treat patients 
 who are ill with pleurisy, pneumonia, cholera, etc. 
 
 Thus understood, individualization takes note not only of 
 the diagnosis of the various diseases, but also of their form and 
 variety ; of epidemic influences ; of the stage of the disease, its 
 complications, and the idiosyncrasies of th,e patient, — idiosyn- 
 crasies which sometimes are strangely revealed by those special 
 symptoms to which the most rigid homoeopaths attach so great 
 an importance. 
 
 These particular symptoms belong to the individual more 
 than to the disease, and they form no part of the nosographic 
 description. They are of real importance, however, in decid- 
 ing upon the choice of a remedy, where several remedies are 
 equally indicated by the totality of the morbid phenomena. 
 For example, here is a patient with pleurodynia, characterized 
 by pain under the breast ; this pain is intense, increased by res- 
 piration, and by coughing. Several remedies are appropriate, 
 among others nux vomica and bryonia. If the patient is re- 
 lieved by lying on the sound side, nux vomica is indicated ; on 
 the contrary, if he is easier when resting upon the affected side, 
 bryonia is the proper remedy. Thus the position of the patient, 
 by aggravating or relieving the pain, is, in this case, the symp- 
 tom which individualizes the case, and decides the choice of 
 the remedy. 
 
 We differ in another respect from the early homceopathists 
 in the great importance that we attach to clinical experience. 
 Hahnemann and his first disciples expressly advised against 
 the drawing of any indications whatever from the use of reme- 
 dies in disease, ab usu in morbis. A precept so opposed to a 
 11 
 
162 THE MEDICAL CLINIC. 
 
 sound medical judgment could not be enforced for any consid- 
 erable time, and we believe that there are few physicians 
 to-day who uphold this extreme doctrine in therapeutics of 
 taking no note whatever of clinical experience. 
 
 Beyond a doubt, the law of similars was the guide for ho- 
 moeopathic physicians in finding the remedies which they pre- 
 scribed for their first patients ; but it is clinical experience that 
 has definitely settled their practice. When the first homoeo- 
 paths found themselves face to face with the cholera, and with 
 dysentery, the law of similars offered them a certain number of 
 remedies ; but it was clinical experience that fixed the value of 
 veratrum, of arsenicum, of cuprum, of carbo-vegetabilis, and of 
 camphor, in the cholera ; and of ipecac, of mercurius, of arsen- 
 icum, and of phosphorus, in dysentery. 
 
 The proof of the insufficiency of the law of similars to 
 determine the treatment of a disease is in the changes that have 
 been made by clinical experience in the practice of most phy- 
 sicians. Who treats the croup to-day with aconite and spongia, 
 or typhoid fever with the rhus toxicodendron ? To what do 
 we owe the precise indications for cantharis in pleurisy, and 
 for apis mellifica in ulcerative keratitis, if not to clinical ex- 
 perience ( 
 
 Clinical experience confirms or weakens the appropriate- 
 ness of the choice made by the law of similars ; it proves that 
 the cure has been well or badly made. Clinical experience 
 decides upon the value of the indications, and eliminates the 
 remedies that are unreliable. It declares the worth of reme- 
 dies in a given case authoritatively. Thus veratrum, tartar 
 emetic, aconite and colchicum are indicated for the symptoms 
 of confirmed cholera, but experience has long ago proved the 
 superiority of veratrum. The spasmodic cough in phthisis, 
 with the vomiting of food, demands drosera, hepar sulphur, 
 silicea, etc.; but clinical experience has placed drosera at the 
 head of the remedies indicated in such cases. 
 
(w "individualization." 163 
 
 Lastly, clinical experience eliminates those remedies whose 
 action is uncertain, and their number is very great. How 
 many of these remedies appear with a pathogeny that is more 
 or less complete, and with promises, according to the law of 
 similars, of brilliant success, and how many return to the 
 obscurity in which they should have been permitted to rest! 
 Who of us has forgotten the marvelous effects promised from 
 glonoine in headaches, or from gelsemium, which was to cure 
 meningitis, or from thalium, a specific for the affections of the 
 spinal marrow, and of many others which cumber the pages 
 of our periodicals and the shelves of our pharmacies ? 
 
 The laborious researches of our brethren produce new prov- 
 ings without end ;. the clinic takes possession of these new 
 agents, and, rejecting such as are worthless, it retains with 
 gratitude such as sanguinaria, apis mellijlca, actea racemosa, 
 and numerous others that are of the greatest service to us 
 every day. It is, finally, the law of similars which indicates 
 to the physician the proper remedies in the treatment of dis- 
 ease, but it is - clinical experience which stamps the real value 
 of those remedies. 
 
LECTUEE XIV. 
 
 Summary. — Remedies. The Materia Medica Pura; indications; examples. 
 Case of abscess of the liver; indications for the opening of these abscesses. 
 Case of chronic pleurisy; indications for thoracentesis ; suppuration follow- 
 ing the operation made with Dieulafoy's aspirator; the abuse of thoracente- 
 sis; indications for it in empyema. The law of contraries and the law of 
 similars. 
 
 Remedies — Indications — The Experimental Materia Medica. 
 
 Gentlemen : We may, without further preamble, enter 
 upon that part of the clinic which treats of symptoms and of 
 lesions, because semiotics and pathological anatomy rest on 
 a basis accepted by all, and which needs no discussion. But 
 it is not so with therapeutics, for this part of medicine has, 
 even in our day, undergone many changes, and we cannot 
 enter upon this territory without some preliminary considera- 
 tions. 
 
 The ancient hypotheses, which served as the basis of thera- 
 peutics, have been overthrown by modern physiological dis- 
 coveries ; and since Harvey's work on the circulation of the 
 blood, we may say that the therapeutics of Galen, which con- 
 trolled the schools for so long a period, have no scientific 
 foundation. And therefore the treatises of Materia Medica 
 and therapeutics that were inspired by the superannuated hy- 
 potheses of ancient and modern humoralism constitute, in our 
 day, a real anachronism of which, let us hope, the work of 
 Trousseau and Pidoux may be the last example. The science 
 of therapeutics is now undergoing a transformation, and it 
 belongs to us, who have been, if not the first, at least the most 
 ardent, promoters of this reform, to enter at once upon the 
 
KEMEDIES INDICATIONS. 165 
 
 solution of such problems in experimental therapeutics as shall 
 present themselves to us. 
 
 We shall not repeat this year what we said to you last year 
 concerning the place of homoeopathy in therapeutics, but we 
 shall, with your permission, recall to your minds some of the 
 general principles of therapeutics. You know that the science 
 of therapeutics includes two subjects : (a) the remedy, and (b) 
 the rules which serve for the application of the remedy, or, 
 in other words, what is called the lavj of indications. 
 
 The remedy is a substance which appertains either to the 
 animal, the vegetable, or the mineral kingdom, and which, 
 administered to the living organism, has the property of de- 
 termining in that organism a totality of symptoms and of 
 lesions, presenting a special character, and subject to a cer- 
 tain evolution. 
 
 You observe that the definition of the remedy resembles the 
 definition of the disease. The positive effects of a drug on a 
 healthy organism are, in fact, very analogous to disease, and 
 you are aware that the history of cases of poisoning constitute 
 a complete department in nosography. The knowledge of 
 a remedy, therefore, does not end with understanding its 
 physical and chemical properties merely, but, above all, it 
 must include the study of the symptoms and lesions which 
 it produces when given to a healthy person. It was upon this 
 immovable basis that Hahnemann built the monument of the 
 Materia Medica Pura. It was a materia medica that was 
 pure in a theoretical sense, but a still better name for it would 
 be to call it the Experimental Materia Medica. 
 
 The rules which serve for the application of a remedy in 
 the treatment of disease have received the name of indica- 
 tions. These rules are numerous, and sometimes contradictory; 
 but first let us see what is meant bv the word indication. 
 
166 .THE MEDICAL CLINIC. 
 
 Traditional science explains through the mouth of Galen : 
 u The indication is the evident necessity for a fixed course of 
 action" If we examine the terms of this definition, gentle- 
 men, we shall find in this axiom the surest and wisest rule 
 by which the physician and surgeon can be guided in the 
 practice of his art. 
 
 " The indication is the evident necessity for a fixed' course of 
 action." Thus, in order that the physician or surgeon may 
 act as he should, the necessity for such action must be evi- 
 dent. Without this necessity they have no right to proceed, 
 for what man has the right to interfere in the great drama 
 of suffering which constitutes disease, if the necessity for 
 doing so is not obvious? It is this necessity alone which 
 permits the physician to carry the heavy responsibility of 
 the treatment of the sick. The patient, it has often been 
 said, is a child that is entirely at the discretion of the doctor, 
 of whose science he is no judge, and whose authority he may 
 not dispute. He is entirely in the hands of his adviser, and 
 for this reason the physician is not justified in interfering to 
 modify the course of the disease unless there is an evident 
 necessity for it. Mere routine, trifling and fancy in the com- 
 bat with disease at the bed-side are out of place, and are a 
 serious abuse of the patient's confidence. 
 
 Galen very properly adds that the physician should not 
 only act, but he should act in a decided manner. This com- 
 plement to the definition is absolutely necessary, and the 
 doctor, when in the presence of a case where the necessity 
 for action demands his interference, knows this very well, 
 although he may hesitate about the particular means to be 
 employed. An example, which is not theoretical merely, 
 but which is practical and genuine, will best serve to illus- 
 trate this definition of the word indication. 
 
REMEDIES INDICATIONS. 167 
 
 Case XLI. — Abscess of the Liver. — A child of eight years 
 had a fluctuating tumor of the liver. This tumor was located 
 on the anterior face of the organ, and had the effect to raise 
 the ribs in a very noticeable manner. It was accompanied 
 by transient pains ; the child was thin and pale, but he ate 
 well, and was up and out-of-doors every day. 
 
 The diagnosis was doubtful, and, although taking the 
 age of the patient, and the absence of pathological antece- 
 dents into account, we inclined to the idea of a hydatid cyst 
 of the liver, we were not absolutely certain of the nature 
 of this tumor. One of my old comrades while an interne, 
 and who to-day is a surgeon at the Hotel Dieu, called in 
 consultation, hesitated about interfering by an operation, and 
 we waited because there was no evident necessity for action. 
 
 A month later the affection had developed itself. The 
 pain had become permanent ; there was fever and consider- 
 able emaciation ; the size of the tumor had increased, and 
 another important symptom developed itself, viz : an oedema 
 of the integument about the tumor. 
 
 The diagnosis settled the fact that, whether an hydatid 
 cyst existed or not, the fever, the pain and the puffed appear- 
 ance of the skin showed, at least, that there was a purulent 
 collection, and a purulent formation, that was designed to 
 eliminate something, which condition also showed the evi- 
 dent necessity for a determined action on our part. 
 
 It was imperative that the abscess should be opened at 
 once, or nature itself would, perhaps, do so, and discharge 
 its contents into the peritoneal or the pleural cavities. The 
 location of the abscess also decided the mode of operation. 
 An incision by a bistoury would, in this case, have been 
 very inconvenient ; the use of the Vienna paste would have 
 been too tedious. It was necessary that the method should 
 be prompt, and one in which there would be no danger of 
 an overflow of the liquid into the neighboring cavities. The 
 
168 THE MEDICAL CLINIC. 
 
 indication was not founded upon a whim, nor upon an hypo- 
 thesis, but it was positive. The trocar ~No. 2 of Dieulafoy's 
 aspirator was passed into the center of the tumor, from which 
 we drew sixty grammes of a thick, reddish pus. The child 
 was relieved at once, the pain ceased, and the cure is now 
 complete. 
 
 The microscopic examination of the liquid taken from this 
 abscess, made by M. Davaine, showed that it was composed 
 of pus, with a little blood, and some debris of hepatic cells. 
 
 The indications are not, I know, always as clear and as 
 positive as in this case ; but from its very clearness the defi- 
 nition of Galen may be better understood. 
 
 Another example, which of itself is of great interest, is 
 that of 
 
 Case XLII. — Chronic Pleurisy — Thoracentesis — Empyema. 
 A man, whom you may have noticed during the summer 
 in a private room of the hospital, came first to the clinic in 
 May, 1874. 
 
 At that time a large eifusion occupied two-thirds of the 
 left pleural cavity. The clinical history, which was gathered 
 carefully, made it impossible to doubt that this pleurisy was 
 a chronic one. The patient, of good constitution formerly, 
 and very robust, aged thirty-five years, was able to resist 
 the disease up to this time, and to continue the mode of life, 
 or nearly so, of those about him. For some months past 
 this has been changed ; the dyspnoea increased very much ; 
 the emaciation and loss of strength had made such progress 
 that when he came to us he looked like one in the last stage 
 of phthisis. He still was able to be up a little and out occa- 
 sionally ; but the appetite and sleep had left him, and the 
 constant increase of the symptoms gave warning of a sad 
 issue in the course of a few months. An attentive ausculta- 
 tion, and the absence of fever, s;ave us reason, however, for 
 
REMEDIES INDICATIONS. 169 
 
 pronouncing that there was neither pulmonary phthisis nor a 
 purulent transformation of the effusion. The organism was 
 fast failing, and giving signs of yielding in a short time to 
 the influence of an imperfect respiration and obstructed cir- 
 culation that was due to a displacement of the heart. 
 
 Here again there was the evident necessity for action, and 
 I will add that the action itself was decided. 
 
 In this case, in fact, no account needed to be taken of 
 therapeutical resources. Since the beginning of the pleu- 
 risy the patient had vainly exhausted ^the whole series of 
 revulsives and of derivatives employed in similar conditions, 
 and the large cicatrices proved clearly that the use of these 
 means had been pushed as far as possible. To acquit my 
 own conscience, I had prescribed cantharis and sulphur for 
 several weeks, during which time I took occasion to study the 
 question of remedies more carefully in order to act with de- 
 cision ; but this treatment, which is usually so successful in 
 my hands, failed entirely. Should we try other remedies % 
 Certainly not ; for pathological anatomy teaches us, in fact, 
 that very old pleuritic effusions constitute veritable cysts that 
 are almost as rebellious in the resorption of their liquids as 
 the cysts of the ovary. If we add that the lung which had 
 been compressed for ten years, and which was fixed and flat- 
 tened along the vertebral column by organized bands that 
 had been there for years, would only obstruct this resorption 
 and make it the more difficult, you will understand that we 
 only gave a few remedies as a sop to conscience, and to afford 
 us time in which to decide upon a more energetic plan of 
 treatment. 
 
 There was, then, in this case a necessity for action, and the 
 only effective method of action was to evacuate the liquid by a 
 surgical procedure. And not only was the necessity for giving 
 vent to the liquid evident on account of the compression of 
 the lung and the displacement of the heart, which interfered 
 
170 THE MEDICAL CLINIC. 
 
 with hematosis, but the method of this action was also indi- 
 cated. In fact, the absence of fever, and the long duration 
 of the effusion, led us to believe that the liquid was serous, 
 and the simple operation of thoracentesis was called for, as 
 offering the last chance of a cure. 
 
 By auscultation and percussion, we found that the lung was 
 crowded upward and backward, and that the effused fluid 
 occupied three-fourths of the pleural cavity. The heart was 
 strongly pushed to the right, the apex beating beneath the 
 sternum. 
 
 Percussion gave a flat sound in all the parts included by 
 the effusion, and by auscultation we could hear the soft soulfle 
 of pleurisy. 
 
 In making the operation of thoracentesis, we chose Dieu- 
 lafoy's instrument, and the first puncture was made in the 
 posterior and outer part, between the sixth and the seventh 
 ribs. From this we took more than a quart of a serous fluid, 
 which looked like veal broth, and which contained a great deal 
 of albumen. We did not draw off any more, because toward 
 the end of the operation the patient complained very much of 
 drawing sensations that were extremely painful. 
 
 After the operation, and during the next few days, he was 
 very much relieved; the respiration became easy, and his 
 strength and appetite returned. 
 
 In the space of fifteen days we tapped his thorax four 
 times, drawing at each time about three pints of a liquid that 
 was of the same character as that withdrawn at the first 
 operation. The patient improved constantly, and by physical 
 examination we found that the quantity of effused fluid was 
 steadily reduced, and we, therefore, hoped for a successful 
 termination of the case. 
 
 But the second day after the fourth operation the patient, 
 who was always careless about the observance of proper hy- 
 gienic rules, -went out-of-doors. The weather was damp and 
 
REMEDIES INDICATIONS. 171 
 
 cold, and he returned in a chill. When we saw him again the 
 next morning he was in a violent fever. 
 
 On the third and fourth days after this relapse the patient 
 grew rapidly worse ; he became emaciated, and felt his 
 strength to be failing, while at the same time the dyspnoea 
 increased every hour ; the side became very painful, and this 
 pain was increased by pressure, and his breath became very 
 foetid. In three days the effusion was as large as ever, and 
 there were unmistakable signs of the purulent transformation 
 of the fluid. The event proved the correctness of our diag- 
 nosis. 
 
 Before going any farther, let us note this fact with regard 
 to the purulent transformation of a serous effusion from tap- 
 ping, which is recommended as being absolutely safe. For 
 several years physicians have been accustomed to consider 
 thoracentesis as an operation that was unattended by danger ; 
 and the ease with which it may be made by the use of the 
 ingenious instruments of Dieulafoy and of Potain has brought 
 about such a real abuse of tapping the pleural cavity that, with 
 many physicians, it constitutes the exclusive treatment for 
 pleurisy, just as others make tracheotomy the specific for 
 croup. 
 
 The publication of this fact, in addition to those already 
 so numerous, in which death has occurred a few hours after 
 the operation, from a too sudden relief of the compressed 
 lung, and consequent and frightful oedema which has followed, 
 are calculated to make the physician careful and prudent, and 
 to cause him to remember that fashion and fancy are wretched 
 counselors in the sick chamber. 
 
 But to return to our comments on Galen's definition of 
 the word indication. What ought we to have done in the 
 case of this unfortunate patient ; and what indication should 
 we have drawn from the risk of death by asphyxia, and by 
 
172 THE MEDICAL CLINIC. 
 
 the progress of a suppurative fever? Was there in this case 
 an evident necessity for action, or should we have left the 
 patient to the unaided efforts of nature ? 
 
 First, let us examine this last method. Purulent pleurisy 
 provoked by such conditions, and left to its natural course, must 
 end, either in the rapid death of the patient from the violence 
 of the fever, or it must terminate in the opening of the intra- 
 pleural abscess. Now this abscess might discharge itself exter- 
 nally, into the bronchii, or even into the peritoneum. Without 
 opening into the peritoneum, the inflammation, which accompa- 
 nies and which initiates the opening of all abscesses, might 
 spread to the peritoneum and produce death by inflammation of 
 this very extensive serous membrane. These peritoneal com- 
 plications are not imaginary, or merely theoretical, for they have 
 already been seen in a number of cases. * 
 
 The only chance of cure, therefore, which remains to our 
 patient, and which is the natural discharge of the empyema ex- 
 ternally, is as seriously compromised by the duration of the dis- 
 ease as it is by the danger of which it is the source. However, 
 if the opening can be obtained will our patient then be certain 
 to recover ? 
 
 Beyond a doubt, there have been a number of cases of em- 
 pyema, with spontaneous opening through the thorax exter- 
 nally, and even into the bronchial tubes, that have terminated 
 in the complete recovery of the patient ; but the cases which 
 end in the exhaustion of the patient from hectic fever and 
 from the bad results that accompany the decomposition of 
 pus are infinitely more numerous. Indeed these effusions 
 almost always open in the mammary region, which is too high 
 up for the pus to discharge itself freely, f 
 
 * See Andral's Clinic, Case 20, Vol. IV, page 480; and Case 36, page 542 of 
 the same volume. 
 
 f Andral's Clinic, Case 17, Vol. IV, page 464 ; and especially Case 36, p. 542. 
 This last case is of great interest from another point of view. It is in fact an un- 
 doubted illustration of the spontaneous development of the purulent diathesis. 
 
REMEDIES INDICATIONS. 173 
 
 The opening, which is too small to permit a free escape of 
 the fluid, is large enough to establish an easy communication 
 with the air, and the abscess is thus in the worst possible con- 
 dition, being too high, and the opening so small that the pus 
 stagnates and putrifies in the pleural cavity. 
 
 Therefore, if we had not "acted" we should have had but two 
 alternatives, — either the death of the patient by suppurative 
 fever, or the breaking through of the intra-pleural abscess. In 
 this last alternative the natural opening of the abscess would 
 have placed the patient in a far more dangerous condition than 
 its artificial discharge. This state of things created an " evident 
 necessity for action" ; and a free opening of the chest was posi- 
 tively indicated. We did not even discuss the possibility of 
 emptying the abscess by numerous tappings with the aspirator. 
 The extreme difficulty of bringing the lung and the parietes of the 
 thorax together did not prompt me to try a method which must 
 be quick in order to be successful. 
 
 The operation of thoracentesis was made on the most slop- 
 ing part of the chest, and by flattening the superior surface of 
 the diaphragm. The skin and the muscular layers were suc- 
 cessively incised, and after having penetrated the pleural cav- 
 ity, the surgeon enlarged the opening with his bistoury, so as to 
 make it about ten centimetres in length. A flow of pus, which 
 was grayish in appearance, and foetid, poured from this open- 
 ing. There was at least three and one-half pints of this matter. 
 A large compress of lint was introduced into the wound in the 
 form of a tent ; and abundant injections containing alcohol 
 were given three times a day. The fever subsided, the appetite 
 and the strength returned, and, in fact, the operation that was 
 indicated produced just what was expected of it, which is always 
 the case when we conform strictly to the law of indications. 
 
 Permit me, gentlemen, to give you, incidentally, the re- 
 maining history of this interesting case. He remained three 
 
174 THE MEDICAL CLINIC. 
 
 months longer in this hospital under local treatment, consist- 
 ing of repeated injections, sometimes of water and alcohol, 
 and sometimes of the tincture of iodine in water. His health 
 returned gradually, and the capacity of the pleural cavity grew 
 less each day, as much from retraction of the ribs as from 
 expansion of the lungs. He had a return of fever every 
 now and then, sometimes because of' his own imprudence, and 
 sometimes because the injection was not thoroughly given. 
 
 These accidents and accidental drawbacks were counter- 
 acted chiefly by arsenicum and aconite. At the beginning 
 of the cold season he left for the south in order to complete 
 his recovery. He returned to Paris in May. His general 
 condition was good ; he has gained a great deal in flesh, and 
 has no fever, but he still has the pleural fistula. The ribs 
 are badly retracted, the shoulder is very much depressed, 
 and the patient leans toward the affected side. The pulmonary 
 expansion is heard over almost the whole thorax ; but there 
 still remains a zone of three fingers' breadth about the fistula, 
 where all the normal sounds are absent. The heart has 
 returned to its place. 
 
 In the month of July, 1875, I saw this patient again. He 
 still has the fistula, which has discharged blood once or twice 
 in rather large quantities. He is more of a hypochondriac 
 than ever, and complains of " windf but he is stronger, more 
 active, and has no cough nor oppression of breathing. 
 
 The author might also have found an illustration in those cases of puerperal 
 poisoning in which the means that are called for are prophylactic and curative, 
 although they are not strictly medical. The risk of septic and purulent infec- 
 tion, either through the laceration of the soft parts, that is an almost necessary 
 consequence of labor, or through the uterine sinuses that have been left open 
 by the separation of the placenta, or by both these avenues, is very great. And 
 emergencies arise in which a very prompt and decided action, that looks to the 
 removal of the cause of the trouble, is imperatively demanded. When the 
 temperature of a lying-in woman is at or above 103°, with an arrest of the in- 
 volution of the uterus, a diminution or disappearance of the lochial and of the 
 lacteal flow, with a hot skin and a quick pulse, delirium, and more or less local 
 pain in the abdominal and pelvic regions, the indication is to irrigate and disin- 
 
THE LAW OF CONTRARIES AND OF SIMILARS. 175 
 
 feet the vagina and" uterus as speedily as possible. We must wash away the 
 post-organic matters, arrest the sepsis, and, by a direct and tangible remedy, 
 make it possible that life should continue by bringing the temperature down to 
 a living standard and keeping it there. — L. 
 
 These examples are quite sufficient to make you understand 
 what I have quoted from G-alen. Now the word indication 
 has, therefore, a well-defined meaning, and the therapeutics 
 of inspiration and of fancy will be certain of your scorn ; for 
 you have a rule to guide you in the treatment of such cases 
 which is as clear as it is inflexible, id est, the necessity for 
 decided action. 
 
 We now understand the remedy and the indication, as they 
 are included in the general subject of therapeutics ; but when 
 we come to their application, that is to say, to fix the rule 
 which must govern this "decided action," depending upon 
 the evident necessity for interference, we find ourselves con- 
 fronted by two laws, viz : 
 
 The Law of Contraries and the Law of Similars. 
 
 The law of contraries being that which is most generally 
 accepted, we shall speak of it first in order. This law rests 
 upon two formulae, of which one is the complement of the 
 other, — contraria conirariis curantur, and sublata causa tol- 
 litur effectus. This last formula has the style and character 
 of an axiom. ~No one, in fact, has ever contested that when 
 the cause was destroyed the effect would not continue to exist, 
 and that whenever the cause can be directly attacked by its 
 opposite, a rapid and certain cure will follow. But this cause, 
 which must be removed or destroyed, cannot be determined, 
 defined or understood, except in the large class of 'diseases 
 that arise from external causes, — such, for example, as trau- 
 matism, parasitical affections, and cases of poisoning in their 
 earliest stages. Kill the parasite ; expel or antidote the poi- 
 son ; reduce a fracture or dislocation, and you have destroyed 
 
176 THE MEDICAL CLINIC. 
 
 the cause of the suffering, and by an opposite remedy : — 
 suhlata causa tollitur effectus. 
 
 In this domain the simplicity of the method is only equaled 
 by its efficiency. Surgery triumphs in this case in the certainty 
 of its therapeutics ; to open an abscess, to tie up an artery, to 
 remove a tumor or a foreign body, is often to heal the wounded 
 or to cure the sick, and it is always a direct means for remedy- 
 ing an important lesion. 
 
 But if we enter on the domain of the veritable diseases 
 which arise from internal causes, the law of contraries is no 
 longer applicable. 
 
 General pathology teaches us that the external circum- 
 stances, which have received the name of the external causes, 
 of disease, are merely conditional or contingent, and that they 
 furnish an occasion for the development of disease, whilst the 
 real cause itself is to be found in a special predisposition that 
 belongs to the organism. Thus, for example, cold and fatigue 
 may favor the development of pneumonia, but only in those 
 persons who are predisposed to it. In certain cases, and in the 
 absence of cold or fatigue, the predisposition alone will suffice 
 to develop this disease. 
 
 How could we hope to find in a remedy the contrary to an 
 organic disposition or tendency if we were ignorant of its essen- 
 tial nature % 
 
 This is the way in which the old leaders in therapeutics 
 have wandered from one hypothesis to another in search for 
 the opposite, or the contrary, of the direct causes of disease. 
 
 The Galenists believed that the proximate cause of disease 
 predominated over the four humors of the body. From this 
 came the resort to evacuating remedies, that are designed to 
 expel the hypothetical cause of the disease. The iatro-chemists 
 have tried to neutralize the acids and alkalies, from which, 
 they tell us, all diseases proceed. The solidists have fought 
 
THE LAW OF CONTRARIES AND OF SIMILARS. ITT 
 
 irritation, whether excessive or deficient, through indications 
 that called for leeches and tonics; and those who hold that 
 diseases are due to a poisoned state of the blood are still hunt- 
 ing for the antidotes with which to cure them. 
 
 These are the hypotheses, more or less absurd and more or 
 less ingenious, which have reigned for a long time, and which 
 continue to reign, in therapeutics. If we add that, up to the 
 close of the last century physicians entirely ignored the posi- 
 tive action of medicines upon a healthy man ; and that on this 
 point, which is so important in materia ruedica, they were 
 possessed of hypothetical notions exclusively, we may gain a 
 pretty correct idea of what they would do in the treatment of 
 disease, depending as they did upon the imaginary virtues of 
 their remedies. And you mav form some idea of the bad 
 repute into which therapeutics and the Materia Medica had 
 fallen before Hahnemann instituted his reform. The old-school 
 therapeutics have been well characterized by Scarron : 
 
 " I saw the shadow of a valet, 
 Who, with the shadow of a broom, 
 Brushed away the shadow of a coach/' 
 
 The shadow of the broom is the imaginary virtue of the 
 remedy, and the shadow of the coach is the hypothetical cause 
 of the disease. 
 
 It is useless to argue this point. The law of contraries, the 
 sublata causa, is not applicable to the treatment of diseases 
 that arise from internal causes. 
 
 The law of similars is formulated in this manner : ' ' Apply 
 to the treatment of a certain morbid condition the medicine 
 which, given to a healthy man, would produce a totality of 
 lesions and of symptoms which are like those of the disease." 
 
 You observe this law presupposes a knowledge of the 
 
 action of the drug upon a healthy man ; and it rests, therefore, 
 
 upon an experimental basis. And as its application is founded 
 12 
 
178 THE MEDICAL CLINIC. 
 
 entirely upon this positive knowledge, and the clinical recog- 
 nition of the symptoms and lesions of the disease that is to 
 be treated, as it has need of no hypotheses whatever in its 
 application, we are authorized to conclude that the law of 
 similars is the law of positive indications. 
 
 In the application of the law of similars, the necessity of a 
 knowledge of the action of the drug upon a healthy person 
 explains why this law remained without application for Hahn- 
 emann to put it into use. Until the experimental study of 
 the Materia Medica had reached a certain degree of perfection, 
 no physician could apply the law of similars. This is why 
 Hahnemann, who inaugurated on a large scale this very impor- 
 tant study, is really the founder of Homoeopathy, and why 
 Paracelsus, Van Helmont and Hunter should be considered 
 only his precursors, because, being ignorant of this materia 
 medica, they could not apply the law of similars. 
 
 But, as we have already indicated, we believe that the 
 law of similars is not always and altogether sufficient for the 
 choice of the remedy. In our first lecture we spoke of the 
 legitimate role of empiricism, and of palliative medication in 
 therapeutics. And in Lecture XIII we have tried to detail 
 and to establish the value of clinical experience as another 
 aid in the selection of the remedv. 
 
LECTURE XT. 
 
 Summary. — Hemoptysis, case. What is hemoptysis ? Differential diagnosis of 
 hemoptysis from hematemesis and epistaxis. Varieties of hemoptysis and 
 their semiotic value. Therapeutic indications for the relief of hemoptysis; 
 ligation of the extremities; ice and cold; aconitum, arnica, millefolium, 
 ledum palustre, ferrum perchloricum, ipecac, phosphorus, hamamelis and 
 nux vomica. The old-school treatment of hemoptysis. Hemoptysis is 
 never the cause of phthisis. Niemeyer's error. A rare case. 
 
 Hemoptysis. 
 
 Gentlemen: We have just seen in JSTo. 4, of the men's 
 ward, an extremely serious case of hemoptysis. The patient 
 is a young man, who has all the signs of incipient phthisis. 
 The following is a detailed account of the case : 
 
 Case XLIII. — M. L , an artist, twenty-one years of 
 
 .age, entered the hospital on the 9th of December, and left it 
 on the 11th of January. This young man is of a frail and 
 delicate constitution ; the skin is fine and transparent, with a 
 bright color, and he is without hereditary antecedents. His 
 parents are still living, and well. 
 
 Although the disease for which he comes to us is of only 
 three months' duration, he says he has suffered from difficult 
 respiration for nine years past. When this began he had an 
 attack of pneumonia or pleurisy in the left side, which lasted, 
 he says, for two or three months ; but notwithstanding this 
 difficulty of breathing, his general health has been good until 
 within the last three months. 
 
 Three months ago he began to cough. The cough was dry, 
 and came in paroxysms which returned principally at night ; 
 but in spite of this he retained his strength and appetite, and 
 showed no signs of fever. 
 
 On the 24th of November, after a more than usually severe 
 fit of coughing, he commenced to vomit blood by the mouth- 
 
180 THE MEDICAL CLINIC. 
 
 ful. He continued to raise blood almost every day after this 
 during the fortnight which preceded his entrance into the hos- 
 pital ; he lost in this way more than three pints of blood. 
 
 He is now extremely feeble, and the pulse is small and fre- 
 quent. There is slight heat of the skin, and no appetite. 
 
 By auscultation, which is necessarily imperfect, we find 
 there are humid rales on the left side when he breathes deeply. 
 The heart is perfectly healthy ; the patient scarcely coughs at 
 all ; the sputa are very slight, and consist of mucus tinged with 
 blood. We prescribed millefolium, 3d dil. , three drops in 200 
 grammes of water, one spoonful to be taken every three hours. 
 The diet to consist of milk. 
 
 December 14. The patient has not expectorated any pure 
 blood since he entered the hospital ; the fever has disappeared. 
 Ipecac, 3d dil., for the cough with a bloody expectoration. He 
 is allowed some soup. 
 
 December 16. The strength and the appetite have partially 
 returned. The slight matters raised are rounded in form, white, 
 and more opaque. Phosphorus, 12th dil., four globules in 200 
 grammes of water, and three spoonfuls during the day. 
 
 December 18. The general health of the patient improves 
 each day; the cough is much better. Phosphorus, 12th dil.; 
 the vegetable diet, with beer for a drink. 
 
 December 21. The patient is doing well, and all medica- 
 tion was suspended. 
 
 December 23. There is a slight bloody expectoration this 
 morning. Phosphorus, 12th dil. 
 
 December 26. The patient complains of pain in the left 
 third intercostal space when coughing. Bryonia, 3d dil., 
 three drops. 
 
 December 30. The pain in the side is gone ; the cough is 
 considerably diminished ; the digestion is bad ; the appetite is 
 less than for some days. We prescribed nux vomica, 12th dil., 
 one hour before eating, and graphites, 12th dil., one hour after 
 meals. 
 
 January 3. Under the influence of these last remedies the 
 digestive troubles have disappeared. The appetite is excel- 
 lent. 
 
HEMOPTYSIS. 181 
 
 We suspended the nux vomica and the graphites, and gave 
 hryonia, 3d dil., for the pain in the side, which has returned, 
 but is less violent than at first. The patient left the hospital 
 on the 11th of January, in a very good condition. 
 
 The examination of this patient at the time of his quitting 
 the hospital showed that on percussion there was a compara- 
 tively dull sound in both apices, especially in that of the left 
 lung ; the respiration is obscure, and is scarcely perceptible on 
 the left side and behind. But the patient has gained con- 
 siderable flesh ; his strength has returned, and he scarcely 
 ever coughs any more. I allowed him to eat meat three times 
 a week, but not more than one meal per day, and he continues 
 to drink beer. 
 
 I saw this young man on the 15th of March, when he 
 seemed very well. 
 
 This patient had been treated at home by millefolium, and 
 came to us just at the end of an attack of hemoptysis. For 
 this reason I will read you a case from my private records, in 
 which ipecac, and millefolium have been of very great service. 
 This second case will also be useful in completing the clinical 
 history of hemoptysis, and it will show you that the very 
 grave prognosis that is usually given in this difficulty ought to 
 be qualified. 
 
 Case XLIY. — M. L., an employe in a large establishment, 
 is twenty-four years of age. He has, heretofore, suffered from 
 scrofulous affections, and recently from scrofulides on the face, 
 which have left their indelible traces. He is of a very nervous 
 temperament, and has some symptoms of hysteria. His skin 
 is pale, and he is of a slender figure, and he has a cough 
 which has no very decided peculiarities. He was subject to 
 epistaxis during childhood. 
 
 In the month of March, 1870, he was taken, during the 
 night, with paroxysms of coughing, accompanied by an abun- 
 
182 THE MEDICAL CLINIC. 
 
 dant expectoration, of a bloody, frothy, foamy nature. This 
 hemoptysis returned several times during the week, but was 
 not so copious as it was in the first attack. At the end of a 
 week nothing of it remained, save a loose cough with frequent 
 expectoration, at first of blackish blood, then of a chocolate- 
 colored fluid, and finally of mucus tinged for several days 
 with a varying proportion of blood. 
 
 We were very reserved in resorting to auscultation during 
 the hemoptysis ; thus we only recognized some moist rales in 
 the chest, and a perfectly physiological condition of the heart 
 and of the larger vessels. 
 
 In the onset, my colleague, Doctor Fredault, who was 
 called in my absence, prescribed ipecac, 3d dil., and mille- 
 folium, 3d dil., two potions with three drops of each remedy 
 to 150 grammes of water for alternation, one teaspoonful to 
 be given each hour, and afterward every two hours. 
 
 We continued this prescription. The next morning we 
 added to it the cold and milk diet, with rest and absolute 
 silence. 
 
 Ipecac, and millefolium were continued as long as the sputa 
 contained portions of bright blood ; and later, when they were of 
 a chocolate and rusty color, we prescribed of jphosjphomts, 12th 
 dil., six globules to be put in 200 grammes of water, and from 
 three to six spoonfuls to be taken during the day. 
 
 The patient was for a long time kept in quiet and silence. 
 We added to the milk the vegetable diet, and gave him beer to 
 drink, and toward the latter part of June we had the satisfac- 
 tion of seeing our patient completely restored to health. 
 
 At that time, on auscultation by another physician and my- 
 self, no positive sign of tuberculosis was to be found. The pa- 
 tient took the hydropathic treatment at Bellevue ; and although 
 six years have now passed since the former attacks, he has had 
 no symptom of a pulmonary affection. On the other hand, he 
 
HEMOPTYSIS. 183 
 
 has developed several scrofulous affections, as a sore throat 
 with ulceration of the anterior folds of the veil of the palate ; 
 the incipient symptoms of osteitis of the nasal bones, and a 
 cold abscess of the perineum. These different affections have 
 yielded with singular promptness to the Jcali jodatus in doses of 
 1.50 grammes each day; and this result, joined to the character 
 of the affection of the throat, and those of the nasal bones, has 
 strongly inclined me to believe that there was a syphilitic com- 
 plication, although the patient has positively denied the possi- 
 bility of any such condition whatever. 
 
 These two cases clearly demonstrate that the prognosis, even 
 in case of an abundant hemoptysis, and even in young persons, 
 is not always so bad as has been supposed. We may draw 
 from these cases some clinical and curative conclusions which 
 ought to be settled definitely. 
 
 I apply the term hemoptysis to a syndrome which is charac- 
 terized by the pouring out of pure blood from the inferior res- 
 piratory passages, and which is discharged either by vomiting 
 or by expectoration. 
 
 In the two cases cited we made the diagnosis without hesi- 
 tation, and thus declared that the blood which escaped came 
 neither from the nasal fossae (epistaxis) nor from the stomach 
 (hematemesis), because we found in both these patients the posi- 
 tive signs of hemoptysis before, during and after the hemor- 
 rhage. Before it, the cough ; during it, the expectoration of 
 frothy, red blood ; and after it, the expectoration of brownish 
 blood that had remained for some time in the bronchii. The 
 cough indicated that the lung was the diseased organ ; the 
 frothy, red mucus showed that the blood had been mixed with 
 air, and, consequently, that it came from the bronchial tubes ; 
 and finally, the brownish expectoration, which, for some days 
 succeeding the spitting of blood, afforded a stronger and more 
 decided proof of the primitive seat of the difficulty. 
 
184 THE MEDICAL CLINIC. 
 
 But all cases of the kind are not so simple. For example, 
 a very abundant epistaxis, if it occurs during sleep, may be 
 accompanied by the unconscious introduction of a certain quan- 
 tity of blood into the respiratory passages, and may, therefore, 
 be followed by the expectoration of this blood ; but the blood 
 which takes this course is always in a very small quantity, and a 
 nose-bleed is always free and easily detected. In such a case it 
 is sufficient to have the patient blow his nose to prove that the 
 blood comes from the nasal fossae, and moreover it is mixed 
 with nasal mucus. Let me add that some writers have attached 
 a great importance to the differential diagnosis of such a case, 
 because, when the blood flows too freely from the nasal fossa 1 
 of a patient who is lying down, or in whom the nostrils have 
 been plugged, the blood will flow into the stomach. Then, 
 afterward, he may vomit it, or pass it from the bowels, and a 
 careless observer might mistake the attack for one of hema- 
 temesis, or of hemorrhage from the bowels. 
 
 The differential diagnosis of hemoptysis from hematemesis 
 has also been indicated. It is true that in some cases of hemop- 
 tysis the blood is a little dark, and that, in a fit of convulsive 
 coughing, hemoptysis may be accompanied by the vomiting of 
 the food ; that the blood which flows too abundantly in hemop- 
 tysis may reach the stomach, and either be expelled by vomit- 
 ing, or altered by the gastric juices, and afterward its surplus 
 may be passed the next day by the bowels. Here are evident 
 sources of error in diagnosis, but these conditions are brought 
 together in this way upon theoretical grounds, for they never 
 exist conjointly in actual practice. At all events, we may, in 
 a few words, sum up the differential characters of hemoptysis 
 and hematemesis. 
 
 In hemoptysis the blood is usually without clots, mixed 
 with bubbles of air, and frothy. When it is darker, and con- 
 tains small clots, the hemoptysis is associated either with an 
 
HEMOPTYSIS. 185 
 
 affection of the mitral valves, or with a tuberculous cavity, and 
 these are lesions that are unmistakable. The practicing physi- 
 cian need not hesitate regarding the source of the hemorrhage, 
 even if the color is a little dark, and there are clots which 
 make him think of hematemesis. 
 
 In hematemesis, the vomiting of blood is preceded by 
 nausea, and by a sense of weight in the stomach. These two 
 symptoms are indeed of great value in the differential diagnosis 
 of this affection. The blood is usually black and clotted, and 
 mixed with food, and it is discharged by the effort of vomiting. 
 If some particles of the matter ejected fall into the trachea, 
 this accident is succeeded by a paroxysmal cough which is of 
 longer or shorter duration. But the date of the appearance of 
 this cough is very important; it is a symptom which comes 
 during the vomiting, and the mechanism of which it is easy to 
 explain, for it cannot mislead us in the diagnosis. 
 
 There is also a sign, which in doubtful cases should be 
 carefully sought for, which is the alkalinity or the acidity of 
 the blood. The blood ejected in hemoptysis preserves its 
 proper alkaline reaction, while that which comes from the 
 stomach in hematemesis is more or less changed and acidu- 
 lated by the gastric juice. 
 
 Finally, if the physician looks for the symptoms of this 
 affection as laid down in its symptomatology, he will find 
 included with the hemoptysis some diseases that are easily 
 recognized, id est, pulmonary phthisis, affections of the mitral 
 valves, and aneurism of the aorta. 
 
 Hematemesis will often reveal to us the existence either of 
 cancer of the stomach, or of a simple ulceration of that organ, 
 in which case the diagnosis will have acquired a mathematical 
 precision. 
 
186 THE MEDICAL CLINIC. 
 
 It is only in supplementary hemorrhage, and in those which 
 are symptomatic of purpura, or of a very serious fever, that the 
 diagnosis will be very difficult. It is so much the more difficult 
 because several hemorrhages may occur at the same time. In 
 such cases the signs of epistaxis, of hemoptysis, and of hemate- 
 mesis are often more or less confounded, and more or less ob- 
 scure, and error is therefore possible. We may add that this 
 is not a serious thing, for in such cases the prognosis, like the 
 treatment, is more subordinate to the disease itself than to any 
 of its symptoms. 
 
 Now that we have with some degree of care settled the 
 question of the significance of hemoptysis, and clearly distin- 
 guished it from the hemorrhages that are liable to be con- 
 founded with it, let us examine its semiotic value, and the 
 therapeutic indications which it presents. 
 
 There are five principal varieties of hemoptysis : 
 A. — The overwhelming variety of Hemoptysis. — In this case 
 the blood is foamy, and escapes in streams from the nose and 
 from the mouth ; filling the bronchial tubes, and falling into the 
 stomach, the patient dies from syncope. It is the sign of the 
 rupture of an aortic aneurism. 
 
 This kind of hemoptysis is sometimes met with at the 
 onset of tuberculous phthisis, but oftener in the more ad- 
 vanced period of the disease. 
 
 There are two varieties of a copious hemoptysis : 
 (a) In the first the blood is foamy and frothy. It is ejected 
 by the cough and by a sort of vomiting ; in a few moments 
 the patient may lose from 200 to 300 or 500 grammes of blood r 
 and after an interval which varies from a quarter of an hour 
 to several hours, the hemorrhage begins again. Death by 
 syncope may occur after a few hours, but oftener the patient 
 resists and the hemorrhage is arrested. This variety is al- 
 
HEMOPTYSIS. 18T 
 
 most always symptomatic of pulmonary phthisis, being in 
 some cases an initial symptom, and at others a sign of the 
 confirmed stage of the disease. 
 
 This same form of hemoptysis is also to be observed in 
 cases of supplementary hemorrhage. 
 
 Finally, it may exist as an idiopathic affection, in which 
 case it usually repeats itself several times during the life of 
 the patient, and rarely stops with a single attack. 
 
 (b) In the second of these sub-varieties the blood lost is 
 always abundant, but it is much darker than in the preceding 
 variety. It is a very little frothy, and it is the usual sign 
 of an affection of the mitral valves, and also, according to 
 INIemeyer, of a rupture of an artery in a tuberculous cavity. 
 This form of hemoptysis also occurs in bad cases of hemor- 
 rhagic fever, in variola, scarlet fever, and in purpura. 
 
 B. — Slight Hemoptysis. — This variety also has its sub- 
 divisions : 
 
 (a) In the first of these the blood is foamy and frothy, but 
 it is ejected in detached portions. This is the hemorrhage 
 of confirmed pulmonary tuberculosis. 
 
 (b) In the second of these forms the blood is also thrown 
 out in a detached way, but it is dark and not frothy. This 
 is the sign of an affection of the heart, and we have even 
 seen it in chronic catarrh, with dilatation of the bronchial 
 tubes. 
 
 (c) In the third variety there are bloody sputa, but the blood 
 is not mixed with mucus as it is in pneumonia. When the 
 expectoration is viscous, it is the certain sign of a pulmonary 
 congestion that is symptomatic of an affection of the heart, 
 or of the aorta, but when it is diffluent, it is indicative either 
 of phthisis or of chronic catarrh. 
 
 (d) In the fourth we may have habitual or periodical 
 hemoptysis. Independently of the varieties of hemoptysis, 
 
188 THE MEDICAL CLINIC. 
 
 which depend upon the abundance and color of the blood 
 that is expectorated, we recognize still other varieties in which 
 the type and duration of the hemorrhage are peculiar. 
 
 Thus the vicarious hemoptysis, that is symptomatic of 
 amenorrhcea, comes, like the menses, at a fixed period each 
 month ; and in the form of pulmonary phthisis that we 
 call hemoptoic, the spitting of blood becomes habitual, and 
 patients sometimes have it almost daily for two or three 
 months. A correct idea should be had of these two varieties, 
 the periodical and the habitual, for they are important, both 
 from a diagnostic and from a therapeutical point of view. 
 
 In our clinic at the Hahnemann Hospital we have lately shown the class 
 three sisters, each and all of whom have had hemoptysis in connection with the 
 establishment of puberty. For three years, in the eldest of them, this hemor- 
 rhage had continued to alternate pretty regularly with amenorrhcea. She 
 would miss her period for one month, or perhaps for two, and then have an 
 attack of spitting of blood instead. The youngest of the three sisters some- 
 times had hemoptysis, and again epistaxis, with irregular menstruation. All 
 these girls were anaemic, and manifestly of the hemorrhagic diathesis. The 
 mother, who came with them to the clinic, was a healthy-looking, robust 
 woman, who complained of symptoms incident to the climacteric, and also of 
 hemorrhoids . — L . 
 
 Therapeutic Indications Drawn from the Different Varie- 
 ties of Hemoptysis. — When hemoptysis is overwhelming, we 
 should not think of internal remedies, but the patient should 
 be taken to an open window, his body should be straight- 
 ened, and the extremities ligated by a wide band as in prac- 
 ticing venesection. 
 
 If this method is successful the bands should be loosened 
 one after another, and carefully, for the great quantity of blood 
 that is retained in the extremities by the ligature may, by 
 reentering the circulation suddenly, reproduce the hemor- 
 rhage. At the same time ice should be applied to the chest, 
 or, if it cannot be had, a cloth, wet in very cold water and 
 constantly changed, may be substituted for it. Arnica will 
 be the principal remedy if there is time in which to give it. 
 
HEMOPTYSIS. 1S9 
 
 In the moderate form of hemoptysis, where the discharge 
 is composed of red, frothy blood, ipecac, millefolium, ledum 
 palustre and aconitum are the principal remedies. 
 
 When the blood is black, the hamamelis is a precious 
 remedy, as are also arnica and digitalis. To the use of 
 these medicines we should add the hygienic methods already 
 indicated in the preceding paragraphs, and of which we shall 
 have more to say directly. 
 
 In the less violent forms of hemoptysis, millefolium and 
 aconite are the principal remedies, especially when the blood 
 is foamy ; when it is black, we give nux vomica. 
 
 Phosphorus is the principal remedy for the hemoptysis 
 that is associated with dangerous cases of fever. 
 
 Phosphorus is not a valuable remedy for the active stage of hemoptysis; 
 but when the flow of blood has ceased, if there are signs of inflammation and 
 induration of the pulmonary tissue, or of tuberculosis, with a rough, hoarse 
 voice and cough; or, if there is a frequent hacking, dry cough, with great op- 
 pression of the chest and tickling in the throat, with a short, rapid, panting 
 respiration, it is invaluable. The chief indication for phosphorus in this, as in 
 all other hemorrhages, is found in the hemorrhagic diathesis, against which, all 
 things considered, it is undoubtedly the best remedy that we have. — L. 
 
 Ferrum perchloricum has been given empirically for co- 
 pious and rebellious hemoptysis, but it is almost always given 
 in strong doses, say of from fifteen to twenty drops of the 
 perchloride in a potion of 200 grammes of water. We have 
 sometimes used it successfully in habitual hemoptysis. 
 
 Let us now consider each one of these remedies, and en- 
 deavor, with the aid of the Materia Medica, and of clinical 
 experience, to fix the indications for each of them. 
 
 Aconitum is the remedy for those congestions and hem- 
 orrhages that are called active. The blood is red, frothy and 
 abundant, with an incessant cough. The chest is the seat 
 
190 THE MEDICAL CLINIC. 
 
 of heat and of a characteristic sound, like boiling. The face 
 is red, the pulse is quick and hard, and the patient anxious. 
 
 Hartmann recommends it, also, in an opposite condition 
 of the circulation, viz : where the pulse is feeble and filiform, 
 and can scarcely be recognized, and the face is pale and ex- 
 pressive of anguish. 
 
 Aconite has often been successfully given in tuberculous 
 hemoptysis, in that which accompanies cardiac affections, and 
 also in that which is incident to pregnancy. The symptoms 
 upon which we rely are those of active congestion in the 
 lungs, anxiety, agitation, and the two states of the pulse just 
 now indicated. We prescribe the lower dilutions, which, in 
 copious hemoptysis, are to be repeated very often, the inter- 
 vals between the doses to be lengthened as the risk dimin- 
 ishes. 
 
 Arnica is a popular remedy that is principally indicated 
 by an abundant hemoptysis, where the flow is composed of 
 blackish blood with clots. Great sadness or despondency only 
 confirms the indication for its use. It is particularly useful 
 in cases of hemoptysis that are connected with heart aifections 
 or with traumatism. The sixth dilution is the one which is 
 most generally employed. I have prescribed the mother tinc- 
 ture with good results. 
 
 Millefolium is perhaps the remedy that is most frequently 
 prescribed in the treatment of hemoptysis. It is, above all 
 others, a faithful remedy, id est, it almost always justifies the 
 indications furnished by the Materia Medica for its use. The 
 "thousand leaves" is a very old remedy. Cazin says it con- 
 tains many resinous principles. ** It has the power to bring on 
 the menses again, and the lochia also, and to increase the 
 former when they have already begun to flow. For all this, 
 
 * Traite des plantes medicinales indigenes. 
 
HEMOPTYSIS. 191 
 
 Oazin, a homoeopathist without knowing it, prescribes the mil- 
 lefolium as a remedy for the control of hemorrhage. 
 
 The foregoing indication for this remedy is invaluable. It is especially 
 called for in case the hemoptysis is complicated with amenorrhea, and in the 
 puerperal state also, where it follows a suppression of the lochia. Under these 
 circumstances it is quite as prompt and useful as it is in bleeding piles, where 
 the flow of blood is vicarious of menstruation, or where it is connected with 
 chronic uterine disease. — L. 
 
 Millefolium is especially indicated in the slighter forms of 
 hemoptysis occurring in tuberculous subjects, when the blood 
 is red, frothy, and ejected without the violent effort of cough- 
 ing. It is often alternated with ipecac. Millefolium has also 
 been successfully used in cardiac and supplementary hemop- 
 tysis. 
 
 Hamamelis is one of our best remedies in hemoptysis occurring in persons, 
 and especially in women, of an hemorrhagic diathesis. It is adapted to the 
 venous constitution, and is indicated when the blood that is expectorated is of a 
 dark, venous hue. It is most useful when, with a tickling cough, there is a 
 taste of blood, or of sulphur; when there is a tightness and constriction of the 
 chest, and when, because of difficult breathing from congestion, the patient 
 cannot lie down. In this country it is more frequently given than any other 
 remedy in the onset of hemoptysis, and, if we are not mistaken, the general 
 preference is for the first or the second attenuation. — L. 
 
 Ledum palustre, or the wild rosemary, is a plant that also 
 contains many resinous qualities. Outside of homoeopathy it 
 is employed in the tanning of leather ;. indeed, it is this which 
 gives to the Russian leather the peculiar odor which has 
 brought it into such demand. This plant is capable of causing 
 hemorrhages, and ought therefore to be useful in their treat- 
 ment. 
 
 Ledum is indicated by an abundant hemoptysis, with a loss 
 of red and frothy blood, accompanied by a strong pulse and a 
 violent spasmodic cough, and especially when it is provoked by 
 tickling in the larynx and the trachea. 
 
 Ipecac, whose curative virtues in hemoptysis had already 
 been tested in the treatment of dysentery, is indicated in an 
 
192 THE MEDICAL CLINIC. 
 
 abundant hemoptysis, when it is preceded by a sensation like 
 that of bubbling in the chest. 
 
 Experience has taught us that it is well to alternate this 
 remedy with the millefolium. We prescribe it in the lower 
 dilutions. But beside the use of remedies, there are certain 
 hygienic indications that should not be forgotten : A well-aired 
 room, and not too warm; the elevation of the head and chest; 
 the feet to be kept warm ; the food and drinks cold ; the milk 
 diet, if the patient can bear it, and in all cases the vegetable 
 diet, constitute very necessary aids to treatment. 
 
 One word now of the treatment of hemoptysis by the old 
 school, and my lecture will close. First of all, and without any 
 partisan spirit, one is struck by the extreme poverty of the 
 officinal therapeutics, and the absence of special indications. 
 Excepting ergot and the perchloride of iron, which are pre- 
 scribed empirically, what are their resources against hemop- 
 tysis? Only one single remedy, and that is ipecac, which was 
 praised by Trousseau, who in this case, as in a good many 
 others, did not hesitate to borrow a remedy from the homceo- 
 pathists. Let us add that he gave it in emetic doses, thus use- 
 lessly exhausting his patient's strength; for if it was not the 
 action of ipecac, but that of a mere emetic, that he sought, 
 why did he not give the tartar emetic, or the sulphate of 
 copper ? 
 
 In terminating this lecture on hemoptysis, we should ex- 
 amine one question of pathology which has recently been 
 raised by Niemeyer. 
 
 The frequency of hemoptysis as the initiatory sign of 
 phthisis caused the ancients to believe that that disease often 
 resulted from pulmonary hemorrhage. In this view of the 
 matter the hemoptysis was always accompanied by a lesion, or 
 a wound in the lung, and this wound was thought to be the 
 origin of the characteristic ulceration of phthisis. Hoffmann 
 
HEMOPTYSIS. 193 
 
 and Morton described phthisis ab hemopto'e. This doctrine was 
 upset by Bayle and Laennec, and the question appeared to 
 have been definitely settled until Niemeyer adopted the old 
 notion, and tried to give it a new life. He professes that, in 
 hemoptysis, a certain quantity of blood remains in the ultimate 
 bronchial branches and in the pulmonary air-cells. He says 
 that this blood becomes a powerful cause of irritation to these 
 organs ; that this irritation gives rise to caseous pneumonia, 
 and that, consequently, hemoptysis is certainly, in such cases, 
 the origin and cause of the pulmonary phthisis. 
 
 Jaccoud, who has but too often accepted an opinion because 
 it was offered him with a German stamp on it, affirms, in his 
 Medical Clinic,* that from the point of view of the pathology 
 of phthisis we must distinguish in the broncho-pulmonary hem- 
 orrhages those which terminate brusquely, and in which the 
 last expectorations are still composed of foamy blood, and 
 those which have for several days discharged a brownish mat- 
 ter composed of blood that has been altered by its arrest in the 
 bronchial tubes. According to Jaccoud, it is this last form of 
 hemoptysis that should be followed by pulmonary tuberculosis, 
 because it has left a certain quantity of decomposed blood in 
 the capillary tubes of the bronchii. 
 
 J^iemeyer's opinion consists of as many hypotheses and 
 errors as there are affirmations. u Some blood remains in the 
 bronchial tubes and the pulmonary vesicles." This purely 
 hypothetical statement is contrary to all that we know of the 
 physiology of the bronchial passages. The blood of this pul- 
 monary pneumorrhagia, which Laennec denominated pulmo- 
 nary apoplexy, alone remains infiltrated in the vesicles and 
 pulmonary tissues. But when the blood has not filtered into 
 the lungs, when it is poured into the bronchial tubes it is ex- 
 pelled and discharged by the expectoration at the end of a few 
 
 Tome II, page 29, et seq. 
 13 
 
194 THE MEDICAL CLINIC. 
 
 days, iii the same maimer as the mucus and other foreign sub- 
 stances contained in the bronchial tubes. 
 
 "This blood becomes a cause of irritation, or of caseous 
 pneumonia." Here is another hypothesis, for it has not been 
 demonstrated that the blood is a cause of irritation to the 
 bronchii, and if the infarctus of apoplexy becomes occasionally 
 the point of departure for an inflammation of the lung, we 
 must be able to observe a wound, or a tearing of the tissue. 
 There is a gap between these two propositions, that the blood, 
 which is said to be contained in the bronchial tube, is a cause 
 of irritation, and this irritation gives rise to caseous pneumo- 
 nia. However, Niemeyer decided arbitrarily between them, 
 and without giving us even the beginning of a necessary proof 
 for observation, teaches us that when the nucleus of pulmo- 
 nary apoplexy becomes the point of departure for an inflam- 
 mation, this inflammation can terminate only in three ways, 
 viz : either by resolution, suppuration, or gangrene. The ter- 
 mination by caseous pneumonia is, therefore, purely theo- 
 retical. 
 
 Finally, the distinction, proposed by Jaccoud, between the 
 hemoptysis that terminates abruptly, and that which is fol- 
 lowed for several days by the expectoration of a brownish and 
 disorganized blood, is evidently theoretical and not clinical. 
 We have sought in vain, for years, for a case of this kind, 
 in which the hemoptysis ended so abruptly ; and for that 
 matter we are at a loss to understand how the bronchial tubes 
 can relieve themselves completely and instantly of all the 
 blood which, under the circumstances, they have contained. 
 It is, moreover, perfectly useless to search for this patholog- 
 ical rarity, for in the two cases of hemoptysis, which serve as 
 the text of this lecture, we have two very opposite examples, 
 in which, for several days, there was an expectoration of blood 
 that was altered in character and brownish in color ; and yet 
 we are able to state that, in neither of our patients, were there 
 
HEMOPTYSIS. 195 
 
 any symptoms of irritation or of caseous pneumonia ; neither 
 was there the rapid progress of phthisis, of which these hemor- 
 rhages were an undoubted symptom, at least in the first of 
 the two cases. 
 
 We may, therefore, conclude that Memeyer's attempt to 
 reinstate the phthisis ah hemoptoe has as little foundation in 
 fact as his famous theory of caseous or tuberculous pneumonia. 
 They are two errors with which it is a pity to have encum- 
 bered a subject that was so clearly set forth by Laennec. 
 
 Ten days ago we were called to a case of hemoptysis which was, in some 
 respects, peculiar. The patient, a beautiful, intelligent miss of eighteen, and a 
 recent graduate of our high school, had been ill for some time with what her 
 physician decided was an inflammation of the upper lobe of the left lung. 
 During a fit of coughing she was seized with hemoptysis, of which she had had 
 several slight attacks before. The blood raised was bright and copious, and I 
 found her very pale, weak, and almost pulseless. Hamamelis, 1st dil., soon 
 stopped the flow; but a harassing cough followed for which she took aconite, 
 3d dil. This was at six o'clock in the evening. Two hours later she expecto- 
 rated a mouthful of bloody mucus which evidently contained a foreign body, 
 for it rattled when it fell into the cup. This foreign body was fished up and 
 found to be the brass tip of the crochet-needle which she had swalloiced ten 
 years before. She remembers having swallowed it, and has, indeed, always in- 
 sisted that it never had been discharged. 
 
 A little while after the accident — which happened when she was eight years 
 old — she was seized with what appeared to be whooping-cough. The cough 
 was very intractable, and did not respond to remedies, but finally wore itself out. 
 As she grew older she became more and more delicate, and although there is no 
 hereditary tendency to phthisis in her family, her friends have been positive that 
 she was going into a decline. Indeed, they had lately come to the determina- 
 tion, through the advice of her physician, who is well informed and responsible, 
 that as soon as she should recover from the present attack of pneumonia she 
 must try the effect of a change of climate. — L. 
 
LECTUKE XVI. 
 
 Summaky. — Hemorrhoids, case. Are hemorrhoids only varices of the hemor- 
 rhoidal veins, or do they constitute a disease ? The connection between 
 gout and hemorrhoids. Hemorrhoids with profuse hemorrhages. Indica- 
 tions for sulphur, nux vomica, cesculus hippocastanum, hamamelis, millefo- 
 lium, ferrum perchloricum, aloes, the phosphoric and muriatic acids, arsen- 
 icum, carbo-vegetabilis, capsicum, collinsonia and sedum acre. 
 
 Hemorrhoids. 
 
 Gentlemen : Among our patients is a man who came to 
 trie hospital for a hemorrhoidal flux, which was of such fre- 
 quent occurrence, and so abundant, as to give him great un- 
 easiness. In this case you can judge of the efficacy of the 
 homoeopathic treatment, from the rapid cure of this man by 
 the hamamelis virginica. 
 
 Case XLV. — M. F , fifty years of age, a coachman, 
 
 entered the hospital on the 17th of December, 1874, bed No. 
 5, and left on the 18th of January, 1875. 
 
 This man has been troubled with hemorrhoids since the age 
 of fifteen. From 'time to time he lost blood at stool, which 
 did not, however, weaken him, nor affect his general health, 
 which latter has remained good until six months ago. At that 
 time, and from no known cause, a hemorrhoidal flux occurred, 
 which has continued almost constantly ever since. The blood 
 flows quite freely on the slightest movement. Even during re- 
 pose he has had a constant oozing away of this blood. 
 
 When he came to us he presented all the symptoms of 
 anaemia. He complained of having lost almost all his strength. 
 The appetite, however, is good. At the margin of the anus 
 there was a large hemorrhoidal swelling. 
 
 He was given hamamelis virg., in the 3d dil. 
 
 December 19. The patient is already a little better, but he 
 always loses a little blood at stool. The same remedy. 
 
HEMORRHOIDS. 197 
 
 December 24. The blood no longer flows when the patient 
 is quiet. Hamamelis, 3 dil. 
 
 December 27. He is much better. He has lost but a small 
 quantity of blood since he came to us. He was ordered the 
 perchloride of iron, in the 6th dil. 
 
 December 30. The patient lost a small quantity of blood 
 during the night. Continued the same medicine. 
 
 January 2. Since taking the perchloride, he is not so well. 
 Yesterday, during the day, he had several stools, and with 
 each one some blood was passed. Resumed the hamamelis, in 
 the 6th dil. 
 
 January 6. He is better again under the influence of the 
 old remedy. He can rise and walk about a little without any 
 loss of blood. Hamamelis, 30th dil. 
 
 January 8. The improvement continues. The remedy was 
 suspended. 
 
 January 10. The "patient has lost some blood during the 
 past two days, but in much smaller quantities than heretofore. 
 The same remedy. 
 
 January 12. He continues to do well. There is a very 
 slight oozing of blood at stool. He. took hamamelis, 3d dil., 
 again, which he continued to take until the time of his dis- 
 charge from the hospital. When he left he was entirely cured. 
 
 This patient promised to write us if the hemorrhages re- 
 turned, but we have heard nothing from him.* 
 
 Are Hemorrhoids a Local or a General Disease, or both f — 
 In this connection I have something to say on the subject of 
 hemorrhoids. It is a very difficult subject, and one that 
 is full of contradiction. We And in medical tradition two 
 totally different views, both of which have been perpetuated 
 from the time of Galen to our own day. By some of them, 
 and I find in this list the names of most of the masters of 
 our art — the Stahls and Sydenhams, etc. (I do not mention 
 the most illustrious) — the hemorrhoidal affection was consid- 
 ered as a disease, totius substantias, of which the rectal varices 
 
 * The hemorrhages did not return for six months. He placed himself in 
 the care of a surgeon, was operated upon, and died a few weeks after. 
 
198 THE MEDICAL CLINIC. 
 
 were but a symptom. Others, from Boerhaave to Yirchow, 
 including your professor, M. Gosselin, believe hemorrhoids 
 to be a simple affection of the veins of the rectum and of the 
 anus, — they are varices which are due to the compression 
 of the hemorrhoidal veins, or an aifection arising from purely 
 mechanical and local causes. 
 
 With which of these opinions shall we agree ; and how 
 are we to know the truth in looking at the matter from two 
 points of view that are so radically opposed to each other, 
 and each of which is supported by the eminent men whose 
 names I have given \ 
 
 The first thing to do is to study the question from a purely 
 clinical standpoint. Let us begin with the local affection, 
 and see whether a mere compression of the hemorrhoidal 
 veins will explain the development of this affection. The 
 local hemorrhoidal difficulty consists, essentially, of three 
 things, — the tumor, the pain, and the bloody discharge. M. 
 Gosselin, who is the modern representative of one of these 
 views, speaks as follows of the pathology of this affection : 
 
 "Constipation induces straining at stool; the fcecal mass 
 forces down the mucous membrane so as to make a hernia at 
 the anus ; the hemorrhoidal veins, which are very much 
 swollen because of the contraction of the circular fibres of 
 the rectum, are strangulated by the spasm of the sphincter, 
 and the hemorrhoidal tumors are the consequence." {Nou- 
 veau Dictionnaire de medecine et de chirurgie pratiques, t. 
 XVII, page £18.) 
 
 This mechanical explanation of the cause of hemorrhoidal 
 tumors is not supported by clinical proof, and may be upset 
 by merely observing, on the one hand, that all constipated 
 people do not have hemorrhoids, and on the other, that there 
 are numerous cases of hemorrhoids without constipation, as, 
 for example, those which are complicated with chronic diar- 
 rhoea in warm climates. 
 
HEMORRHOIDS. 199 
 
 It is a fact that has been very much insisted upon by authors, that the hem- 
 orrhoids are very prevalent in warm countries. Boerhaave reports that in Greece 
 and throughout Asia, they are as common as menstruation is in colder latitudes, 
 it being the exception for a person, whether male or female, not to have them. 
 He, however, attributes it to the existence of constipation, with which, he says, 
 nearly all the people are afflicted. — L. 
 
 Those physicians who consider a local hemorrhoidal af- 
 fection as a symptom, the effect of a disease, totius substan- 
 tia, assume that all this trouble with the anus is due, not 
 to the influence of a mechanical pressure, but to that of a 
 congestion which comes and goes under' the influence of the 
 disease. 
 
 The great variation in the size of the hemorrhoidal tumors 
 confirms this idea, and entirely disproves the mechanical doc- 
 trine concerning their origin and special pathology. These 
 congestions, in fact, are often periodical, and come as regu- 
 larly as the menses in a woman. In some women the hemor- 
 rhoids accompany the menstrual flow, and are manifestly the 
 result of the sanguinary afflux to the pelvic organs, id est, 
 of the molimen, which precedes and accompanies that func- 
 tion. The morbid process that results in the hemorrhoidal 
 discharge is of itself a real congestion, and all the symptoms 
 of this hemorrhagic molimen, as, for example, heat, weight, 
 throbbing at the anus, and in the loins, are symptoms of a 
 general plethora, the existence of which has often been con- 
 firmed by careful clinical observation. Besides the physical 
 and moral relief that follows, the sanguinary discharge in 
 hemorrhoids has all the characteristics of a salutary crisis, 
 and of the termination of a pathological process, and not 
 those of a flow which was due to a compression of the veins. 
 
 It seems to me useless to speak further of the untenable 
 theory of the mechanical and organic cause of hemorrhoids. 
 Yirchow tried, but in vain, to help the matter by giving it 
 the weight of his endorsement ; but, since this explanation of 
 
200 THE MEDICAL CLINIC. 
 
 the source of the affection was insufficient, he added that a 
 catarrh of the rectum was also a prominent factor in causing 
 it. But this catarrh is another demonstration of a morbid 
 determination of blood, and consequently of a disease of which 
 the suffering that is located at the extremity of the rectum 
 and at the anus is only a symptom. 
 
 Let us now enlarge the scope of our observation. If we 
 examine a hemorrhoidal patient let us note whether, outside 
 of this local affection, he does not present an array of symp- 
 toms and lesions having a definite and special character, and 
 which constitute the disease. Take, for example, a patient 
 of from forty to fifty years, he will tell you that in his youth 
 he was subject to attacks of bleeding at the nose, that were 
 more or less frequent, and that they originated and returned 
 without any known traumatic cause. The women will tell 
 you of early and profuse menstruation, and other patients will 
 also have suffered from hemoptysis or hematemesis. Thus 
 hemorrhoidal sufferers are those persons who, from their 
 youth, and sometimes from infancy, have shown a marked 
 predisposition to hemorrhages. If we continue this analysis 
 of the hemorrhoidal constitution, we find the nervous system 
 so affected as to cause vertigo, neuralgia, headache, hypochon- 
 dria, and, above all, the sclerosis of the nervous tissue, which 
 is so carefully studied in our day. It is the hemorrhoidal 
 subjects who furnish nearly all the cases of general paralysis 
 of the insane, and of locomotor ataxia. 
 
 In the respiratory system you will find special affections, 
 as asthma and catarrh ; in the vascular system, chronic en- 
 docarditis, aortitis and angina pectoris, which is merely a 
 sequel of the last-named lesion, but all of which are hemor- 
 rhoidal affections. 
 
 Lastly, in the digestive system, you will find flatulent dys- 
 pepsia and gastralgia. You should study each and all of 
 
HEMORRHOIDS. 201 
 
 these affections, and make note of their character and of their 
 order of succession in hemorrhoidal patients, and yon will 
 finally conclude that they constitute a veritable disease, like 
 the gout, the scrofula, etc. 
 
 Hemorrhoids may be related, either as a cause or a complication, with con- 
 junctivitis, blepharitis, coryza, acne, eczema, herpes, lichen, prurigo, furuncles, 
 vesical catarrh, urethritis, phlebitis, chronic hepatic, renal and cardiac dis- 
 orders, bronchitis, laryngitis, spasmodic asthma, headache, melancholy, epi- 
 lepsy, angina pectoris, and intractable forms of neuralgia. This fact has an 
 important bearing in the selection of remedies, for here, as elsewhere, it may 
 happen that the most appropriate remedy will be indicated by symptoms be- 
 longing to a remote or a symptomatic affection. — L. 
 
 Do not hesitate, therefore, to regard this disease from a 
 higher point of view than that which is generally taken by our 
 surgeons, who see only the local affection in hemorrhoids. 
 Fortunately, this old surgical notion is changing somewhat, 
 and I have read with pleasure an article contained in the 
 "Noumau Dictionnare de medecine et de chirurgie pratiques" 
 entitled, "Hemorrhoids treated in a Medical Way, " by a young 
 professor, Doctor Lannelongue. 
 
 This question of hemorrhoids, however, seems destined to 
 remain obscure, and to be endlessly discussed. If the careful 
 study of its symptoms causes us to recognize it as a general 
 disease, that should no longer be confounded with varices of 
 the rectum, still the numerous connections between hemor- 
 rhoids and gout serve to complicate the matter, and to embar- 
 rass the whole subject. This leads me to say that most hem- 
 orrhoidal affections, as headache, neuralgia, asthma, flatulent 
 dyspepsia, endocarditis, etc., are equally common in gouty 
 patients ; that nearly all gouty subjects at a certain stage of 
 the disease show signs of very severe rectal and hemorrhoidal 
 difficulties, as a bloody discharge, pain, tumors, etc., and that 
 those physicians who have recognized a hemorrhoidal affection 
 as distinct from gout, profess that the patient is subject to pains 
 
202 THE MEDICAL CLINIC. 
 
 in the joints and to arthritis. You will see how extremely diffi- 
 cult it is to clearly separate these affections from each other. 
 
 The Connection between Gout and Hemorrhoids. — Are hem- 
 orrhoids simply a gouty affection, characterizing a particular 
 form of this disease, which should receive the name of hemor- 
 rhoidal gout, or do the hemorrhoids themselves constitute a 
 disease which differs essentially and radically from the gout? 
 This is a plain question, and clinical experience must answer it. 
 
 Let us look at the positive results that have been gleaned 
 from observation. First of all, these results show that the local 
 hemorrhoidal symptoms are frequently met with in gouty sub- 
 jects ; of this fact there can be no doubt. It is also true that, 
 in a certain proportion of cases, the general symptoms of the 
 hemorrhoidal affection are so pronounced that it cannot be 
 mistaken. The case which serves as the illustration for this 
 lecture is a very clear example of this. Here is a man fifty 
 years of age who has never had asthma, headache, or any gas- 
 tric troubles. This is a simple case of hemorrhoids, which is 
 known by the hemorrhage, the hemorrhoidal tumor, and by 
 the symptoms which directly belong to the congestion, and to 
 the anal hemorrhages. We may add that, in cases like this one^ 
 the rectal affection is excessive, and that these are the patients 
 in whom the hemorrhages, because of their abundance and 
 of their frequent repetition also, compromise the life of the 
 patient. It seems that in such cases the disease exhausts itself 
 through a single symptom. This illustrates what, in scrofula, 
 is called a fixed form,, as in cases where the disease spends 
 its whole force upon one serious lesion, such as tuberculous 
 meningitis, Pott's disease, white swelling, etc. etc. 
 
 Shall we, therefore, conclude that hemorrhoids do not exist 
 separately, but that they are only a gouty affection ? But 
 what shall we do with those cases in which there is no symp- 
 tom of gout ? 
 
HEMORRHOIDS. 203 
 
 Let us rather say that since the morbid species are not 
 distinct ; since they are only species by analogy, not being 
 as distinct and separate as the animal species, we need not be 
 surprised to find a mixture of them on pathological domain. 
 This state of things may vex the nosologist, but it should 
 not be neglected by the clinical teacher. In all cases let us 
 remember that the local affection is common both to gout 
 and to hemorrhoids. 
 
 But to return to our patient, whose t case is the subject 
 of this lecture. His attack was one of the serious kind 
 which often necessitate surgical interference, and which may 
 terminate fatally. He was rapidly cured by homoeopathic rem- 
 edies. Before knowing the resources which the new method of 
 treatment offered, I treated cases like this one by external ap- 
 plications of the perchloride of iron, and, in desperation, by 
 the actual cautery. You will find cases in which these pow- 
 erful measures have not prevented the death of the patient. 
 The article by Lannelongue, to which I have already re- 
 ferred, quotes an example of this kind. It is therefore very 
 important to arrange a definite plan of treatment for hem- 
 orrhoids. I will profit by this occasion to speak to you of the 
 treatment of hemorrhoids and of their contingent disorders. 
 
 The Treatment of Hemorrhoids. — In the treatment of this 
 affection there are two remedies which dominate the rest, and 
 they are nux vomica and sulphur. These two remedies not 
 only correspond to the local affection, but also to the con- 
 gestion, the neuralgia, the dyspepsia, the hemorrhages, and, 
 in brief, to the greater part of the general symptoms of this 
 constitutional complaint. 
 
 Nux vomica is especially indicated in cases where the 
 following symptoms are observed : An ineffectual desire to 
 go to stool ; tenesmus ; anal constriction ; diarrhoea or constipa- 
 
204 THE MEDICAL CLINIC. 
 
 tion, with clear blood or mucus in the stools. The general 
 symptoms that call for this remedy are congestion and hem- 
 orrhage, epistaxis or metrorrhagia, neuralgia, dyspepsia and 
 hypochondria. I ought, in this connection, to speak to you 
 of its remarkable efficacy in epistaxis. which, as a rule, is 
 almost always one of the symptoms of the hemorrhoidal dia- 
 thesis. When the nose-bleed is preceded by slight head- 
 ache or redness of the cheeks, or when it comes on during 
 sleep, it may almost always be cured by nux vomica. I gen- 
 erally use the 6th or the 12th dilution in globules. 
 
 Sulphur does not correspond very well to the local affec- 
 tion ; but clinical experience has long ago confirmed its effi- 
 cacy when given in alternation with nux vomica. This rem- 
 edy has the following pathogenetic symptoms : Itching with 
 or without smarting pain ; tenesmus ; mucus or blood with 
 the stools, and constipation. We have also among its gen- 
 eral symptoms a rush of blood to the head, with vertigo and 
 sense of fullness and pain. 
 
 A third remedy, and one that is not so well known or care- 
 fully studied, is the cesculus hi/ppocastanum. According to a 
 legend, which everyone who has practiced medicine knows, 
 this remedy has been used for a long time. You know that a 
 goodly number of hemorrhoidal patients are in the habit of 
 carrying horse-chestnuts in their pockets, supposing that they 
 bring them relief. I do not know whether they are useful in 
 this way or not. I have no faith in this traditional prescrip- 
 tion ; but it is certain that, from an empirical use of this kind, 
 this remedy has passed into the general medical practice. 
 
 In America it is often prescribed for hemorrhoids. Dr. 
 Richard Hughes recommends it where there is obstinate con- 
 stipation, with sharp pains and slight hemorrhages. He also 
 advises it for the pains which follow the stools, pains which 
 
HEMORRHOIDS. 205 
 
 resemble those proper to a fissure. We shall see that the 
 sedum acris is particularly indicated in this latter case. 
 
 The cbscuIus was experimentally tested upon the healthy 
 man some years ago. It produced different symptoms on dif- 
 ferent subjects, but notably there were pains in the rectum and 
 anus. It also caused suffering in the throat; and you are 
 aware that a majority of those who have chronic pharyngo- 
 laryngitis are also subject to hemorrhoids. Among those 
 experimented on, one man, who had never had the hemor- 
 rhoids, experienced, according to Richard' Hughes, the devel- 
 opment of real hemorrhoidal tumors, which was due to the 
 influence of this drug. 
 
 Some months ago, my friend Dr. C. S. Fahnestock told me that he had 
 met with a case of dysmenorrhea which was associated with an intractable 
 sore-throat, and that he had cured the former affection by addressing his reme- 
 dies specifically to the latter. There are some cases of this kind; and there are 
 others also in which both the painful menstruation and the pharyngo-laryngitis 
 are associated with hemorrhoids. Cases of dysmenorrhcea occurring in those 
 who have had children are very apt to be associated with the piles, and when 
 they are, the collinsonia can. is a valuable remedy. — L. 
 
 How are those cases to be treated in which the hemorrhage 
 is excessive 1 The remedy which appears to have been most 
 useful against this form of the complaint is the hamamelis vir- 
 ginica. It is indicated in an abundant, sanguinary flow, and 
 above all, with those persons who have varices of the anus. 
 Clinical experience has confirmed this indication very exten- 
 sively, so that the hamamelis may be looked upon as a certain 
 remedy. It is much employed in England, and the old- 
 school pharmaceutists have prepared an anti-hemorrhoidal 
 mixture, of which hamamelis is the principal ingredient. 
 
 Millefolium comes next, and may be used for profuse 
 hemorrhages. Cazin cites examples in which he has used it 
 successfully for hemorrhoidal losses of blood. 
 
206 THE MEDICAL CLINIC. 
 
 When the hemorrhages are slight, but frequent, producing, 
 by their repetition, a tendency to anaemia, the perchloride of 
 iron is preferable. I have given it in the sixth dilution with 
 excellent results. 
 
 Another symptom, and one that is very much dreaded by 
 patients, is the painful inflammation of the hemorrhoidal tu- 
 mors. Where this is present we have recourse to a remedy 
 that is well known to the Old School, where they use it with 
 good results to produce a slight congestion of the anus. This 
 remedy is aloes, a pinch of which is used as a powder ; and 
 it is a popular remedy for this difficulty as well as a source 
 of income to the druggists. This remedy, which is perfectly 
 homoeopathic, is applicable to cases in which there is a con- 
 gestive determination of blood to the head, and deafness 
 accompanied by hemorrhoidal tumors that are excoriated with 
 smarting and burning pains. 
 
 The phosphoric and muriatic acids are indicated in case of 
 hemorrhages with painful swelling of the hemorrhoidal tu- 
 mors. 
 
 Arsenicum is suited for burning, itching pains, with nightly 
 exacerbations, and where the tumors burn like fire. 
 
 Carbo vegetabilis presents, in its symptomatology, oozing 
 of a serous liquid and the excoriation of the anus. This is 
 the remedy for the white hemorrhoids, or for the mucous or 
 the muco-purulent discharge, which, in some patients, charac- 
 terize the hemorrhoidal affection. 
 
 Next to carbo vegetabilis we may mention borax and mer- 
 curius. These remedies are less frequently used. I will say 
 but little about them, as I do not wish to burden your memory, 
 and because I intend to call your attention to a remedy which 
 has been very successful, and which has a great reputation 
 
HEMORRHOIDS. 207 
 
 among a goodly number of our brethren. This remedy is 
 capsicum, which was presented to the Academy of Medicine, 
 of Paris, about fifteen years ago, as a good remedy in cases 
 of hemorrhoids. It was accepted by that illustrious body, 
 in ignorance of the fact that this homoeopathic medicine was 
 recommended by a homoeopathic physician, which circum- 
 stance called from Prof. Imbert Gourbeyre the remark that 
 this presentation of pepper smacked a little of salt ! Capsicum 
 is indicated in peculiar cases, where the hemorrhoidal affec- 
 tion is accompanied by diarrhoea and tenesmus, and by the 
 presence of mucus and of blood in the stools. 
 
 There is a tradition among the people in some parts of the country, which 
 is as old as the hills, to the effect that "if a man will eat Cayenne pepper 
 freely and habitually with his food, he will never have the piles.' 1 An old 
 physician, of fifty years' practice, assures us that where this rule has been faith- 
 fully applied he has never known it to fail. So much, therefore, for capsicum 
 as a prophylactic. — L. 
 
 The American physicians praise the collinsonia can., and 
 judging from its pathogeny, this remedy affects the rectum 
 principally. It produces the following symptoms : flatulency 
 and colic, constipation, with straining and a dull pain in the 
 anus after the stool. It is, therefore, principally indicated 
 in hemorrhoids with constipation. Dr. Richard Hughes, from 
 whom I have borrowed these details, adds that the collin- 
 sonia is also an excellent cardiac remedy, which affords a good 
 reason for trying it in the cases of endocarditis and aortitis 
 that are so frequent in hemorrhoidal subjects. Pruritus of 
 the vulva, which is so often an incidental symptom of hemor- 
 rhoids, has been cured by this remedy. 
 
 We have often used this remedy both in hospital and private practice. It 
 seems especially adapted to women, and to those women who have hemorrhoids 
 either during, or as a sequel to, pregnancy and parturition, or in complication 
 with obstinate constipation or chronic inflammation with slight displacements 
 of the womb. For the first of these cases, where the trouble dates from gesta- 
 tion or from labor, or from both, and the condition has become chronic, there 
 is no remedy to compare with it for efficiency. We have cured a dozen cases of 
 this kind that have been sent to us by physicians from as many states, with the 
 
208 THE MEDICAL CLINIC. 
 
 collinsonia in the third dilution. And the college class can bear witness to its 
 remarkable efficacy in many such cases in our clinic at the Hahnemann Hos- 
 pital. "When the hemorrhoids are associated with constipation, and with a mild 
 form of retro-flexion or retro- version, and especially with prolapse of the uterus, 
 it will often relieve the whole difficulty. 
 
 There can be no doubt of its efficacy when the above-named symptoms are 
 associated with functional disturbance of the heart's action; and, for aught that 
 appears, it may be equally useful in some forms of organic disease of the heart. — L. 
 
 I have read, in an article on hemorrhoids, that the use of 
 
 the sedum telephum for hemorrhoids is common in Italy. I 
 
 knew that this plant, of the same family as the sedum majus 
 
 {Joubarbe des toits), was recommended for painful hemorrhoids, 
 
 and especially for fissures of the anus. I inquired of Catellan, 
 
 our pharmacist, if he had the sedum telephum, and on his 
 
 replying that just at that time he had only the sedum acre, I 
 
 took the latter, and prescribed it in the third dilution for a 
 
 man who was suffering from an extremely painful fissure of 
 
 the anus. The relief was very rapid, and it was followed by 
 
 his cure after a few weeks' employment of this remedy. Since 
 
 then I have continued to prescribe it ; and although it is 
 
 not always successful, yet it has often produced a happy effect 
 
 in relieving the pains that are incident to fissures of the anus 
 
 and to hemorrhoids. The indication for the sedum. acre is : 
 
 excessive pain, which is greater after the stool, and which 
 
 may persist for some hours. 
 
 The first of these varieties of the sedum is the sempervivum tectoram, the 
 vulgar name for which is the house leek. In his excellent monograph on Hem- 
 orrhoids, page 256, Dr. Fr6dault says : "The sedum telephum, or orpin, has 
 been very much extolled in former times. At Naples it was a popular remedy 
 in all kinds of hemorrhoids. Ettmuller and other authors have recommended 
 it, especially in the dry and painful form of the disease. I have used it in the 
 third trituration, and also in the sixth dilution. In one case of large hemor- 
 rhoidal tumors, where the discharge was copious, and the case had resisted 
 other remedies, it caused the tumors to disappear and the discharge to cease 
 promptly. In other instances, where there was only an acute pain, the relief 
 to the suffering was quite as prompt and decided ; but where there were fissures, 
 and I had hoped that this remedy would render me the best service, it did not 
 come up to my expectation. For although it cured two rebellious cases of this 
 kind, I prefer the podophyllum ." The reader will find a suggestive memoir 
 upon the sedum acre, contributed by Dr. Ladelci, in the Transactions of the In- 
 ternational Homoeopathic Congress, held in Paris, 1878, page 121. — L. 
 
LECTURE XVII. 
 
 Summary. — Chronic gastritis, case; the potencies vary with the disease. Brous- 
 sais and gastritis. Typhoid fever. J. Davasse and reform in the doctrine 
 of fevers. Confusion in the German school. Distinction between chronic 
 gastritis, dyspepsia and gastralgia. Treatment of these three aifections. 
 Remedies correspond to the suffering organ more than to the disease 
 itself. General and special indications for remedies in gastritis, dyspepsia 
 and gastralgia. Nux vomica, ignatia, carbo-vegetabilis, cocculns, arseni- 
 cum, lycopodium, sulphur, Pulsatilla, plumbum, chamomilla, belladonna, 
 veratrum and graphites; the alternation of nux vomica and graphites. 
 Case of chlorotic dyspepsia. 
 
 Chronic Gastritis. 
 
 Gentlemen : Here are the notes of a case of chronic gas- 
 tritis. 
 
 Case XL VI. — M. Tardy, aged fifty-three years, entered 
 the hospital on the 2d of December, and left it on the 17th of 
 December. 
 
 Tardy is a man of strong and vigorous constitution, and 
 has never shown any signs of the gout, herpes or hemorrhoids. 
 Being a poor man, he has usually been badly nourished. While 
 he was a soldier in Africa, fifteen years ago, he used alcohol 
 to excess, but he assures us that, since his return to France, he 
 has always kept sober. 
 
 The disease for which this man entered the hospital began 
 three years ago with great difficulty of digestion and cramps in 
 the stomach (?). In two or three months he commenced to 
 vomit. At first the vomiting was not frequent, but by degrees 
 the attacks grew nearer together, and for the past two years 
 they have been of almost daily occurrence. 
 
 The vomiting sometimes occurs before meals, and some- 
 times after them, the matter ejected after the meals being com- 
 posed of the ingesta; before eating, of a slimy liquid that is 
 partly colored. The patient has grown very thin, but, strange 
 to say, has always retained his appetite. 
 14 
 
210 THE MEDICAL CLINK*. 
 
 He has never vomited blood nor any black matters. The 
 pain, from which the patient suffers in the pit of the stomach, 
 is increased by pressure, while, on the contrary, firm pressure 
 upon the abdominal wall gives a slight feeling of relief. 
 
 December 3. The patient is allowed to eat meat and vege- 
 tables. We prescribe nux vomica, 12th dil., to be taken an 
 hour before eating; and graphites, 12th dil., an hour after eat- 
 ing. These medicines are in the form of globules. 
 
 December 1. He vomited considerably, throwing up a 
 slimy liquid and water in the morning. The vomiting was 
 preceded by a slight increase of pain in the epigastric region. 
 The same treatment. 
 
 December 5th. There was no vomiting during the day. 
 The sensibility at the pit of the stomach has considerably 
 diminished. Nux vomica, 30th dil., in globules dissolved in 
 water, three spoonfuls during the day. 
 
 December 7. Yesterday the patient had a painful attack, 
 accompanied by cramps in the stomach, but without vomiting. 
 The appetite is excellent. Suspend the remedy. 
 
 December 9. The pain, of which he complained so con- 
 tinually, has entirely left. 
 
 December 11. Yesterday he had a very slight attack, but 
 without vomiting. Ntix vomica, 30th dil., as before. 
 
 December 13. Patient is not so well ; he suffers in the 
 epigastrium and in the abdomen, and the appetite has failed. 
 No remedies. 
 
 December 17. He improves continually. He vomits no 
 longer, and suffers no pain. He eats well, begins to gain 
 flesh, and insists upon returning to his work. 
 
 The following case is one that is taken from my private rec- 
 ords, and is the more conclusive from the duration and severity 
 of the disease. Two distinguished physicians had diagnosti- 
 cated it to be a cancer of the pylorus, and the patient, in fact, 
 presented the usual signs of that disease. Notwithstanding 
 this, a cure was effected in a few months, and there has been 
 no relapse ; so that it is impossible that this diagnosis could 
 have been correct. Nux vomica, in globules, in the 12th and 
 30th dilutions, was the only remedy used in this case. 
 
CHRONIC GASTRITIS. 211 
 
 Case XLYII. — M. C , forty-three years of age, has 
 
 been ill for four years. His trouble began with attacks of 
 vomiting of his food, which at first were infrequent, with a 
 failure of the appetite and obstinate constipation. Although 
 
 Mr. C sometimes eats to excess, yet he does not abuse 
 
 the habit of taking alcohol. He is of sedentary habits ; is em- 
 ployed in a large business house, and passes his Sundays in 
 fishing. During the previous six months the disease had made 
 great progress, and I found him in the following condition : 
 
 Great emaciation, with so little strength that he is obliged 
 to lie down almost the entire day, and he can scarcely walk 
 a short distance in his room. The face is anaemic, but not 
 of that yellow straw color that is peculiar to the cancerous 
 subject ; the feet are very cedematous. 
 
 Percussion reveals an enormous dilatation of the stomach. 
 The patient vomits every week, and oftener if he is careless of 
 his diet, which usually consists only of broth and milk. The 
 vomiting is copious, and the matters thrown up seem to be 
 composed of the undigested food which has accumulated for 
 several days. There are, therefore, symptoms of contraction 
 of the pylorus with consecutive dilatation of the stomach. I 
 am assured that M. Grueneau de Mussy diagnosticated the case 
 as one of scirrhus of the pylorus. I made a most careful ex- 
 amination, and found a smooth and lengthened induration, 
 which followed the movements of the diaphragm, and which 
 left me without a doubt concerning the nature of the tumor. 
 
 The patient's diet consists of milk and broth. He takes 
 a purgative enema every alternate night and an opiate every 
 night ; the march of the disease is slow but continuous. 
 
 November 2. I prescribed a continuation of the same diet, 
 but a suppression of the opium and of the purgative injections, 
 and ordered nux vomica, 3(Jth dil., four globules in 125 grammes 
 of water, two teaspoonfuls each day. The patient is expecting 
 to have a fit of vomiting any day. 
 
 December 7. He has not yet vomited ; he finished his 
 medicine two days ago. Nux vomica, 30th dil., in 200 
 grammes of water, to be taken in the same manner. 
 
 December 12. There is no vomiting yet. Nux vomica, 
 12th dil., in the same way. 
 
212 THE MEDICAL CLINIC. 
 
 December 15. There is great improvement, for the patient 
 has not vomited for three weeks. He feels a little better ; 
 thinks he could eat; the constipation is less obstinate, although 
 he is sometimes obliged to use an injection of honey. He has 
 continued taking nux vomica in the 30th dil. 
 
 December 28. The improvement is decided ; the swelling 
 of the feet has disappeared. The patient is stronger ; walks 
 about his room ; insists upon taking food ; he has not vomited 
 for seven weeks, and the constipation has disappeared. His 
 diet has been improved by the addition of rice-cream, cream to 
 drink, soups, and finally roast chicken, all of which is well 
 digested. His strength returns, and we allow him wine. 
 Continue nux vomica, 30th dil. 
 
 At the beginning of January his convalescence was com- 
 plete ; he ate two good meals with some meat each day, and 
 commenced to go out again. This good result has continued 
 for a year, notwithstanding occasional excesses at the table, the 
 attractions of which he has not had the courage to resist. A 
 few months after the cure he suffered from sub-orbital neuralgia, 
 and later from an eczema of the extremities. 
 
 These two are very remarkable cases. They once more 
 illustrate the heroic virtues of nux vomica in affections of the 
 stomach; the efficacy of the smallest doses, as the 12th and 
 30th dilutions, in globules ; the propriety of suspending a 
 remedy, and the aggravations easily induced by their con- 
 tinuance. In fact, in Case XLYII we have seen that nux 
 vomica in the 30th dilution could not be continued for more 
 than two days without increasing the suffering, and that the 
 improvement continued and a cure was effected in the absence 
 of any other remedy. 
 
 The following case, which in many respects is similar to Case XLVII, was 
 recently reported to the Clinical Society of the Hahnemann Hospital by my 
 colleague, Prof. A. E. Small. It will serve to illustrate that nux vomica is some- 
 times very useful, when given in the lower potencies in gastric affections of a 
 serious character. This case has never before been published. — L. 
 
 Case. — "A gentleman, aged fifty, of large physical frame, 
 and of a sanguine temperament, who resided in a malarious 
 
CHRONIC GASTRITIS. 213 
 
 district, was seized early in May, 1877, with a gastric fever, 
 from which he suffered intensely for five weeks, from continuous 
 vomiting. His stomach was so irritable and inflamed that, 
 during this entire period, he could retain nothing either in the 
 shape of food or drink. He was first treated by physicians of 
 the regular school, who finally decided that he was the victim 
 of some organic and probably fatal difficulty which resisted 
 all their efforts to obviate. At the conclusion of this period of 
 suffering a change of practice was determined upon, and the 
 writer was called in to take charge of the ,case. 
 
 "June 8. A careful examination revealed the following 
 symptoms: Great distress in the epigastric region, accompanied 
 by the vomiting, every ten or fifteen minutes, of a dark-colored 
 mucus, mingled with the delicately prepared food which he had 
 taken into the stomach. The stomach was greatly distended, 
 and the entire gastric region was exceedingly sensitive to the 
 touch. Nude vomica , in the third decimal trituration, was pre- 
 scribed in the evening, the dose to be repeated every three 
 hours until there was some relief or change. After the third 
 dose was administered the vomiting ceased, and the patient 
 was able to retain some gruel. 
 
 "June 10. He was very uncomfortable from the distension 
 and pain, and on further examination it was ascertained that 
 the parietes of the stomach were completely indurated, from 
 the pyloric to the cardiac orifice. The external appearance 
 was that of an indurated tumor, which involved the whole 
 epigastric region. The third decimal of nux vomica was re- 
 peated at intervals of three hours for the succeeding two days. 
 
 "June 12. The patient is still able to retain some food 
 without vomiting. He complains much of the weight and press- 
 ure of the tumor. To him it seems like the weight of a brick 
 or a stone pressing upon the stomach. He also complains of a 
 burning sensation and thirst, which the nux vomica had not 
 relieved. The third decimal trituration of arsenicum was sub- 
 
214 THE MEDICAL CLINIC. 
 
 stituted for the mix vomica, but without affording any relief. 
 His vomiting partially returned. 
 
 "June 16. Resumed the nux vomica, and applied cooling 
 emollients externally. This treatment was continued for the 
 next week with some benefit. 
 
 " June 24. Finding no improvement in the induration, and 
 fearing some serious if not fatal organic derangement, Prof. 
 Ludlam was called in consultation. The case appeared to indi- 
 cate some formidable growth the nature of which was not 
 easily determined, but that of a scirrhous tumor was feared. 
 
 "July 1. Another consultation was had with Dr. L., and 
 it was mutually agreed that nux vomica was having a favorable 
 effect, and this remedy, in connection with the external emol- 
 lients, having stayed the progress of the disease, it was thought 
 best to rely upon it in the future treatment of the case. Two 
 weeks later the patient exhibited a decided improvement, and 
 from this time onward the induration gradually disappeared 
 and the normal function of the stomach became restored. The 
 weight of the patient when taken sick was 215 pounds, and 
 when convalescence began his weight was only 140 pounds. 
 
 "Since nutrition became established he has regained his 
 flesh, and after many months the tumor was completely dissi- 
 pated, or absorbed. His suffering from first to last was modi- 
 fied, restrained and ultimately cured by nux vomica in the 
 third decimal trituration. ' ' 
 
 We shall see that in other chronic diseases, as, for example, 
 in eczema and in scrofulous ophthalmia, and contrary to what 
 we have said of gastritis and nux vomica, it is sometimes 
 necessary to give the low dilutions, sometimes the mother 
 tincture ; and that these stronger preparations must be con- 
 tinued for some weeks without interruption. There are com- 
 plications that are full of obscurities, to which we do not 
 possess the key, and which make the treatment of chronic 
 
CHRONIC GASTRITIS. 215 
 
 affections so difficult. I know very well that there are those 
 who say that when a medicine is well chosen, the smallest 
 doses are not only sufficient, but that they are the best. If 
 this be the case, I am surprised that during so many years 
 the proper remedies for eczema and ophthalmia have not been 
 discovered, and that in these serious affections we are still 
 obliged to employ such strong doses, and to continue them 
 for a long time, if we desire to effect a cure ; and for my- 
 self, I prefer to confess frankly that, outside of clinical ex- 
 perience, we have no certain rule to govern us in the choice 
 of the attenuation. 
 
 The Clinical History of Gastritis and Dyspepsia. — I pre- 
 sume that you will be surprised at my employment of the 
 term chronic gastritis, for I do not know if in sixty years we 
 have ever heard of acute or chronic gastritis. The expres- 
 sion, by a reaction which belongs to human nature, fell out 
 of our medical literature, as though the maladies appeared 
 and disappeared at the command of those who make and 
 fashion the different theories. It is, therefore, useful that 
 we should dwell a moment on this question of gastritis, and 
 give it its positive value by showing that it serves to desig- 
 nate a disease that is very clearly defined. 
 
 When Cullen created the class which he styled the dys- 
 pepsias, and reunited, under this name, all the organic affec- 
 tions of the stomach excepting cancer, there was no longer 
 a question of gastritis or of gastralgia. 
 
 During the reign of Broussais, the dyspepsias disappeared 
 as tainted with speculation ; gastralgia was considered as an 
 effect of inflammation, and everything was gastritis. 
 
 At this time nosology became marvelously simple. All 
 chronic diseases belonged to the class of chronic gastritis, 
 and all the acute diseases either to acute gastritis or acute 
 gastro-enteritis. 
 
216 THE MEDICAL CLINIC. 
 
 Through the sympathy of the organs with the stomach, 
 Broussais explained the symptoms of each and every dis- 
 ease. We know that, concerning acute gastritis, he reunited 
 the four continued fevers of the ancients in one, thus contribut- 
 ing to the unity of typhoid fever, never supposing that, in this, 
 he was striving to establish the essential nature of fevers, a 
 doctrine which he had so violently opposed under the name 
 of ontology. 
 
 Broussais still reigned, but a threatening reaction had al- 
 ready begun against his system when, in 1826, Barras pub- 
 lished his treatise on gastralgia. This affection next took 
 the place of gastritis ; as for dyspepsias, they had fallen into 
 oblivion. However, Chomel, and several physicians of his 
 time, commenced to write about dyspepsia. The teachings of 
 Cullen were again accorded their deserved honor, and we en- 
 tered upon true nosology, in recognizing, as distinct affections, 
 chronic gastritis, dyspepsia and gastralgia. 
 
 About the same time, Jules Davasse, one of M. J. -P. 
 Tessier's most distinguished pupils, completed Broussais' 
 work by writing on ephemeral fever and synochal fever, 
 which, with the typhoid, includes all the continuous fevers. 
 
 In this way (and the work was done almost entirely by 
 the French physicians) modern pyretology was developed, 
 so that we now have the eruptive, the intermittent and 
 the continuous fevers, including the ephemeral, the syno- 
 chal and the typhoid fevers. ' 
 
 Niemeyer, who resumes and adopts the theory of gastritis 
 under the title of gastro-intestinal catarrh, — has sought to re- 
 construct the old system under the names of gastric, bilious 
 and mucous fevers ; and Jaccoud has followed this author in his 
 treatise on special pathology. This tendency, which is greatly 
 to be deplored and regretted, and the consequences of which 
 we begin to feel in the imperfect diagnoses of ?nucous and hi- 
 
CHRONIC GASTRITIS. 217 
 
 ions fevers, rests upon a faulty study of semiotics and of 
 pathological anatomy. It is only a system that will pass 
 away like all others, and to which we need pay but very 
 little attention. 
 
 The Differential Diagnosis of Chronic Gastritis from Dys- 
 pepsia and GastroJgia. — Let us, then, return to the distinc- 
 tions between gastritis, dyspepsia and gastralgia. 
 
 Dyspepsia is an affection (it is not a -disease) that may be 
 symptomatic of gout, of hemorrhoids, of herpes, of chlorosis, 
 or of hysteria. It is generally found to be present in the 
 greater number of chronic diseases, such as phthisis, scrofula, 
 cancer, diseases of the heart, etc. etc. The lesions of the 
 liver are always a more or less marked cause of dyspepsia; 
 and chronic poisoning, alcoholism in particular, may be a 
 cause of dyspepsia and of chronic gastritis. 
 
 Dyspepsia, as its name indicates, is characterized by a dif- 
 ficulty of digestion. Sometimes the trouble is slight, a mere 
 sluggishness of this function that causes the food to remain 
 a long time in the stomach. This is the variety that is known 
 by the unmusical name of oradyspepsia. 
 
 Again, this difficulty of digestion is accompanied by the 
 development of gas in the stomach and in the intestines, with 
 borborygmus and a burning regurgitation of gas that is almost 
 always inodorous. This is the flatident dyspepsia. 
 
 When there are regurgitations of liquid and of acid food, 
 and veritable eructations of what has been swallowed, it is 
 the acid form of dyspepsia. 
 
 Finally, dyspepsia is sometimes characterized especially by 
 cardiac or cephalic suffering, dizziness, cephalalgia, palpitation 
 of the heart, breathlessness, spurious pleurisy, arrest and 
 irregular beating of the heart. This is the masked form, be- 
 cause the symptoms of indigestion are not very pronounced. 
 
218 THE MEDICAL CLINIC. 
 
 but are, so to speak, obscured by the cerebral and cardiac 
 symptoms. 
 
 Each of these forms presents sub-varieties, which differ 
 with the diseases of which the dyspepsia is a symptom. In 
 dyspepsia the tongue is clean, the appetite is usually retained, 
 a fact that distinguishes it in a characteristic way from gastritis 
 and from other organic affections of the stomach. 
 
 Gastralgia is an affection that is more clearly defined. 
 It is a cramp of the stomach, and, like all other neuralgias, 
 is habitually symptomatic, and it often alternates with other 
 forms of neuralgia. 
 
 Gastralgia is characterized by an extremely acute pain, 
 that may be accompanied or not by a feeling of constriction, 
 located in the epigastrium, but which radiates along the inter- 
 costal nerves and their anastomosing branches. The pain 
 returns in paroxysms, is accompanied by a feeling of anguish, 
 crying aloud, by hot and cold sweats, sometimes by lipothy- 
 mia, and more rarely by efforts to vomit. 
 
 Moral causes and variations of the temperature, storms, and 
 thawing and melting snow, have all a remarkable influence 
 over the repetition of the attacks. 
 
 As for chronic gastritis, it may be recognized by a dull 
 pain, accompanied by the vomiting of food, or of an acid 
 mucus. The tongue is usually furred, and the urine contains 
 a large proportion of the phosphates. The emaciation and 
 loss of strength are much more rapid, and much greater in 
 this disease than in dyspepsia. 
 
 When this form of gastritis has lasted a long time, the 
 membranes of the stomach are hypertrophied at its pyloric 
 portion, which occasions a real contraction of this orifice. 
 Then follows a considerable dilatation of the stomach, and 
 the sensation of a hardening or induration in the region of 
 
THE TREATMENT OF CHRONIC GASTRITIS. 219 
 
 the pylorus, while at the same time the patient is seized with 
 copious vomiting of the aliment that had been taken into the 
 stomach several days before, while, perhaps, the food swallowed 
 the same day is retained. 
 
 At this period it may be very difficult to make the diagnosis 
 between cancer of the stomach and chronic gastritis. But 
 in this last affection the appetite is always more constant and 
 reliable than in cancer of the stomach, and this is a sign that 
 is worthy of your attention. The emaciation is also less rapid, 
 the straw-colored complexion and the vomiting of blood, 
 which characterize the cancer of the stomach, are lacking. 
 
 Case XLYII is an excellent example of chronic gatritis, 
 which simulated cancer of the stomach. You recollect that 
 one of the most skillful practitioners in Paris made a mistake 
 in this case, and that the cure of the patient alone enabled 
 us to settle the diagnosis satisfactorily. 
 
 You have seen that nux vomica was the principal remedy 
 for chronic gastritis. We will now mark out its exact indica- 
 tions, and also speak of other medicines that may be given 
 in this disease. 
 
 The Treatment of Chronic Gastritis. 
 
 With your permission, we will examine the treatment of 
 chronic gastritis, dyspepsia and gastralgia. You will observe 
 that the same remedies are frequently indicated in the treat- 
 ment of all three of these affections. This is not strange to 
 us as homceopathists. For we very well know that medicines 
 are not specifics for any one disease in particular ; but that 
 they correspond to a totality of symptoms and of lesions ; 
 that, consequently, their action is rather upon the organ and 
 its perturbed functions than upon the disease itself. There 
 are, therefore, medicines for the stomach, just as there are 
 medicines for the brain, the heart, the kidneys, etc. etc. 
 
220 THE MEDICAL CLINIC. 
 
 We will not forget these principles, and whenever we 
 study a remedy that may be indicated in the treatment of 
 gastritis, of dyspepsia, or of gastralgia, we shall commence by 
 recognizing the general properties of that medicine, because 
 these very properties may serve to determine the choice of a 
 remedy in the treatment of any disorder of the stomach in 
 which it is indicated. 
 
 Nux vomica is the principal gastric remedy. It is suited 
 to hemorrhoidal cases, and, as Hahnemann said, to vigorous, 
 sanguine and irascible constitutions. A sedentary life, the 
 abuse of good living, and the effects of too assiduous intel- 
 lectual labor, are all indications for the employment of this 
 remedy. 
 
 The sufferings of the digestive organs which principally 
 indicate this medicine are : constipation with tenesmus, diffi- 
 cult digestion with disposition to sleep after dinner, and 
 insomnia after midnight, and pains in the stomach in the 
 morning. 
 
 Nux vomica is an excellent remedy in dyspepsia. The 
 feeling of weight on the stomach after eating, flatulence and 
 pyrosis especially call for nux vomica. The tongue is covered 
 only on the posterior part (Dr. Boyer) ; bitter or acid taste, 
 with eructations of the same nature (Hughes) ; weight in the 
 head, sometimes the canine appetite with quick satiety, and 
 the predisposition to nausea after eating, all confirm this 
 indication. But, above all, we recommend the alternation of 
 graphites with nux vomica in the treatment of dyspepsia. We 
 will return to this treatment farther on. 
 
 In gastralgia, nux vomica is indicated when there is great 
 flatulency, the pains have the character of cramps, radiating 
 either into the hypochondria or beneath the sternum and 
 toward the neck, following the course of the phrenic nerve. 
 
THE TREATMENT OF CHRONIC GASTRITIS. 221 
 
 The disease must also present the general characters that 
 are found in the provings of this remedy. I have remarked 
 that,, as in this case, it was necessary to give it in the medium 
 and higher potencies, viz : the 1 8th, 30th and 200th dilu- 
 tions, in order to avoid bringing on the very painful parox- 
 ysms. Let us observe here that nux vomica is not a rem- 
 edy for the paroxysms, but its effect is better if given be- 
 tween the fits, say two doses a day for four days, then suspend 
 its use for four days, and afterward resume it again. Ignatia, 
 chamomilla, veratrum and belladonna are medicines that are 
 suited for the paroxysms, as we shall see directly. 
 
 In chronic gastritis we have found that nux vomica was 
 a very reliable medicine (Cases XLYII and XL VIII). In- 
 dependently of the dyspeptic symptoms already given, we 
 find as an indication for nux vomica in chronic gastritis : an 
 habitual pain in the pit of the stomach, regurgitations of 
 bitter and acid liquids, vomiting of the same nature, and 
 the vomiting of food. Clinical experience also teaches us, 
 that nux vomica is indicated by a contraction of the pylorus 
 with dilatation of the stomach, when this lesion follows chronic 
 gastritis. Abundant vomiting of food occurring long after eat- 
 ing, and containing the aliment that was taken some days ago, 
 to the exclusion of that which was taken more recently, being 
 the usual symptom of contraction of the pylorus, also indicates 
 the employment of nux vomica. 
 
 Ignatia, which is so analogous to nux vomica, is distin- 
 guished from it by the preponderance of the hysterical symp- 
 toms. Clinical experience long ago proved to us that the 
 St. Ignatius bean can rarely be successfully used in chronic 
 gastritis and dyspepsia, but that it is the principal remedy 
 that is required in gastralgia. 
 
 The symptoms that particularly indicate ignatia in gas- 
 
222 THE MEDICAL CLINIC. 
 
 tralgia are periodical attacks of cramps of the stomach, com- 
 ing on usually at night or after eating, which are aggravated 
 by the slightest contact, and relieved or mitigated by a change 
 of position. 
 
 Carbo-vegetabilis. — This is a remedy for hemorrhoidal sub- 
 jects and for those patients who are disposed to diarrhoea 
 with a great deal of flatus, the stools slight and flatulent, 
 with the evacuation of which the desire to go to stool ceases. 
 Hahnemann expressly noted that this flatus was almost al- 
 ways inodorous, although Dr. Richard Hughes, and most 
 other homoeopathic physicians, have considered the fetidity 
 of the excretions as a positive indication for carbo-vegetabilis. 
 This discrepancy probably arises from the fact that the symp- 
 tom of inodorous gas spoken of by Hahnemann was one of 
 the curative effects produced by the medicine in making the 
 proving. 
 
 To the great flatulency developed in the stomach and in- 
 testines, and the putridity of the stools, must also be added 
 a sensation of burning in the stomach, bordering often on 
 pyrosis ; eructations that are acid, bitter or sweet ; epigastric 
 distress and absence of vomiting, as specifying the range of 
 use for the carbo-vegetabilis in dyspepsia. 
 
 Cocculus. — The Materia Medica Pura of Hahnemann con- 
 tains symptoms which make it impossible to neglect the Indian 
 berry in the treatment of gastralgia: "Violent cardialgia, a 
 constrictive pain in the stomach ; cardialgia, a stricture in 
 the epigastrium ; constrictive pain in the stomach, as though 
 it were tightened by a band', compression as though from pinch- 
 ing in the epigastrium, which interrupts the respiration." Dr. 
 Richard Hughes very properly says that cocculus affects the 
 muscular system especially. It is, therefore, the remedy for 
 a genuine cramp of the stomach. Hartmann speaks positively 
 
THE TREATMENT OF CHRONIC GASTRITIS. 223 
 
 of having cured the most obstinate cases of gastralgia with 
 cocculus, but under the following circumstances : where the 
 patients were constipated, where they had no pyrosis, and, 
 above all, where the treatment had been commenced by nux 
 vomica. I will add, as symptoms proper for fixing the choice 
 of cocculus, great flatulency and considerable flow of the 
 saliva. 
 
 China. — The allopathic school furnishes us every day, by 
 its abuse of quinine, and by the suffering which results from 
 this abuse, the proof that it is a remedy for gastric difficulties. 
 China agrees principally with those patients who have been 
 exhausted by privation, by losses of fluids, by hemorrhages, 
 or by some previous disease. Hahnemann says that china 
 is not efficacious unless the patient's sleep at night is troubled, 
 as it is when the drug is taken by healthy persons. The 
 peculiarity of this sleep is that it is agitated with anxious 
 and frightful dreams, the terror continuing even after awaking. 
 
 China is an important remedy in dyspepsia. The slowness 
 of the digestion is accompanied by a sense of weight and diffi- 
 culty of breathing. Great flatulency, and stools of a liquid 
 nature passed immediately after eating, is a characteristic 
 symptom. Observe, again, that it is a special indication for 
 china in dyspepsia when the tongue is thickly covered with 
 a yellow coating ; there is a predominating bitter taste in the 
 mouth, the appetite continues, and there is a temporary relief 
 from gastric suffering by eating. 
 
 China corresponds in its symptoms, in a healthy man, to 
 cardialgia with suffocation, and may also be given in the 
 masked form of dyspepsia, with cardiac symptoms. 
 
 I am not in possession of such clinical experience as will 
 permit me to decide upon the indications for china in gastritis 
 and gastralgia. 
 
224: THE MEDICAL CLINIC. 
 
 Arsenicum. — This remedy acts with great power on the 
 organs of digestion, and provokes, when given to a healthy 
 man, acute and chronic inflammations, examples of which 
 abound in the history of cases of poisoning by arsenic. A 
 sensation of faintness during the suffering, palor, emaciation, 
 loss of strength, thirst, nocturnal aggravations, eczema and 
 psoriasis, which may be either primary or secondary, form the 
 characteristics of this remedy. 
 
 In chronic gastritis, arsenicum has been successfully em- 
 ployed. The special symptoms which indicate it are: a white 
 tongue, loss of appetite, acid and bitter eructations, very fre- 
 quent bilious and alimentary vomiting, constant pain in the 
 stomach, and habitual burning, which is worse some time after 
 eating. 
 
 In dyspepsia, arsenicum has done me good service, espe- 
 cially where this affection has developed from herpetic dis- 
 orders. The general symptoms of this medicine, as well as 
 those enumerated under the head of gastritis, will guide the 
 physician in the choice of arsenicum for the treatment of 'dys- 
 pepsia. The following symptoms may be added : yawning, a 
 desire to sleep and great prostration after eating ; thirst, with 
 relief from warm drinks, and often a diarrhoea, or loose stools. 
 Great anxiety, with very painful cardiac pressure, indicate 
 arsenic in the masked form of dyspepsia. 
 
 Arsenicum has sometimes cured those cases of gastralgia 
 which are symptomatic of dartrous affections. Here there is 
 relief from hot drinks and warm applications, and a burning 
 cardialgia, with anxiety, and lipothymia are especial indica- 
 tions for arsenic in gastralgia. 
 
 Lycopodium. — Lycopodium seems to us to be principally 
 useful in the hysterical, chlorotic and dartrous subjects. Here 
 are some general signs by which we may regulate the employ- 
 
THE TREATMENT OE CHRONIC GASTRITIS. 225 
 
 ment of lycopodium, and which we borrow from Dr. Guerin- 
 Menneville's translation of Dr. Richard Hughes' work: "In- 
 stead of the acute disorders, we find gradually advancing 
 chronic disease ; instead of excitement, we have depression 
 and decay. Mental, nervous and bodily weakness ; sallow 
 complexion and cold extremities ; anorexia, slow and irregular 
 digestion, flatulence and constipation • a passive catarrh of the 
 air passages, and an unhealthy state of the skin, are the 
 morbid conditions presented to us." 
 
 We have emphasized several of these symptoms, which 
 indicate the evident action of lycopodium upon the stomach. 
 
 Lycopodium has rendered its greatest service in dyspepsia 
 and flatulent dyspepsia, and Richard Hughes does not hesitate 
 to recommend it as a very important remedy in the treatment 
 of this disease. The following are its principal indications: 
 pyrosis, flatulency and constipation. As accessory symptoms, 
 bitter or acid eructations, bulimia, with repugnance and dis- 
 gust of food, and intestinal meteorism. Dr. Hughes also says 
 that an irresistible desire to sleep after dinner, followed by 
 great weariness, are indications, and that lycopodium may be 
 successfully used for dyspepsia engendered by the abuse of 
 farinaceous food. 
 
 Some of the symptoms of lycopodium indicate its employ- 
 ment in gastralgia and in chronic gastritis • some very serious 
 cases of the last-named disease, with black vomiting, have 
 been cured by it. It should, therefore, always be remem- 
 bered in grave cases of gastritis of a chronic nature. 
 
 Sulphur. — Sulphur is rarely advised in affections of the 
 
 stomach. However, its pathogenesis affords a complete picture 
 
 of dyspepsia, and I am indebted to it for the cure of several 
 
 very chronic cases. The habitual failure of this remedy in 
 
 gastric disorders is probably owing to the fact that its indica- 
 15 
 
226 THE MEDICAL CLINIC. 
 
 tions have not been as carefully sought for as they should have 
 been. 
 
 Sulphur is better than arsenicum in the treatment of inter- 
 nal affections which alternate with, or which follow, certain 
 cutaneous disorders. Like mix vomica, it may be used in 
 hemorrhoidal subjects. Everyone knows that the skin affec- 
 tions of sulphur are characterized by itching of the whole sur- 
 face of the body. This pruritus is aggravated by friction, and 
 is increased at night by the warmth of the bed. 
 
 The gastric symptoms of sulphur are much like those of 
 chronic gastritis and dyspepsia, the principal of which are: 
 great weight in the stomach, slow and difficult digestion, with 
 rumination, and sometimes vomiting of food a long time after 
 eating • the digestion of meat is particularly difficult ; there 
 are sour or sweetish eructations ; a feeling of cold or of heat in 
 the stomach, and various pains in the epigastrium. The dys- 
 pepsia of sulphur is accompanied by acidity, flatulency and 
 dyspnoea. 
 
 Pulsatilla is a medicine that is not to be forgotten in dys- 
 pepsia. We know that this remedy is especially suited to 
 blonde, fleshy persons of a mild and indolent disposition. The 
 importance of these symptoms, as given by Hahnemann, have 
 been so exaggerated that our physicians are too much inclined 
 to prescribe it only for women or for effeminate men. I attach 
 more importance to a frequent chilliness, and to the absence of 
 thirst, as generally characteristic of this medicine. Dr. Hughes 
 has given the special and precise indications for pulsatilla in 
 the treatment of dyspepsia. The tongue is covered with a 
 thick coating of a dirty white color ; there is constant nausea, 
 with slight vomiting and little pain • the diarrhoea is almost 
 passive, and occurs principally at night, and a feeling of dis- 
 tension after meals, forcing the patient to loosen his clothes. 
 To these symptoms we may add the rising of water into the 
 
THE TREATMENT OF CHRONIC GASTRITIS. 227 
 
 mouth in considerable quantity, and the predominance of a 
 hitter or a putrid taste. 
 
 Plumbum. — Plumbum is a remedy that is seldom given in 
 gastric affections. However, I cannot forget that by using it 
 I effected a cure in one serious case of chronic gastritis, which 
 had caused and been accompanied by great emaciation and loss 
 of strength. 
 
 The symptoms which, according to my experience, indicate 
 plumbum, either in chronic gastritis or dyspepsia, are quite 
 characteristic. They are: abundant vomiting of a thick, white 
 fluid, which falls in a trembling mass, like the white of an 
 uncooked egg ; stubborn constipation, and violent pain in the 
 epigastrium. 
 
 I sometimes alternate opium with plumbum in obstinate 
 cases. I have always used the thirtieth dilution of plumbum, 
 but Dr. Richard Hughes advises the low dilutions, as the 
 third and sixth of the carbonate of lead. 
 
 Chamomilla, belladonna and veratrum are very important 
 remedies in the treatment of gastralgia, especially during the 
 paroxysms. Veratrum is indicated where the pains are very 
 violent and accompanied by palor and cold sweats. Chamo- 
 milla is the remedy for the same pains with unrest, anxiety, 
 frightful cardiac oppression, as if the heart would be crushed, 
 redness of the face and a warm perspiration. In cases where, 
 despite these indications, it does not act, I have found it use- 
 ful to alternate chamomilla with belladonna, both remedies 
 to be given in the third dilution. In these cases veratrum 
 is also given in the third and the sixth dilutions, and the 
 doses may sometimes be repeated as often as every fifteen 
 minutes. As the pain diminishes, however, the medicine 
 should be given less frequently. 
 
228 THE MEDICAL CLINIC. 
 
 Bryonia. — Dr. Marston, in the Monthly Homoeopathic Review, London, 
 1867-8, speaks very highly of this remedy, and suggests that it is especially 
 adapted to those cases of dyspepsia in which the muscular coat of the stomach 
 is chiefly at fault. The symptoms indicating bryonia in this affection are: "a 
 sense of pressure after taking food, as if a stone was lying on the stomach, 
 bitter taste and vomiting, and tenderness of the epigastrium to the touch and 
 on movement, especially when making a false step." In our experience, bryo- 
 nia is often adapted to the dyspepsia of bilious and aguish subjects, especially 
 if they have much headache, and are inclined to constipation. — L. 
 
 Graphites. — I must speak, before closing, of the good 
 effects obtained in the treatment of dyspepsia by the alter- 
 nation of nux vomica and graphites. For this reason I have 
 reserved the history of this medicine for the termination of 
 my lecture. Graphites produces, in its provings, many of 
 the symptoms of dyspepsia, the most characteristic of which 
 are the following : Bitter or acid regurgitation of food, a kind 
 of rumination, obstinate vomiting of food, salivation, the rais- 
 ing of phlegm, and the indigestion of liquids. 
 
 Clinical experience has taught us that the alternation of 
 nux vomica and of graphites constitutes an excellent plan of 
 treatment for dyspepsia. We are indebted to Dr. Emery, of 
 Lyons, for having suggested it. His custom was to give 
 nux vomica, 12th dil., six globules in 200 grammes of water, 
 one teaspoonful to be taken an hour before eating the two 
 principal meals, and graphites, 12th dil., prepared in the same 
 way, to be taken an hour after eating. This mode of alter- 
 nating these two remedies almost always succeeds in relieving 
 the dyspeptic symptoms, at least temporarily, and very often 
 we have obtained a complete cure by it. It is one of the 
 very best prescriptions for illustrating the efficacy of infini- 
 tesimal doses, as well because of the frequency of dyspepsia 
 as because of the certainty of a cure. When the twelfth dilu- 
 tion fails, I am in the habit of using the sixth, or even the 
 third, trituration. 
 
 To cite an example of a case, which has passed under 
 your notice, I will read you the clinical history of the patient 
 
THE TREATMENT OF CHRONIC GASTRITIS. 229 
 
 who occupied bed No. 2 of ward No. 1, and who had the 
 chlorotic form of dyspepsia. 
 
 Case XLYIII. — Miss G-uillot, a servant, twenty years of 
 age, entered on the 11th, and left the hospital on the 21st 
 of December. 
 
 This young girl, of delicate health, came to Paris in 1871. 
 At the end of two years the disease, which finally brought 
 her to our wards for treatment, forced her to return to the 
 country. While there, her health was partially restored, and 
 in about two months she returned to Paria. 
 
 She fell ill again immediately upon her arrival in town, and 
 her condition, when she came to us, was as follows : 
 
 She presents the facial expression which is typical of 
 chlorosis ; her skin is transparent and of a yellowish cast, and 
 her lips are quite colorless. 
 
 The slightest movement provokes vertigo and palpitation ; 
 the appetite is almost gone ; the digestion is excessively slow 
 and painful ; the occular and palpebral mucous membranes are 
 pale and colorless. 
 
 Her menstruation was regular until the month of October. 
 Since that time, however, she has not menstruated but once, 
 which was in the early part of December, the now continuing 
 only a few hours. 
 
 Auscultation in the region of the heart is negative in its 
 results, but in the vessels of the neck, on the contrary, a con- 
 tinuous bruit de souffle may be heard. 
 
 Ferrum metallicum, 6th dil., was prescribed. 
 
 December 14. No improvement from the ferrum, metalli- 
 eum. 
 
 The patient complains of oppression after each meal, and 
 of difficulty of digestion. The appetite being very moderate, 
 we began a systematic treatment, and gave her nux vomica, 
 12th dil., before her meals, and graphites, 12th dil., after 
 them. 
 
 December 16. The digestion is easier. The palpitation, 
 which was very frequent a few days ago, even when the patient 
 was lying down, seldom returns. The same treatment. 
 
230 THE MEDICAL CLINIC. 
 
 December 18. She is improving. The appetite has con- 
 siderably increased. Continue the nux vomica and the graph- 
 ites, and give, at the same time, the protoxalate of iron, in the 
 first decimal trituration, ten centigrammes daily. 
 
 December 21. The patient has partly recovered her 
 strength. Her general condition is very satisfactory. Hav- 
 ing secured employment in which she would have but little 
 work, she asked permission to leave the hospital. She was 
 given nux vomica and graphites, each in the 12th dil., and 
 the protoxalate of iron, also, to be taken as before. 
 
 We have seen this patient since she left the hospital, and 
 her health is entirely re-established and continues good. 
 
 In very exceptional cases of mere functional dyspepsia, where the patient 
 was anaemic and the vitality very low, we have had good results from practicing 
 Brown-Se*quard's method of giving only a small quantity of liquid or of solid 
 food at one time and at regular intervals, varying from ten to twenty minutes, 
 or perhaps half an hour. This plan may need to be persevered in for from two 
 to three weeks, after which the patient may gradually resume the three meals 
 daily. — L. 
 
LECTURE XVIII. 
 
 Summary. — Chronic Congestion of the Liver, case. What is a chronic con- 
 gestion of the liver? The diseases in which it occurs. Its symptoms. A 
 study of the symptoms of hepatic dullness. Gravity of this congestion. 
 Indications for the animal poisons and for nux vomica. Hypochondria, 
 case. Indications for nux vomica and aurum. 
 
 Chronic Congestion of the Liver. 
 
 Gentlemen : Here is another fact which affords indubitable 
 evidence of the efficacy of the homoeopathic remedies. It 
 does not relate to one of those nervous affections that some- 
 times astonish us by their sudden and unexpected cure ; nor 
 yet to one of those lesions which disappear by the unaided 
 efforts of nature. A chronic congestion which had gone so 
 far as to develop a decided and tangible lesion of the liver ; 
 a congestion which had resulted from the dysentery of warm 
 climates ; which had had its alternations of being better and. 
 worse, but which had not disappeared in eight years ; which 
 had resisted all the resources of the Old School, and the benefit 
 to be derived from a change of climate seven years ago, im- 
 proved for some days, and then disappeared entirely, under the 
 influence of lachesis and of nux vomica. This cure was con- 
 firmed ten months after the patient had left our hospital. 
 This clinical fact includes, I think, all those conditions which 
 should carry conviction to the minds of such as are not blind 
 to the merits of any system of treatment excepting their own. 
 Here is the detailed clinical history of this patient: 
 
 Case XLIX. — M. Rochelin, aged thirty-six, was admitted 
 on the 26th of December, 1874, and discharged on the 8th of 
 January, 1875. 
 
232 THE MEDICAL CLINIC. 
 
 This man, who was of a robust constitution, had enjoyed 
 very good health until the year 1866. 
 
 He then went to Egypt, where, after a residence of some 
 months, he contracted a dysentery, with an affection of the 
 liver. He says he was treated in that country for an hepatic 
 congestion. 
 
 For a month, while he was ill in Egypt, he had a diar- 
 rhoea. The stools were brownish, but more frequently bloody. 
 
 The right hypochondrium became the seat of a pretty vio- 
 lent pain, accompanied by fever and loss of appetite. At the 
 same time he became jaundiced, but the discoloration was lim- 
 ited to the conjunctiva and to the face. 
 
 He returned to France in 1867. His health was very im- 
 perfectly restored, and he continued subject to gastro-intestinal 
 troubles that were almost constant. In 1872 he had a slight 
 indisposition, with some fever, which was soon followed by a 
 diarrhoea that was almost identical with that which he had had 
 in Egypt ; by a slight jaundice, and also by pains in the region 
 of the liver. This attack continued for about six weeks. He 
 was seized again in January, 1874; but in the interval which 
 separated these two last attacks he continued to have pains 
 over the liver, and during all of the last summer he has had 
 diarrhoea, with bloody stools. 
 
 Now he complains of a continuous pain in the right shoul- 
 der, and, at the same time, of a decided uneasiness in the right 
 hypochondrium. By percussion, we find that the volume of the 
 liver is considerably increased. It extends very high, and, at 
 its inferior margin, projects more than three finger-breadths be- 
 low the border of the false ribs. 
 
 The appetite is very poor, the digestion slow and difficult, 
 and there is some constipation. Lachesis, in the 3d trit., was 
 prescribed, 20 centigrammes in four doses during the day. 
 
 December 30. There is a slight improvement. The region 
 of the liver is less sensitive. The same medicine. 
 
 January 3. The good effects that have been produced have 
 disappeared. The patient suffers a great deal with his right 
 shoulder. We hesitate to change the remedy, but considering 
 that there is already a very slight but positive diminution of 
 the hepatic dullness, we continue the lachesis, but order it 
 in the 2d trit. 
 
CHRONIC CONGESTION OF THE LIVER. 233 
 
 January 5. The general condition is better ; the patient- 
 is recovering his strength, and the appetite is returning a 
 little. More than all, by percussion, we are positive that 
 the size of the liver is very much diminished ; it scarcely 
 projects beyond the borders of the false ribs. Lachesis, in 
 the 2d trit. 
 
 January 8. The case goes from good to better. The pain 
 in the right shoulder has entirely disappeared, and the liver has 
 returned very nearly to its normal size. 
 
 We saw the patient ten days later, and he continued to get 
 along very well. We saw him again at, the end of October. 
 Until the month of April he had spells of being better and 
 worse. Now there is an absolute improvement which is very 
 remarkable. The strength and plumpness have returned, and, 
 although the liver is still liable to occasional attacks of conges- 
 tion with enlargement, these attacks are far from being as 
 severe as they were at first. We have found excellent effects, 
 whenever the gastric troubles predominated, from nux vomica, 
 30th dil., given twice a day for four days. The lachesis, in 
 the 2d trit., was given whenever the liver became enlarged. 
 
 October 31. The patient is constantly improving ; he has 
 grown fleshy, and has not had a relapse for several months. 
 
 We may find it useful, gentlemen, to discuss, for a mo- 
 ment, the subject of chronic congestions of the liver. Indeed, 
 it belongs to the clinic to explain the particular facts which 
 are met with, and the problems of pathology, which nosog- 
 raphy, with its didactic method, sometimes leaves without ex- 
 planation. Now, this is the case with chronic congestion of 
 the liver, for physicians in general have a very confused 
 idea of the pathology of this lesion, and of its symptoms. 
 
 Chronic congestion of the liver is essentially due to an 
 afiiux of blood to the organ, which determination * is much 
 more marked than in the physiological state. It differs from 
 hypertrophy, because it is not accompanied by an increase in 
 the number of the hepatic cells ; from chronic hepatitis, be- 
 cause it does not induce a proliferation of the interstitial 
 
234 THE MEDICAL CLINIC. 
 
 cellular tissue, nor a fatty degeneration of the organ ; from 
 organic lesions, because, in chronic congestions of the liver, 
 we do not meet either with amyloid productions or with 
 heterologous degeneration of any kind. 
 
 What are the diseases in which we find the lesion that is 
 known as a chronic congestion of the liver? 
 
 1. In all those cases in which there is a mechanical ob- 
 struction to the return of the blood from the liver to the 
 right side of the heart. Affections of the heart, and espe- 
 cially those of the mitral valves, are the most frequent ; then 
 follows the compression exercised upon the vena cava by 
 glandular and other tumors, and finally, the embarrassment 
 of respiration that is caused by acute or chronic affections of 
 the respiratory organs ; but these latter causes are much less 
 powerful than the former. 
 
 Chronic congestions of the liver, of a mechanical kind, 
 vary with the cause upon which they are dependent. These 
 are the congestions that are styled passive. 
 
 2. Besides the mechanical causes, chronic congestions of 
 the liver are most frequently met with in the cachexia of in- 
 termittent fevers ; in the dysentery of warm climates, and 
 in leucocythemia. These are the three diseases which cause 
 eight-tenths of the cases of chronic congestion of the liver ; 
 almost all others are related to alcoholism. To include every- 
 thing, some cases are due to scurvy, others to gout or to 
 syphilis (apart from syphilis of the liver), and some to 
 scrofula. 
 
 Now that we know positively what this chronic congestion 
 of the liver is, and in what diseases we are liable to meet 
 with it, let us inquire for the symptoms that accompany it, 
 and by which it may be diagnosticated. 
 
 The first and most important symptom, which by itself 
 is sufficient for the diagnosis, and which, being absent, totally 
 
CHRONIC CONGESTION OF THE LIVER. 235 
 
 excludes the possibility of this congestion, is the increase in 
 the volume of the diseased organ. This enlargement of the 
 liver is recognized by percussion and by palpation. 
 
 Palpation will tell us when the liver projects beyond the 
 false ribs. On causing the patient to lie upon the back, with 
 the muscles of the abdomen relaxed, we find the border of 
 the liver below the false ribs, in the right hypochondrium. 
 It gives the sensation of a smooth, resisting tumor, and it 
 exactly follows the movements of the diaphragm during respi- 
 ration. 
 
 But the iiver may be prolapsed without being increased in 
 size, and percussion must be used to verify the signs that are 
 furnished by palpation. 
 
 In order to utilize the percussion of the liver, it is neces- 
 sary to know the height of the dullness in the healthy state ; 
 we must also know that this dullness has a character of its 
 own, and that it is relative at its upper portion, passing from 
 above downward, and absolute at its inferior part. With 
 these two lessons, as we shall see directly, we shall come to 
 recognize very accurately the size of the liver, so as not to 
 confound this hepatic dullness with a dullness that is due to 
 pleuritic effusion. 
 
 According to Monneret, the measurements given by per- 
 cussion of the liver are as follows : upon the median line, 
 the dullness is five and a-half centimetres ; upon the line of 
 the nipple, twelve and a-half centimetres ; upon the axillary 
 line, ten and a-half centimetres, and upon the scapular line, 
 nine and a-half centimetres. 
 
 We said that, in proceeding from above downward, the 
 percussion of the liver, within certain limits,, yields a relative 
 dullness. This phenomenon corresponds with the anatomy 
 of the liver and of the lungs. The right lobe of the liver 
 has a convex surface, which fits exactly into the concavity 
 of the inferior surface of the diaphragm. At its base the 
 
236 THE MEDICAL CLINIC. 
 
 lung presents a corresponding concavity, making a cap, so 
 to speak, for the right lobe of the liver. Now, this natural 
 arrangement finds itself exaggerated when the liver is in- 
 creased in its volume. The thin borders of the base of the 
 right lung rest in the groove of the diaphragm, whilst the 
 centre is depressed and hollowed out, in order to receive the 
 hypertrophied liver. 
 
 This topographical arrangement explains perfectly how the 
 upper part of an enlarged liver gives a comparative dullness on 
 percussion, whilst the organ which furnishes the type of abso- 
 lute dullness is separated from the ribs by a portion of the 
 lung, which is an extremely sonorous organ. It also explains 
 how the pulmonary layer, interposed between the liver and the 
 ribs, becomes thinner as we approach the base of the thorax ; 
 from which it results that the dullness increases in proportion 
 as we descend with the percussion, becoming absolute when it 
 reaches the point at which the liver is no longer protected, or, 
 rather, covered by the lung. 
 
 There is, therefore, a particular form of dullness, and if we 
 have insisted upon its peculiarities it is because of their ex- 
 treme importance in diagnosis. Do not forget that the liver 
 may project beyond the false ribs without being really hyper- 
 trophied ; that it may, for example, be forced out of its place 
 by a pleuritic effusion. Yery well ; but how in this case are 
 you to distinguish by percussion alone a liver that is forced 
 down in consequence of a pleuritic effusion from one that is 
 hypertrophied ? By the outline and the characters of this 
 dullness. 
 
 Suppose that we haA 7 e an effusion which reaches to the 
 nipple in front, and that the liver is forced down three finger- 
 breadths below the false ribs. The dullness will be absolute 
 from the superior limit of the effusion to the inferior mar- 
 gin of the liver. If, on the contrary, it is the liver that 
 reaches to the nipple, the dullness will be imperfect, com- 
 
CHRONIC CONGESTION OF THE LIVER. 237 
 
 parative at least for three finger-breadths, and this character 
 will be sufficiently diagnostic of the lesion. 
 
 The second symptom due to congestion of the liver is the 
 pain. This pain is sometimes dull and disagreeable; it is 
 located in the right hypochondrium and often extends to the 
 shoulder of the same side. Such was the case with our 
 patient. This peculiar pain is increased by palpation and 
 by motion. 
 
 A certain degree of dyspnoea, of dyspepsia, of constipa- 
 tion, and more frequently of diarrhoea with icterus, are the 
 usual consequences of chronic congestion of the liver. Our 
 patient had these symptoms also. 
 
 The prognosis, in congestion of the liver, is generally 
 serious. If we are to believe the authorities, a case of the 
 kind which has existed for more than eight years must long 
 ago have reached the stage of hypertrophy and of cirrhosis, 
 id est, of almost certain incurability. The detailed history of 
 the case, which serves as the basis for this lecture, demon- 
 strates the error of such teaching ; for this man has had, with 
 alternations of tolerable good health it is true, for eight long 
 years this lesion, and in all that time it has neither resulted 
 in destruction of the gland nor become incurable. The cure 
 of such a chronic case is not more remarkable than the cate- 
 gorical proof which it gives of the efficacy of the homoeopathic 
 treatment. 
 
 Why did we give the poison of the serpent to this patient ? 
 
 The history of cases of poisoning from the bite of the 
 viper, and of all venomous serpents, shows an evident action 
 of the poison upon the liver. The swelling, the pain and the 
 jaundice are symptoms that have been noted by observers, and 
 which it would be ridiculous to attribute to the fright of the 
 victim. It has been observed in the autopsy of those who 
 
238 THE MEDICAL CLINIC. 
 
 have died from the bite of the trigonocephalus, and of the 
 cro talus, that there was a marked congestion, and sometimes 
 a softening of the parenchyma of the liver. 
 
 Therefore, the poison of the serpent is a remedy that is 
 adapted to certain diseases of the liver. I have chosen that 
 of the viper because my clinical experience has often shown 
 its efficacy in similar cases. 
 
 I should remark, that on the eighth day of the adminis- 
 tration of this remedy, and after a decided improvement had 
 been observed, there was a characteristic aggravation of the 
 symptoms, as shown by a very severe pain in the right shoul- 
 der. Should we have continued the use of the same medi- 
 cine, or should we have tried another ? I confess that I hesi- 
 tated somewhat ; but, when there was a diminution in the 
 size of the liver, which, although slight, was nevertheless 
 certain, I continued the remedy, but increased the strength 
 of it by passing from the third to the second trituration. In 
 two days more there was a new and a very decided improve- 
 ment. In this case I gave it in a lower form, in order that 
 the doubt concerning the good effect of the remedy should 
 not prolong itself indefinitely, and because I attributed the 
 return of the pain, not to a badly-chosen remedy, but to the 
 insufficiency of the dose. 
 
 What would have happened if, on account of the aggra- 
 vation of the pain in the shoulder, I had changed the medi- 
 cine ? It is very probable that the patient would not have 
 been cured, and that, in lieu of success, we should have been 
 forced to report a failure ? 
 
 Let me recall a precept which I have already given you, 
 and which is that, without a very good reason, it is not well 
 to change the remedy in our treatment of disease. It is a 
 hundred times better to lose some hours in an acute disease, 
 and some days in a chronic one, by the continuation of a 
 
INTERMITTENT HYPOCHONDRIA. 239 
 
 useless remedy, than it would be to change a remedy at the 
 very moment in which it begins to take effect. 
 
 By acting very favorably upon the digestive functions, 
 the nux vomica has contributed to the cure of our patient, 
 and has been a powerful auxiliary of the lachesis. 
 
 The ammonium mur. (which Dr. Dunham extols in sciatica, see Allen's Mat. 
 Med., Vol. I, page 298) is of the greatest service in the milder forms of this dis- 
 ease as met with in the Western and Southern States. Attention was first 
 drawn to it by Dr. William Stewart, in the British Medical Journal for 1870. 
 This notice was followed by other papers explaining its use and mode of action 
 in diseases of the liver, more especially in congestion* and inflammation of this 
 organ, as it occurs within the tropics. In his work upon the Diseases of the 
 Liver, Murchison speaks of it as "holding a preeminent place " as a remedy. 
 — L. 
 
 Intermittent Hypochondria. 
 
 If, in closing these remarks upon congestion of the liver, 
 we direct your attention to the patient in ~No. 2, of the same 
 ward, and who is affected with hypochondria, it is not be- 
 cause we accept the ancient theory concerning the role that 
 the liver and atrabile play in the production of hypochondria. 
 We reject both the humoral hypothesis and the more modern 
 psychical theory also; for we insist upon it, that the mania 
 for a physiological explanation of disease is the plague of a 
 sound nosology. While physiology affords very valuable in- 
 struction for the explanation of symptoms, which are only 
 functional, it nevertheless is powerless to explain that con- 
 dition of the living being which constitutes disease. If I 
 speak to you, therefore, of our hypochondriac to-day, it is 
 because he is going away very soon, and at a later period 
 you may, perhaps, have forgotten him. This is his clinical 
 history : 
 
 Case L. — M. Dupin, aged forty-five, entered the hospital 
 on the 2d of December, and left on the 29th of December, 1874. 
 
 This man's disease began fifteen months ago. He is thin, 
 pale, and of late appears to have suffered many privations. 
 
240 THE MEDICAL CLINIC. 
 
 The affection for which he came into our wards is remarkable 
 for the crises which recur every two days, and which are char- 
 acterized by a loss of appetite, a general malaise, an extreme 
 weakness and sadness, and a violent headache,- and also by an 
 apathy which renders him quite indifferent to all that is passing 
 around him. 
 
 On the days in which he has no paroxysm he is pretty well. 
 He has a good appetite, and, more than that, his recollections 
 are correct, which is never true on the days in which he has 
 the fit. He is habitually constipated. At first he was treated 
 on the expectant plan. 
 
 December 5. He was given, by hypodermic injection, a 
 solution of the sulphate of soda, 1-10, which was repeated the 
 next day, for the purpose of overcoming the obstinate consti- 
 pation ; but the remedy was not successful. 
 
 December 10. He took diadema, 3d trit., which was con- 
 tinued until the 16th of December. 
 
 December 16. The paroxysms persist and return regularly 
 every two days. J\ T ux vomica, 30th dil. 
 
 December 18. Under the influence of nux vomica there 
 was a slight diminution of the headache at the time of the fit. 
 Continue the same medicine. 
 
 December 23. All medication was suspended, because the 
 improvement is so very marked and the paroxysms have 
 ceased. 
 
 December 27. The improvement continues. Aurum, 
 30th dil., was given because indicated by the great sadness 
 of the patient. This remedy was continued until the 29th 
 of December, when the patient left us, feeling very well. 
 
 This case is a very rare specimen of hypochondria, and 
 one which has not been included in the classical arrange- 
 ment of this disease (see our Medicine pratique, Yol. I, page 
 407). We have divided hypochondria into two forms : a 
 common form, which is continuous, and of an indefinite dura- 
 tion ; and a periodical form, which is characterized by par- 
 oxysms of long duration, and that return at prolonged inter- 
 vals. But here we have an example of the hypochondriacal 
 
INTERMITTENT HYPOCHONDRIA. 241 
 
 paroxysm with a duration of twenty-four hours, and which 
 is of the tertian type. The word periodical, which is appli- 
 cable only to the return of the paroxysm by the week, by 
 the month, or even by the year, is not appropriate to this 
 case. The term intermittent should alone be proper, because 
 it serves to designate the return of the paroxysms at short 
 intervals, which are counted by days, like those of intermittent 
 fever, for example. This is, therefore, as I have just said, an 
 exceptional case ; but the exceptional cases constitute the pecu- 
 liar difficulties in the way of the practice Qf medicine, and it is 
 for this reason that I desire to say something to you concern- 
 ing this patient. 
 
 In the first days which followed the entrance of this man 
 into my ward, I believed he was trying to deceive us ; and 
 I thought that this poor fellow was very willing to enjoy 
 the rest and quiet of the hospital. But a careful observa- 
 tion, in which we have been seconded by our assistant, has 
 caused us to change our opinion. Every two days the patient 
 fell into a kind of stupor, ceased to eat (which in the present 
 case was an unanswerable argument for the fact of his suffer- 
 ing), and the next day he would appear almost entirely natural. 
 
 For eight days he remained under notice and without act- 
 ive treatment. On the eighth day I prescribed diadema, 2d 
 trit. This remedy, as well as the tarentula, has given me 
 good results in the treatment of nervous affections, which re- 
 cur in the form of an intermittent paroxysm. The diadema 
 was continued for six days, but without effect. I then ordered 
 nux vomica, 30th dil., which was indicated for the hypochon- 
 dria. On the third day of its use there was a decided diminu- 
 tion of the headache during the fit ; the eighth day all treat- 
 ment was suspended, because the improvement was manifest 
 and the paroxysms had almost ceased. Four days later we 
 prescribed aurum, 30th dil., which finished the cure. 
 
 It is very useful to remember that nux vomica is, as Hart- 
 16 
 
242 THE MEDICAL CLINIC. 
 
 mann taught, the principal remedy for hypochondria, although 
 more recent authors, and Dr. Richard Hughes in particular, 
 have omitted to give it under this indication. Here are the 
 principal symptoms that indicate mix vomica in the treatment 
 of hypochondria : gastric troubles, dyspepsia, loss of appetite, 
 obstinate constipation, great irritability and profound sadness, 
 more especially if this sadness is accompanied by a fear of 
 death and by an impulse to suicide. Nux vomica is decidedly 
 indicated in hemorrhoidal hypochondria. 
 
 The gastric troubles, the loss of appetite, the constipation, 
 and the return of the paroxysm of the tertian type, were the 
 three symptoms which, in this case, led us to decide upon nux 
 vomica. We should not forget, indeed, that nux vomica cor- 
 responds, like china and arsenic, to intermittent affections, and 
 that, for this reason, it is the best remedy for intermittent 
 neuralgia in case the paroxysms return every morning or every 
 alternate morning. Aicrum was indicated in this case by the 
 profound sadness of the patient. 
 
 During the first eight days that he was under our care we 
 experimented with a remedy prescribed by an M. Luton (of 
 Kheims) against constipation, which consists of hypodermic 
 injections of the sulphate of soda in very small quantities. It 
 was continued in this case for many days, but without result. 
 
LECTUKE XIX. 
 
 Summary. — Scrofulous ophthalmia is an affection which has three forms. 
 Blepharitis; indications for mere, precipitatum rubrum, euphrasia, senega, 
 calcarea carbonica, hepar sulphuris, digitalis. Hordeolum; indications 
 for Pulsatilla, staphysagria, silicea. Inflammation of the lachrymal ducts; 
 indications for silicea and calcarea carbonica. Scrofulous conjunctivitis; 
 indications for ipecac, and apis; cases. Scrofulous lupus of the pharynx; 
 indications for hepar sulphur, arsenicum and opium. Phthisis pulmonalis, 
 two cases. 
 
 Scrofulous Ophthalmia. 
 
 Gentlemen : During this year we have had in our wards, 
 and for consultation also, a variety of cases of scrofulous 
 ophthalmia that have given us an opportunity to study this 
 affection very thoroughly. 
 
 Scrofulous ophthalmia is, in fact, an affection, that is to 
 say, a collection of symptoms and of lesions which are located 
 upon an organ and developed under the influence of a disease, 
 viz : the scrofula, which impresses upon it all of its peculiar 
 characteristics. The tendency to ulceration, to softening, to 
 suppuration, and to become chronic, is characteristic of scrof- 
 ula. The lesions of the lids, of the conjunctiva, of the cornea 
 and of the iris, that we encounter in the different forms of 
 scrofulous ophthalmia, all present these peculiarities, and, 
 therefore, this disease is properly denominated scrofulous. 
 
 The tendency to become chronic, and to be worse and 
 better at long periods, is very marked in scrofulous affections 
 of the eye especially. And this explains the fact that, with- 
 out the most efficacious means of combating the acute attacks, 
 which so often occur in the course of these affections, the case 
 ends by the eye losing its functions either wholly or in part. 
 Thus we find few affections in the treatment of which it will 
 
244 THE MEDICAL CLINIC. 
 
 be so necessary to cultivate patience and perseverance in the 
 use of means in order to bring about a favorable result. If 
 you will remember, at the same time, that scrofulous ophthal- 
 mia is a very common aifection in Paris, you will appreciate 
 the importance of this lecture, and will understand why we 
 venture upon the field of the specialist. 
 
 Scrofulous ophthalmia presents three stages for study ; 
 sicjperficial ophthalmia, which is limited to the lids, and to the 
 lachrymal apparatus, this is blepharitis; conjunctivitis, which 
 is limited to the ocular and the palpebral mucous membrane ; 
 and, finally, ulcerative and interstitial keratitis, which consti- 
 tutes the really dangerous form of this affection. These three 
 conditions may either succeed or coexist in the same individual. 
 Let me add that keratitis may extend to the deeper structures 
 of the eye, and so complicate with iritis, with perforation of 
 the cornea, and dissolution of the eye itself. 
 
 Tubercles springing from the sclerotica and attributed to scrofula have 
 been described. They appear as if they would suppurate, of a yellow or white 
 color, but remain firm; increasing to the size of a pea, they burst without sup- 
 puration. They may be extirpated. Atrophy of the eye-ball. is frequently the 
 result where no treatment is undertaken. — V. 
 
 1. Scrofuloiis blepharitis sometimes begins spontaneously 
 at the age of eight to ten years, and sometimes in complication 
 with other diseases, more especially with measles. Its first 
 seat is upon the free border of the lids, whence it may extend 
 to the Meibomian glands, the conjunctiva, and the lachrymal 
 passages. Sometimes it occupies all of these points at once, 
 but it is usually limited to one of them, or, at least, it pre- 
 dominates in one of these locations. 
 
 In its mildest form this affection is limited to the free 
 border of the eyelids. Here it develops an habitual redness, 
 with a blearing of the eye. In a more advanced stage, it 
 produces granulations of the conjunctiva, little ulcerations on 
 the free borders of the lids, the fall of the eye-lashes, and 
 frequently there are styes. 
 
SCROFULOUS OPHTHALMIA. 245 
 
 We have said that superficial scrofulous ophthalmia may 
 extend to the lachrymal ducts ; let us add that it is a frequent 
 source of chronic epiphora, of tumors, and of fistula lach- 
 rymalis. 
 
 We think that a lachrymal fistula should never be made, and under appro- 
 priate treatment will seldom occur. If such an accident happens, every induce- 
 ment to its speedy healing should be made. To this end the canaliculus should 
 be properly opened, and an exit for the sac accumulations thus made. 
 
 Pulsatilla will often prevent a fistula. Hepar sul., Pulsatilla and silicea 
 greatly aid in curing it. — V. 
 
 This affection is extremely frequent, and having seen a 
 great number of these cases, you have remarked its tenacity, 
 and the comparatively slight effect of our therapeutic means. 
 We have not habitually used external applications, such as 
 ointments and eye-washes, because we have frequently ob- 
 served that this kind of treatment has only a palliative effect. 
 However, in very rebellious cases we should not deprive the 
 patient of the relief which he may derive from external appli- 
 cations, from an unguent of the red precipitate especially. 
 
 We think the red precipitate ointment is unnecessary, and have a some- 
 what large experience at the Eye Department of the Hahnemann Medical 
 College and Hospital, Chicago, corroborative of this opinion. Since it has been 
 under our charge, such cases have been treated wholly without external medi- 
 caments, and with the most satisfactory results. — V. 
 
 I have no particular cases to report to you of this variety 
 of scrofulous ophthalmia, but will confine myself to some 
 remarks upon the principal remedies that are indicated, and 
 which you have known me to prescribe against this affection 
 for the out-patients of our hospital. 
 
 You have often heard me prescribe mercurius, — it is the 
 red precipitate which I order in these cases. It is called for 
 in a certain acuteness of the inflammation. The lids are red, 
 inflamed, swollen and covered with crusts ; they are agglu- 
 tinated in the morning, and the borders are often ulcerated. 
 
246 THE MEDICAL CLINIC. 
 
 Hempel relates that a prover who took the red oxide of mer- 
 cury was cured of a chronic inflammation of the Meibomian 
 glands. 
 
 Euphrasia corresponds to a stage of the disease which 
 is already advanced, and in which there is ulceration of the 
 free borders of the lids. 
 
 Senega is principally indicated by a symptom which is 
 very frequent in this disease: the existence of dry crusts at 
 the base of the eye-lashes, and with the fall of the latter. 
 Calcarea carbonica is also called for under these conditions. 
 
 Hejpar sulphur is very important in the treatment of ble- 
 pharitis. Dr. Richard Hughes recommends it, especially 
 when the Meibomian glands are very much involved. 
 
 Digitalis is highly recommended by Hartmann in chronic 
 cases. The patients are worse in the evening, from exposure 
 to light, and they have a burning and dry sensation upon the 
 tarsal borders, with swelling of the inferior lid. We must 
 add to these symptoms agglutination of the lids and a free 
 secretion of mucus. Inflammation of the Meibomian glands 
 affords a special indication for digitalis. 
 
 Pulsatilla and stajphysagria, but especially silicea, are in- 
 dicated in the case of styes. Finally, silicea and calcarea 
 carbonica have done me good service in the treatment of 
 chronic inflammation of the lachrymal ducts. 
 
 Hepar sulphur is of the greatest service in the treatment of this latter 
 trouble when pus has formed. — Y. 
 
 2. Scrofulous Conjunctivitis. — Placed between blepharitis 
 and keratitis, scrofulous conjunctivitis often precedes, accom- 
 panies or follows these two affections. However, it may exist 
 alone ; its march is more rapid than that of blepharitis, and 
 its cure is much easier ; it never has the gravity of keratitis. 
 
SCROFULOUS OPHTHALMIA. 247 
 
 Scrofulous conjunctivitis begins with redness and swelling 
 of the conjunctiva, of the lid, as well of the palpebral as 
 of the sclerotic covering. It affects especially the external 
 surface of the eye ; it is characterized by the development of 
 the vascular branches which converge toward the cornea, and 
 terminates by a pustule that is soon followed by ulceration. 
 Sometimes, instead of an ulceration, there are pseudo-mem- 
 braneous exudations, and the formation of little prominences 
 as large as a millet seed. This lesion seated upon the scle- 
 rotica, is accompanied by suffusion of the eyes, a certain de- 
 gree of photophobia and a slight pain. It has not the daily 
 evening exacerbations of arthritic conjunctivitis, but its march 
 is subject to irregular aggravations and remissions, like all 
 other scrofulous affections. 
 
 You have observed that I very often prescribe ipecac, in the 
 first decimal trituration for scrofulous conjunctivitis, and you 
 have seen the success that has followed its use, which success 
 was decided in proportion as the case was acute. 
 
 This is a real conquest in current therapeutics ; for, although 
 it is just to recognize that Hartmann had already spoken of 
 ipecacuanha in the treatment of catarrhal ophthalmia, we must 
 add that he had not properly given the -indications for it, in 
 that he did not recognize its real importance. It was only in 
 1869, when Imbert Grourbeyre first published his essay upon 
 ipecacuanha, in UArt Medicate that it was introduced into 
 practice under this indication. And Dr. Hermel at first, and 
 ourselves afterward, have often given it in the dispensary of 
 the rue de Verneuil. We shall return to this subject in speak- 
 ing of the treatment of keratitis. 
 
 It would seem that in this trouble ipecacuanha has not been tried to any 
 extent in this country, as we find no mention of it in any of our standard works. 
 Our experience has been limited, but strongly corroborative of the author's esti- 
 mate. — V. 
 
248 THE MEDICAL CLINIC. 
 
 Belladonna is indicated in two different conditions, viz: when 
 there is a very acute inflammation accompanied by violent con- 
 gestions of the face, redness of the conjunctiva, of the lids and 
 of the sclerotic, photophobia with a slight secretion and dry- 
 ness of the inflamed parts. 
 
 Belladonna is also indicated in the more advanced stage of 
 the disease, when there are vascular fasiculi which extend to 
 the cornea, with pustules or vegetations on the sclerotica ; pho- 
 tophobia, or pains in the eyes, which are increased by opening 
 the lids. 
 
 Euphrasia is adapted to similar conditions, hut with an 
 abundant secretion of tears and fluent coryza. 
 
 There are certainly many other remedies that may be indi- 
 cated in this variety of scrofulous ophthalmia, but we shall not 
 insist upon them farther. This is why we confine ourselves to 
 the cases that you have seen, and in which I have prescribed 
 only one remedy, ipecacuanha, for the excellent reason that it 
 is generallv sufficient for the cure. 
 
 Pulsatilla is an excellent remedy when the pustules are situated on the 
 conjunctiva, the lids are swollen and subject to styes, and the symptoms are 
 relieved by cold applications, and by going into the open air. 
 
 Sulphur is also often called for by smarting, burning and itching in the 
 eyes, and where the secretions are acrid, causing a biting sensation in the lids, 
 and a great desire to rub them. There is usually much redness at the angles of 
 the eyes, and the lids are glued together in the morning. Concomitant sulphur 
 symptoms are present in other parts of the system. 
 
 We do not think any one remedy sufficient for the cure of most cases of 
 this trouble. — V. 
 
 3. Scrofulous Keratitis. — This affection is commonly pre- 
 ceded or accompanied by scrofulous conjunctivitis, and some 
 patients have blepharitis, conjunctivitis and keratitis simulta- 
 neously. The latter affection, however, may exist alone. 
 
 Scrofulous keratitis begins by the formation, on the trans- 
 parent cornea, of phlyctenee, which ulcerate and spread more or 
 
SCKOFULOUS OPHTHALMIA. 249 
 
 less. At the same time, the red vessels develop in this mem- 
 brane, and if one examines it with a glass, with the aid of the 
 oblique light of a lamp, he observes a vascular congestion 
 which is more or less extensive. This examination discloses, 
 at the same time, little islands of plastic lymph between the 
 layers of the cornea. In certain cases this infiltration becomes 
 more considerable, the islands increase in size, and the whole 
 cornea becomes cloudy, grayish, and more or less opaque. This 
 has been styled interstitial keratitis. When the ulceration, or 
 the ulcerations, for this lesion is often multiple, exist without 
 decided infiltration, the keratitis has received the name of 
 ulcerative. Sometimes the ulcerations of the cornea seem as 
 if they had been made with a punch, and have no cloud upon 
 their borders. The cornea then presents multiple facets, like 
 the eye of certain insects. 
 
 The symptoms of scrofulous keratitis are an excessive pain, 
 with much photophobia and suffusion of the eye. The photo- 
 phobia corresponds with the intensity of the inflammation, 
 and, in the acute stage, it is so severe that it is impossible 
 for the patient to open his eyes, and I have seen children 
 remain several weeks with the eyes obstinately closed. 
 
 Like all scrofulous affections, keratitis has a course which is 
 irregularly periodical ; it returns by fits or paroxysms, which 
 are more or less severe, and it is extremely subject to relapses. 
 The return of the catamenial epoch is often, as you have seen 
 in Case LIII, a cause of its aggravation. Working with the 
 eyes, cold, and a cold in the head, are also liable to renew the 
 inflammation which increases the disease. Whilst we observe, 
 from time to time, those inflammations of which the duration 
 is quite brief, scrofulous keratitis is an affection of which the 
 total duration is extremely long, for when it has not been 
 treated properly, it may continue for years. At the beginning, 
 when the remedy is well chosen, a cure may be obtained in 
 a few weeks, as in Case LI. 
 
250 THE MEDICAL CLINIC. 
 
 I have cured some cases of this disease in a fortnight. But 
 when the keratitis has not been treated, or when it has been 
 badly treated, and especially when there are persistent lesions 
 of the cornea, we must not expect a cure before several months 
 have elapsed. The fibrinous exudation upon the cornea, the 
 pustules which have been imperfectly healed, and the vessels 
 of the new formation which has developed in the cornea, are 
 conditions which always threaten a return of the inflammation. 
 
 Scrofulous keratitis may be complicated with serious acci- 
 dents which you should bear in mind. These accidents are : 
 the effusion of pus and the formation of abscesses between 
 the layers of the cornea ; the perforation of this membrane, 
 the escape of the iris through the opening, and the formation 
 of a staphyloma ; iritis, and the inflammation of the deeper 
 structures, and the dissolution of the eye. The young man 
 in Case LII has furnished you with an example of the forma- 
 tion of an abscess between the layers of the transparent 
 cornea. 
 
 When these abscesses develop a tendency to slough, we know of no remedy 
 so valuable as silicea; we prefer the 6th decimal trit. When hypopion, or pus 
 in the anterior chamber, is present, it quickly yields to hepar sulphur. — V. 
 
 Ipecacuanha and apis mdlijica are the two principal reme- 
 dies in scrofulous keratitis. Ipecac, is indicated in preference 
 when the keratitis is accompanied by a violent inflammation 
 of the sclerotic conjunctiva ; and apis when the inflammation, 
 limited to the cornea, has caused either infiltration or ulcera- 
 tion in that organ. We must not, however, conclude that 
 ipecac, acts only upon the conjunctiva, or apis exclusively 
 upon the cornea ; for these two remedies modify this affection 
 in all respects. And yet one of them seems preferable to the 
 other under the conditions that we have named. Here is a 
 case of scrofulous ophthalmia in which the keratitis has yielded 
 quite promptly to these two medicines : 
 
SCROFULOUS OPHTHALMIA. 251 
 
 Case LI. — Juliette Ollivier, aged eight years, was admitted 
 on the 1 8th of January, and discharged on the 14th of February. 
 
 This child, which is quite robust, has the appearance of 
 general good health, but is subject to scrofulous ophthalmia. 
 Two years ago, and last year also, she had a disease of the 
 eye, which continued for a long time. The kerato-conjunc- 
 tivitis, from which she is now suffering, began ten clays ago. 
 It seized the left eye only. The cornea is opaque to a limited 
 extent, which interferes with the vision of that side. Both 
 lids are slightly swollen, and very much congested ; there is no 
 fever or loss of appetite. 
 
 She has taken apis, 2d trit., three times daily. 
 
 January 23. The little patient is somewhat improved. The 
 lachrymation has ceased, and the photophobia is less severe. 
 The same remedy. 
 
 January 28. The conjunctiva of the right eye is congested, 
 and very sensitive to the light. The cornea, however, is trans- 
 parent, and vision on this side is intact. Ipecac, 1st decimal 
 trit., three times daily. 
 
 February 3. The speck on the cornea of the left eye has 
 lessened, and the congestion of the right conjunctiva has con- 
 siderably diminished. The same treatment. 
 
 February 5. There is constant photophobia of the right 
 side, and ciliary blepharitis of this side also. The cornea of 
 the left eye continues to be diseased. Apis, 1st trit., three 
 times daily. 
 
 February 9. Both eyes are better. The child can bear the 
 light without suffering. Apis, 1st trit, as before. 
 
 February 10. Zincum oxidatum, 3d trit., was taken for the 
 affection of the lids until she left the hospital. 
 
 When this child was discharged she was completely cured 
 of the keratitis, although she still had a certain degree of 
 ciliary blepharitis. 
 
 Here is an example of scrofulous ophthalmia in which 
 we find a coexisting blepharitis, conjunctivitis and keratitis, 
 with a predominance, on certain days, of the keratitis, or of 
 the conjunctivitis. You have observed in this case the indi- 
 
252 THE MEDICAL CLINIC. 
 
 cations for ipecac, and apis, and my method of alternating 
 these two remedies in the treatment of scrofulous ophthalmia. 
 The success attained has been rapid, because the lesions of 
 the cornea were comparatively recent, and the child was dis- 
 charged cured, at least for some time, after twenty-five days 
 of treatment. The blepharitis has persisted after the cure 
 of the other affections. It was for this trouble with the lids 
 that I prescribed the zincum oxidatum, but it is too soon to 
 judge of the effects of this remedy. 
 
 Abscess of the Cornea with Scrofulous Ophthalmia. Here 
 we have a case of scrofulous ophthalmia that is much more 
 severe, and in which you could follow the development of the 
 abscess between the layers of the cornea. This case is that 
 of a young man who was already suffering with ulceration 
 of the posterior fauces, and consequently predisposed to seri- 
 ous scrofulous affections. 
 
 Case LII. — M. Frenette, aged seventeen years, was ad- 
 mitted on the 8th of January. 
 
 This young man, who was born of a family in which all 
 the children are scrofulous, entered the hospital to be treated 
 for several affections of a strumous character. The follow- 
 ing is his clinical history : 
 
 Of delicate health, he reached the age of sixteen without 
 presenting the characteristic affections that belong to the scrof- 
 ulous diathesis. Having been treated for nearly a year by an 
 oculist for a conjunctivitis of the right side, he consulted us in 
 November, when he complained of violent pains in the throat 
 interfering with deglutition, and of pains in the left eye. 
 
 On examination, we found some specks upon the cornea and 
 two patches of ulceration in the posterior fauces, which latter 
 had perforated the arch of the palate and also the anterior pil- 
 lar of the veil of the palate. These ulcerations and perforations 
 were seated upon an induration and tumefaction of the whole 
 posterior fauces. The submaxillary glands were extremely 
 swollen and painful. 
 
SCROFULOUS OPHTHALMIA. 253 
 
 The patient had been considerably soothed by the treat- 
 ment which had been used, when, at the beginning of the 
 month of January, he came for consultation. He was then 
 suffering very much from the right eye, the sight of which, he 
 said, was entirely gone. The conjunctiva was congested and 
 formed a red circle about the cornea. Between the layers 
 of the latter there was an abscess of from two to three milli- 
 metres in diameter, and occupying the internal part of the cir- 
 cumference of the cornea. Apis mel., 3d trit., five grains to 
 be taken during the day. 
 
 January 11. There is a slight improvement. The pains 
 of which he complained are less violent.' Apis, 2d trit., four 
 grains in the same manner. 
 
 January 14. The abscess seems smaller. The injection of 
 the conjunctiva is not so great. The same remedy. 
 
 January 18. The improvement is more and more decided. 
 The abscess is already partially reabsorbed, and the patient be- 
 gins to distinguish objects with the right eye. The same treat- 
 ment. 
 
 January 22. The conjunctiva is much more inflamed. The 
 pains have returned in the right eye. Apis, 2d trit. , fifty centi- 
 grammes. 
 
 January 23. During the night the patient has had a diar- 
 rhoea. The apis was suspended and ipecac, 1st decimal trit., 
 was given, twenty-five centigrammes. 
 
 January 25. The diarrhoea has ceased entirely. Apis, 2d 
 trit., fifty centigrammes. 
 
 January 27. The vision of the right side has become pretty 
 good. The cornea appears less opaque on a line with the small 
 purulent collection. Apis as before. 
 
 February 1. The condition of the diseased eye is pretty 
 good. The young man begins to distinguish objects somewhat 
 vaguely. Apis, 1st trit., twenty centigrammes. 
 
 February 3. The right eye is very painful to-day, and, what 
 is more, there is a pretty decided injection about the cornea. 
 Ipecac, 1st decimal trit., twenty centigrammes. 
 
 February 5. There is a fresh accession of inflammation in 
 the cornea. At the superior and internal part of the cornea 
 there is a small purulent collection, being of a somewhat larger 
 
254 THE MEDICAL CLINIC. 
 
 extent than the first. There is some lachrymation and photo- 
 phobia. Apis, 2d trit., twenty centigrammes. 
 
 February 10. The eye is a little better. The injection is 
 less marked, and the pains are not so severe. The same treat- 
 ment. 
 
 February 15. The abscess which came last has almost com- 
 pletely disappeared. A slight opacity takes the place of that 
 which was seated at the inferior part of the cornea. Apis, 2d 
 trit., twenty centigrammes. 
 
 February 17. The improvement continues. Silicea, 30th 
 dil., and apis, 2d trit., twenty centigrammes were given in 
 alternation. 
 
 February 20. The sight is returning feebly. The peri- 
 keratic vascular circle diminishes. Silicea, 30th dil. , and aurum 
 muriaticum, 6th dil., alternately. 
 
 February 22. The inflammation reappeared, and the apis, 
 3d trit., was resumed. 
 
 February 24. The conjunctivitis has almost entirely dis- 
 appeared, but there remain two opaque points upon the cornea 
 occupying the site of the two abscesses. Apis, 1 st trit, twenty 
 centigrammes. 
 
 On the 1st of March there had been a new abscess in the 
 upper part of the cornea. Besides this, and somewhat later, 
 there was an effusion into both of the knee-joints. 
 
 Although this case is not a brilliant success therapeutic- 
 ally, it, however, has its lesson. During the period that this 
 man has remained in our ward, vou have several times seen 
 the marked effect of apis upon the inflammation of the cor- 
 nea ; but what shall we expect from a constitution that is so 
 profoundly affected, and in which all the scrofulous disorders 
 tend to assume a malignant form. 
 
 Daring the months of March and of April, when we were 
 absent, new abscesses formed in the cornea, and the articula- 
 tions of both knees became the seat of an effusion. 
 
 A propos of this young man, I should call your attention 
 to the affection of the throat with which he was attacked, 
 
SCKOFULOUS OPHTHALMIA. 255 
 
 and which you will not very often have the occasion to ob- 
 serve. These deep alterations of the veil of the palate, and 
 of the pillars of the fauces, constitute a scrofulous lupus of the 
 pharynx. This disease seems still to remain almost an incur- 
 able one. It sometimes causes death by hemorrhage, on ac- 
 count of an ulceration of the carotid artery. 
 
 Scrofulous Ophthalmia with Double Keratitis. — The third 
 case presents an example of scrofulous ophthalmia which had 
 existed for many years when the patient placed himself under 
 our care. In this case ipecac, and apis' caused only a slight 
 and temporary improvement, but arsenicum produced an effect 
 that was very marked, and which has now continued for sev- 
 eral months. You will also remark, in this case, that the 
 gravity of the keratitis corresponds with that of the other 
 scrofulous affections to which this patient is subject. For 
 example, during her infancy she has suffered from a scrofu- 
 lous disease of the tibia. This is, therefore, a serious case of 
 scrofula, and it is not surprising that the keratitis is corre- 
 spondingly severe. 
 
 Case LYIII. — Miss Emma, aged twenty- two years. Being 
 of a feeble constitution, this girl has been subject, from her 
 infancy, to many symptoms of scrofula that have principally 
 affected the eyes and the osseous system. 
 
 Her health was really not good, excepting from the tenth 
 to the fifteenth year. At the age of fifteen she was taken 
 with double keratitis, and was under treatment for it for two 
 years. In 1873 she was apparently cured, but the disease 
 soon returned. 
 
 She says that both eyes are never equally affected. As a 
 rule, the left one suffers the least. 
 
 While under treatment for some months, she took a great 
 many remedies, and was alternately better and worse. 
 
 She complains of intense pain in both the eyes, and of 
 frontal headache. As in all similar cases, the lesions of the 
 cornea constitute the points of departure for new attacks of 
 
256 THE MEDICAL CLINIC. 
 
 inflammation, and what is gained in some weeks is soon lost 
 by relapses. The keratitis having existed for several years, 
 these permanent lesions have resulted from it. The relapses 
 are most frequent with the return of the menses. 
 
 The conjunctiva is red, thickened, and presents some phlyc- 
 tenae on the margin of the cornea. The cornea is the seat of 
 an interstitial inflammation, with some congestion, and also 
 some slight ulcerations. 
 
 About the 1st of December we began the treatment with 
 apis, in the 2d trit., twenty-five centigrammes, three times 
 daily. 
 
 December 5. There is a slight improvement, with less 
 photophobia. The same remedy. 
 
 December 14. She can open her eyes much more easily. 
 The injection of the conjunctiva is diminished. The same 
 remedy, one gramme. 
 
 December 16. To-day we are certain of an aggravation, 
 either because or in spite of the apis. She complains of severe 
 pains in the globes of both eyes. There is also considerable 
 lachrymation. Apis, 30th dil. 
 
 December 17. The treatment was suspended. 
 
 December 19. The patient is better. The pains are miti- 
 gated. We return to apis, 3d trit., twenty centigrammes dur- 
 ing the day. 
 
 December 20. The improvement continues. Apis, 2d trit., 
 twenty centigrammes. 
 
 December 25. The patient is menstruating, and all treat- 
 ment is suspended. 
 
 December 28. Apis, 1st trit., twenty-five centigrammes. 
 
 December 30. The patient suffers very much to-day. 
 Ipecac, 1st decimal trit., twenty-five centigrammes. 
 
 January 3. The local condition of the eyes is better. 
 There is almost no lachrymation. Apis, 1st decimal trit., ten 
 centigrammes. 
 
 January 6. The right eye is much better than the left one. 
 She opens it easily enough, and for a certain time can fix it 
 upon a bright object. The same treatment. 
 
 January 15. The improvement continues. The same 
 remedy. 
 
SCROFULOUS OPHTHALMIA. 257 
 
 She took this remedy until the 28th of January, when its 
 use was again suspended during the menstrual epoch. 
 
 January 30. Apis was given again, beginning with the 
 1st trit., ten centigrammes. 
 
 February 1. Apis, as before. 
 
 February 2. Improvement continues from day to day. 
 The cornea becomes more and more clear. There is almost no 
 photophobia. The same remedy. 
 
 February 5. The medicine was stopped because of a de- 
 cided aggravation. 
 
 February 9. Both eyes have remained, in the same condi- 
 tion for some days. Apis, 6th dil., five drops. 
 
 February 13. The lachrymation, as well as the congestion 
 of the conjunctiva, have diminished very decidedly. The treat- 
 ment was suspended, but the inflammation reappeared, and the 
 apis was given again. 
 
 February 18. For two or three days there has been an 
 arrest in the progress of the disease toward resolution. Apis, 
 the 1st decimal trit., twenty centigrammes, was given, and 
 some drops of the following solution of apis, 1st trit., ten cen- 
 tigrammes in five grammes of distilled water, were thrown 
 into the eye. There was considerable aggravation, and all 
 treatment was discontinued. 
 
 February 22. There is a fresh accession of the inflamma- 
 tion in the mucous membrane. The lids are tumefied, and the 
 eyes cannot bear the light. Apis, 1st decimal trit., ten centi- 
 grammes. 
 
 February 27. No improvement thus far. The patient com- 
 plains of much pain in the orbital region, and not having been 
 benefited during the preceding month, was again placed in the 
 care of Dr. Fredault. 
 
 After we had left, this patient was submitted to various 
 kinds of treatment, of which the resident student of the hos- 
 pital has furnished the following history : 
 
 This patient, whose eyes, at the commencement of the 
 month of March, were suffering from a relapse of the in- 
 flammation, took cuprum sulph., 3d trit., until the 9th of 
 
 March. 
 
 17 
 
258 THE MEDICAL CLINIC. 
 
 March 9, she had silicea, 200th dil., which had the effect 
 to calm the violent pains in the orbital region, but without pro- 
 ducing any improvement in the local condition of the eyes. 
 
 March 13. Apis, 3d trit., twenty centigrammes. 
 
 March 18. Graphites, 200th dil. 
 
 March 23. The acute stage persists. Complete photo- 
 phobia. Phosphorus, 6th dil. 
 
 This last remedy was continued until the 7th of April. 
 
 The local inflammation being mitigated, and the cornea 
 being much less thickened, the patient began to perceive 
 objects a little way off, when she had a relapse on the 8th 
 of April. Pulsatilla, 6th dil. 
 
 April 13. No improvement. Phosphorus, 12th dil. 
 
 April 22. She is a little better, but complains of very 
 severe neuralgic pain. Cadmium carbonicum, 3d trit., twenty 
 centigrammes. 
 
 April 26. Oleum harlemsis, 3d trit., twenty centigrammes. 
 
 May 3. The same condition. The cornea and the conjunc- 
 tiva are decidedly congested. Graphites, 6th dil. 
 
 May 11. Graphites, 6th dil., and nux vomica, 6th dil. 
 
 May 17. No improvement. Ghininum sulph., 3d trit., 
 twenty centigrammes. 
 
 May 22. Natrum silicatum, 3d trit. , twenty centigrammes. 
 Under the influence of this remedy she became a little better, 
 and the lachrymation improved. 
 
 May 27. Chininum sulph., 3d trit., twenty centigrammes. 
 
 June 3. Opium tine, two drops, and arsenieum, 6th dil. 
 
 June 6. The patient is decidedly improved. The opium 
 was stopped and arsenieum, 3d dil., was given. 
 
 June 15. The opium was ordered again, two drops to be 
 given daily, and every morning arsenieum, 6th dil., dry upon 
 the tongue, both of which remedies were continued during the 
 month of June. 
 
 Under their influence the improvement became more and 
 more decided. The little pustules that were about the margin 
 of the cornea disappeared. The patient could easily open the 
 eyes, and could even read without very much fatigue. 
 
 July 1. The arsenieum, 6th dil., was continued, but con- 
 currently with it she took sometimes creosote, 6th dil., some- 
 
SCROFULOUS OPHTHALMIA. 259 
 
 times belladonna, in the tincture, or cannabis, 3d dil., until the 
 beginning of August. 
 
 During this month both eyes were seized again, but very 
 lightly. She took apis, 3d trit., twenty centigrammes, until 
 the 15th ; she also took the protoxalate of iron. 
 
 August 15. She is better, the sight has come again. Phos- 
 phorus, 6th dil. 
 
 September 4. The eyes are very decidedly congested, and 
 on the border of the right cornea there is a small pustule. 
 The photophobia, however, is less marked than in the preced- 
 ing attacks. Ipecac, 1st decimal trit., twenty centigrammes. 
 
 September 13. Considerable improvement. Arsenicum, 
 3d trit. 
 
 September 18. Lachrymation and photophobia. Apis, 2d 
 trit., and some days later in the 1st trit. 
 
 October 7. She is in a very satisfactory condition. The 
 congestion of the lids is very slight. The opacity of both 
 corneas has diminished very considerably. Euphrasia, 6th dil. 
 
 October 13. Better. Arsenicum, 12th dil. 
 
 October 15. From this time forward, until the end of the 
 month, she took no other remedy, excepting on the 25th of 
 October, when she was given one dose of arsenicum,, 6th dil. 
 She was discharged on the 4th of November, still having some 
 spots on the cornea of both eyes, but being able to see pretty 
 well. 
 
 In this case you observe that apis and ipecac, have caused 
 a decided, but transient, improvement, and finally that this 
 affection, after three months of treatment, has returned to 
 about the same condition that it was when we began our ser- 
 vice. Opium, in the mother tincture, and arsenicum, 6th dil., 
 given concurrently, then the arsenic, 6th dil., continued alone, 
 had a much more decided effect upon the keratitis, and, we 
 think, have produced as perfect a result as the deep-seated 
 lesion of the cornea would permit. You should not forget the 
 passing effect of belladonna, phosphorus, and especially of the 
 protoxalate of iron, and of the fortunate return, under very 
 proper indications, to apis and ipecac. 
 
260 THE MEDICAL CLINIC. 
 
 This is not the only failure that we have observed with 
 apis and ipecac. In the present year we were called to treat a 
 lady who, during her lying-in with her eighth child, was seized 
 with acute scrofulous keratitis. She had had a first attack in 
 the same eye at the age of twelve or thirteen years. The 
 disease had been very obstinate, and had left its traces in the 
 transparent cornea. During lactation with her fifth child, four 
 or iive years ago, she had had a second attack, but the cure was 
 effected in a fortnight with ipecac, and apis. This year, after a 
 decided improvement following eight days of treatment with 
 the same remedies, these medicines lost their effect, and, in 
 about a month, successive relapses brought on congestion and 
 infiltration of the cornea. However, under the influence of the 
 treatment the acute inflammation had entirely ceased. Being 
 obliged to be absent at this time, the patient, or more properly 
 her family, determined to place her in the care of a specialist. 
 Atropine and other means did no better than the apis and the 
 ipecac. The infiltration of the cornea increased, and she got 
 well, but with a decided scar upon the cornea. 
 
 We should not, therefore, consider apis and ipecac, as infal- 
 lible remedies in the treatment of scrofulous keratitis, but only 
 as those which succeed the most often in this trying infirmity. 
 It is possible that the fact of her being in the puerperal state 
 may have been one of the causes of our failure in this woman's 
 case. 
 
 We have not a doubt of it. For the time being-, in acute diseases of 
 almost all kinds, the puerperal dyscrasia is quite as pronounced, and as impor- 
 tant therapeutically, as the scrofulous, the hemorrhoidal, the dartrous, or the 
 gouty constitution. We do not profess to know very much about the diseases 
 of the eye; but on this theory, as well as pathogenetically, the kali carb. seems 
 to have been indicated. — L. 
 
 In the practice of medicine these questions should be 
 studied from all sides. We should add that, in these two 
 recent cases, where apis mellijica, od and 2d trit. (id est, sl tritu- 
 
SCROFULOUS OPHTHALMIA. 261 
 
 ration of the whole bee), did no good ; the apium virus, 6th 
 dilution (id est, the separate poison only of the bee), produced 
 a rapid cure. Was it a change in the preparation, or in the 
 dilution of the remedy, that caused the difference in the result ? 
 This is a question which further observation will help us to 
 answer, and of which we hope to give the solution in another 
 lecture. 
 
 Before dismissing this subject, let us remember the fact 
 that ipecac, is especially indicated in the case of a violent 
 inflammation of the sclerotic conjunctiva, while apis is more 
 appropriate to inflammations and lesions of the cornea ; and 
 also that these two remedies may be appropriate for the 
 totality of the symptoms in scrofulous ophthalmia. 
 
 Let us inquire what are the other remedies that are likely 
 to be called for in the treatment of scrofulous keratitis ? 
 
 Hepar sulphur is a remedy that clinical experience has 
 demonstrated to be very efficacious in scrofulous ophthalmia. 
 Hartmann insists especially upon its value in keratitis, and, 
 contrary to his usual habit, advises it in the lower triturations. 
 Dr. Richard Hughes is equally certain of its good effects. He 
 regards it as the first remedy in the treatment of scrofulous 
 keratitis, and declares that he has obtained the best results 
 from its use. He also prescribes it in the lower triturations. 
 
 It is very fortunate that clinical observation has generalized 
 the employment of the hepar sulphur in the treatment of 
 scrofulous ophthalmia, for the experimental Materia Medica 
 gives only very vague indications on this point. Hahnemann, 
 in his Chronic Diseases, speaks of redness arid inflammation 
 of the eye ; but he says nothing of ulceration, of spots upon 
 the cornea, nor of any other symptom of keratitis. 
 
 We have already expressed, on page 250, our opinion of hepar sulphur. We 
 prefer the lower trituration. — V. 
 
262 THE MEDICAL CLINIC. 
 
 The attention of physicians was called to arsenieum by the 
 frequency of inflammation of the eyes in cases of poisoning by 
 this substance. Hahnemann's Materia Medica does not con- 
 tain any symptom that especially calls for the use of arsenieum 
 in the treatment of keratitis. Here, also, clinical observation 
 furnishes the indication for the remedy ; but let us add that 
 these indications are very indefinite, and that, as a rule, we 
 prescribe arsenieum when other medicines have failed. This 
 was true in the case of the young girl whose history is recorded 
 in Case LVIIL 
 
 Although by no means the only ones, we think good indications for the 
 employment of arsenieum in keratitis are : an anaemic condition of the general 
 system, with a shifting of the inflammation from one eye to the other; the 
 dread of light is excessive, the opening of the lids causing great shrinking; and 
 usually, but not always, these symptoms are accompanied by a flow of hot tears. 
 We have seen it succeed well, also, when calcarea carbonica was seemingly 
 indicated, but where it had been administered without effecting a cure. — V. 
 
 I should remind you, also, that opium, has undoubtedly 
 been of service in the cure of this difficult case. But since 
 the Materia Medica of our school affords no precise indications 
 for the employment of opium in keratitis, we must acknowl- 
 edge that its use is purely clinical. 
 
 We have not been able to get the effect from opium that we have several 
 times seen attributed to it. — V. 
 
 Phthisis Pulmonalis with. Incidental Bronchitis. 
 
 We have had this year but a very small number of tuber- 
 culous patients ; indeed, we can only report two cases of this 
 disease. The first of these was an example of bronchitis in 
 a tuberculous subject which was treated very successfully by 
 ipecac, and oryonia. The second is an example of phthisis 
 with pulmonary lesions and diarrhoea, which were considera- 
 bly improved by homoeopathic treatment. The vegetable 
 diet has been resorted to with both these patients. 
 
PHTHISIS PULMONALIS WITH INCIDENTAL BRONCHITIS. 263 
 
 Case LIV. — Miss B , aged twenty-nine, was admitted 
 
 on the 4th of January, and discharged on the 20th of January. 
 
 Being the daughter of a scrofulous and tuberculous father 
 and of a gouty mother, this patient had never enjoyed very 
 good health. In her infancy she had had scrofulous attacks, 
 and was liable to take cold very easily. Moreover, her father 
 died of phthisis some years ago. She had coughed in a con- 
 tinuous manner for five or six years only. She has had re- 
 peated attacks of expectorating blood ; her strength is always 
 on the decline, and a physical examination of the chest reveals 
 the following symptoms : 
 
 By percussion, we find a dullness, which is almost complete, 
 at the apex and on the posterior surface of both the lungs. 
 
 Auscultation discloses, on both sides, coarse, humid rales, 
 from the summit to the base of the chest. 
 
 The patient complains, also, of a pain in the left side, 
 which is located about the fourth intercostal space. 
 
 Bryonia and ipecac, 12th dil., were given alternately every 
 two hours, and the aforesaid regimen was ordered. 
 
 January 9. The patient is a little better to-day. The cough 
 is much less frequent. The same treatment. 
 
 January 12. The general condition is improved, but she 
 complains of a continual pain in the left side. The appetite, 
 which had almost disappeared, has returned. Bryonia, 3d 
 dil., three drops four times in the day. 
 
 January 15. The pain in the side has diminished in its in- 
 tensity, but the bronchitis continues. Bryonia, 6th dil., and 
 ipecac, 6th dil., were given alternately. 
 
 January 17. The local condition of the lungs is also im- 
 proved. The rales are less numerous, and the respiration is 
 more free. Bryonia and ipecac 
 
 These remedies were continued until the discharge of the 
 patient, when she seemed to be considerably improved. 
 
 The second case of phthisis is the following : 
 
 Case LY. — Alfred Gozon, eleven years of age, was ad- 
 mitted on the 30th of January, and discharged on the 24 th of 
 February. 
 
264 THE MEDICAL CLINIC. 
 
 This child, who is pale, with soft, flabby flesh, has coughed 
 for some years, and has never had very good health. 
 
 His antecedents are bad enough. His mother' died of 
 phthisis a long time ago. Besides, according to our imper- 
 fect information, it appears that at the beginning of winter he 
 had an attack of pleurisy on the left side. In evidence of this 
 we find the scars that were made by the blisters that had been 
 applied. 
 
 Of late this little fellow has become very much emaciated. 
 Some days ago he had several attacks of hemoptysis. 
 
 We find, on examination of the chest, that percussion gives 
 a slight dullness behind and at the apex of each lung. 
 
 Auscultation by the naked ear discloses a hard respiration ; 
 the expiration is prolonged and even a little blowing in char- 
 acter. In front and at the left we recognize, in the sub-clavicu- 
 lar region, all the signs of a small pulmonary cavity. We can 
 hear, but not easily, some crackling in front and at the right. 
 
 The patient was put upon the vegetable diet, and was or- 
 dered to take of droser a, 3d dil., three drops during the day. 
 
 February 3. The fits of coughing are less frequent. Every 
 evening he is seized with fever; the temperature is 101.4°; the 
 pulse, 104. There is also a serious diarrhoea, which is quite 
 frequent, Veratrum alb., 3d dil., three drops during the day. 
 
 February 5. The diarrhoea continues, but the appetite, 
 which was lost at the beginning, has returned. Fever in 
 the evening; temperature, 101.2°; pulse, 108. Ipecac, 1st 
 decimal trit,, twenty centigrammes during the day. 
 
 February 8. The cough has very much diminished ; the 
 expectoration has almost ceased, and the fever and the diar- 
 rhoea have stopped altogether. The same treatment, 
 
 February 11. He gains strength, and the cough is becom- 
 ing less and less frequent. The same remedy. 
 
 February 17. Continued improvement. By auscultation 
 we cannot hear the rales, but the cavernous signs persist. He 
 took ipecac, 1st decimal trit., until he was dismissed. 
 
 In this case, on account of the diarrhoea, the vegetable diet 
 was not literallv adhered to, but a little meat was allowed. 
 
LECTUKE XX. 
 
 Summary. — Pelvi-peritonitis and peri-uterine hematocele. Case of suppurat- 
 ing pelvi-peritonitis. Description of pelvi-peritonitis. Differential diagnosis 
 from inflammation of the broad ligament and in the iliac fossa. Treatment: 
 Aconite. 
 
 Pelvi-Peritonitis. 
 
 Gentlemen: Here is a patient who has been seized with a 
 very serious but common affection, and one that is still but 
 imperfectly understood by most practitioners. It is a case of 
 pelvi-peritonitis, with adhesions, which has ended with sup- 
 puration. You will permit me to dwell at some length upon 
 its clinical history, the practical value of which is evident. 
 And first, we will have the notes of the case: 
 
 Case L VI. — Mrs. N , aged thirty-one years, of a deli- 
 cate constitution, is feeble and decidedly emaciated. She was 
 delivered, twelve years ago, for the first time, and was treated 
 for eighteen months afterward for ulceration of the cervix uteri. 
 
 Her health has never been completely restored, for she suf- 
 fers continually with pressing and lancinating pains in the lower 
 abdomen. These pains are much more severe at the monthly 
 period, and the flow is always very abundant and long-con- 
 tinued . 
 
 Eighteen months ago she observed that her abdomen began 
 to bloat considerably. Six months later she had a sudden and 
 copious flow, which did not diminish the size of the abdomen 
 in the least. Following this metrorrhagia she had chills every 
 day. Applications of the tincture of iodine, sitz baths and 
 injections were resorted to, but they brought no improvement 
 in her condition. She remained in a state which is character- 
 ized by an irregular febrile movement, with pains in the hypo- 
 gastrium and in the left iliac region, these pains being increased 
 by fatigue and by the return of the menses. There was emacia- 
 
266 THE MEDICAL CLINIC. 
 
 tioii and loss of strength, with increased difficulty in walking-. 
 Occasionally she suffered so much that she was obliged to take 
 to her bed. Finally, in September, 1874, a large quantity of 
 pus was discharged by the rectum. This discharge still recurs T 
 but the pains are not so severe as they were before. 
 
 We can easily recognize a tumor in the hypogastrium, which 
 extends low down upon the left side, and which is also recog- 
 nized by the vaginal touch. It occupies the left lateral cul-de- 
 sac, and also the posterior cul-de-sac. 
 
 This woman has experienced great relief from homoeopathic 
 treatment, which has been prescribed for her by my friend and 
 predecessor, Dr. Groimard. The principal remedy given was 
 silicea. Under its influence the discharge has greatly dimin- 
 ished, and the patient is gaining strength and flesh. Some 
 months later, and after excessive labor and exposure on her 
 part, the discharge by the rectum returned, and the frequent 
 attacks of pain and of fever also. 
 
 Here, then, is a case of adhesive pelvi-peritonitis follow- 
 ing an ulceration of the neck of the womb, and probably a 
 coincident metritis. This disease, which has been aggravated 
 by labor and by venereal excesses, and perhaps also by ill- 
 timed cauterization, finally, after about eighteen months, ter- 
 minated in suppuration. 
 
 The suppuration, characterized at the beginning by an 
 irregular febrile movement, with constant pains, and espe- 
 cially by the marked development of the tumor, finally ended, 
 after a year's duration, by the opening and discharge of the 
 abscess into the rectum. From that time the rectal fistula 
 has persisted, and the patient, after having obtained consider- 
 able relief, experienced a return of the suffering when she 
 resumed her old habits. It is extremely probable that the 
 suppuration will continue, that she will fall into the cachexia 
 of chronic suppuration, and that she will finally die of it. 
 
 I believe it useful at this time to speak to you of pelvi- 
 peritonitis, because it enters into the role of the clinic to give 
 
PELVI-PERITONITIS. 267 
 
 the history of diseases which are but imperfectly known, when- 
 ever such cases fall under our observation. 
 
 Without desiring to spend much time with the bibliography 
 of this affection, I will say that Lisfranc was the first to de- 
 scribe it under the name of Engorgement of the Uterus • and 
 it was a credit to him to indicate a nosological group that is 
 characterized by pelvic pains, and by the existence of a tume- 
 faction, which concerns very intimately a particular portion 
 of the uterus. The name of peri-uterine inflammation, which 
 was suggested by M. Nonat, was unfortunate, because it con- 
 founded uterine engorgement with inflammation seated in the 
 iliac fossa, these two sets of affections being in reality quite 
 distinct. It did, however, signify that the inflammation and 
 tumefaction were not confined to the womb, as it was thought 
 to be prior to the researches of Recamier. The credit of 
 recognizing and of describing the pathological unity of this 
 affection is really due to Bernutz and Groupil. 
 
 It is generally known among gynecologists that the controversy between 
 Drs. Bernutz, Nonat, and others, regarding the comparative frequency of peri- 
 metritis {phlegmon peri-nterin) and pelvi-peritonitis, has been very prolonged, 
 and has given rise to a deal of partisanship among physicians not only in France 
 but also in this country. 
 
 In this connection we cannot refrain from translating and copying the fol- 
 lowing case from Guerin's Lemons clinigues sur les maladies des organes genitaux 
 internes de la femme, Paris, 1878, page 358: 
 
 " I formerly had, as an interne, M. Obedenare, who was a very zealous pupil, 
 and who left me to enter the service of M. Nonat, in the Hopital de la Charite*. 
 When he came to bid me adieu, I expressed a wish to be present at the autopsy 
 of such women as might die of peri-uterine affections under his eye, in his new 
 position, and urged him to notify me when such an occasion offered. 
 
 "One day I received a letter inviting me to come the next morning to the 
 amphitheatre of la Charite, and you may be sure that I went there. Just as 
 they were about to begin the post-mortem, I inquired of M. Nonat of what 
 disease the woman whom we were about to examine had died ? He told me, 
 without hesitation, that she had had a peri-uterine phlegmon. I then asked 
 permission to apply the "touch" to this subject. I found a hard tumor sur- 
 rounding the uterine cervix, which was evident to the touch in front, behind, 
 and at the sides of the os-uteri; and I said that, until that moment, I had al- 
 ways told my pupils that such a lesion as this belonged to pelvi-peritonitis. I 
 
268 THE MEDICAL CLINIC. 
 
 also said that this case would decide the question, for, if this is a uterine 
 phlegmon, I shall no longer have a sign by which to recognize a case of pelvi- 
 peritonitis. 
 
 " They proceeded with the autopsy, and it was proved, in the most conclu- 
 sive manner, that the intestinal folds were so joined with the posterior wall of 
 the uterus as to form a peritoneal pocket on all sides, which was filled with 
 pus."— L. 
 
 The most frequent causes of pelvi-peritonitis are : first, the 
 puerperal state (seventy-five per cent arising from this cause) ; 
 the catanienial period, and blennorrhagia ; and, finally, the 
 traumatic causes, among which we must not forget excessive 
 coitus, the employment of the uterine sound, and of cauteri- 
 zation by the hot iron. 
 
 The cause of the meteorism, the colicky pains, and of the disposition to 
 vomit also, in this disease, is the adhesion of folds of the intestine to parts that 
 are naturally free from such an attachment. Half the women who have tym- 
 panitis, menstrual colic, and vomiting at the "month," are really ill with pelvi- 
 peritonitis, although perhaps in so mild a form that it has not been recognized. 
 
 When these adhesions are roughly broken up, whether by the introduction 
 of the sound, the use of the speculum, or of the sponge-tent, by dilators, or the 
 vaginal or the rectal touch, or by forcible or too frequent coitus, there is a re- 
 newal and extension of the inflammation. And the symptoms induced show, to 
 our mind at least, that Nonat and Emmet are wrong in locating this inflamma- 
 tion in the peri-uterine cellular tissue exclusively. — L. 
 
 M. Bernutz still teaches that pelvi-peritonitis is always an 
 affection which is symptomatic of disease in the uterus, the 
 Fallopian tubes, or of the ovaries. It seems to me, however, 
 that if we recall the causes of pelvi-peritonitis which we have 
 already given, and that are enumerated in M. Bernutz' work, 
 we shall be convinced that this inflammation may occur inde- 
 pendently of any definite disease, or, at least, of what is called 
 a disease, viz : labor, abortion, menstruation, coitus, the use of 
 the sound or of the hot iron. We must conclude that the 
 eminent pathologist from whom we quote, and who has studied 
 this subject so thoroughly, has reached a merely intellectual 
 conclusion when he insists that pelvi-peritonitis is always a 
 symptomatic disorder. We believe that an ensemble so com- 
 plete, so characteristic of symptoms and of lesions, which has 
 
PELVI-PERITONITIS. 269 
 
 undergone so regular a development, and occurred so often 
 in the absence of any other disease, constitutes a veritable 
 morbid species, at least where it cannot be associated with 
 any evident disease of the womb. 
 
 Pelvi-peritonitis consists essentially in an inflammation of 
 the serous membrane within the pelvic basin. In women this 
 inflammation corresponds with inflammation of the tunica 
 vaginalis in men, and blennorrhagic pelvi-peritonitis is only 
 the epididymitis of women. 
 
 This disease presents itself in various forms, the principal 
 of which are the common, or the sero-adhesive form, the benign 
 form, the purulent form, and the chronic form. There is 
 also a tuberculous and a cancerous form. We think that the 
 hemorrhagic form, once admitted by Bernutz, should be classed 
 as a variety of hematocele. 
 
 The common form is characterized by an inflammation of 
 the peritoneum, with the formation of false membranes, and 
 with serous effusion. It is the sero-adhesive variety. Its ad- 
 vent is sometimes sudden ; sometimes it is preceded, for a 
 greater or less length of time, by pains in the lower pelvis, — 
 pains which are connected with some previous uterine disease. 
 
 At first it resembles a mild peritonitis, with the initial chill, 
 repeated vomiting, pinched features, a small, hard and frequent 
 pulse ; diarrhoea or constipation, and pain in one of the iliac 
 fossae. In some cases the vomiting has been so violent that 
 one might mistake it for an attack of cholera. 
 
 The pain is acute ; it is increased by motion, by pressure 
 and by respiration ; it causes the patient to bend herself 
 double, and urination and defecation are very painful. Ber- 
 nutz compares it to the pleuritic stitch. This pain is usually 
 seated in one of the iliac fossae, but sometimes it is located in 
 the hypogastrium. If, on practicing the "touch," we do not 
 
270 THE MEDICAL CLINIC. 
 
 find a tumor, nor a uterine displacement, there will be a great 
 increase in the intra-pelvic pain on account of the manipula- 
 tion. 
 
 For the first few days the pain and the febrile action con- 
 tinue ; the pulse is small and hard, with the same heat of the 
 skin as in pleurisy. Afterward, the general symptoms subside, 
 the pain diminishes, and we begin to recognize in one of the 
 culs-de-sac of the vagina a sort of puffiness, which is the phys- 
 ical sign of a sero-fibrinous collection, and which constitutes the 
 local lesion of pelvi-peritonitis. 
 
 The changes which this tumor undergoes, the deviations of 
 the uterus which it causes, and the dull pain also, are the 
 symptoms proper to this stage of the disease. 
 
 In pelvi-peritonitis, unless it be in the puerperal form, the temperature is 
 not usually very high, for it ranges at from 101° to 103°, rarely reaching 104°. 
 
 The pulse in this disease is frequent (as it always is in peritonitis), but it is 
 not so small as it is in the diffuse form of peritoneal inflammation. — L. 
 
 The signs furnished by the "touch" and by palpation. — 
 At the end of a few days we perceive a decided swelling in one 
 of the vaginal culs-de-sac. This deposit is succeeded by an 
 obscure sense of fluctuation. To this succeeds the possibility 
 of determining the outline of the tumor, which is joined to the 
 uterus, and from which it is separated by a furrow upon one of 
 its sides. This tumor makes its appearance most frequently in 
 the left latero-posterior cul-de-sac, but it may be seated in any 
 other part of this region. By the "touch" we recognize at 
 the same time a deviation of the uterus, which corresponds to 
 the seat of the tumor, and which is changed or modified in 
 proportion to the increasing or the diminishing of the size of 
 the tumor. 
 
 A little later, when the disease has progressed, we' can 
 determine the existence of the tumor by palpation of the 
 hypogastrium. This tumor presents the same peculiarities as 
 
PELVI-PERITONITIS. 271 
 
 are disclosed by the "touch;" it occupies one side of the 
 uterus, is almost always within the pelvic basin, and rarely 
 extends beyond the horizontal ramus of the pubis — a sign 
 which serves to distinguish pelvi-peritonitis from abscess of 
 the broad ligament. 
 
 In exceptional cases the whole of the tumor in pelvi-peritonitis is retro- 
 uterine, and being limited in front by the broad ligament, may be mistaken for 
 an abscess of that ligament. — L. 
 
 This form of peritonitis runs a chronic course with exacer- 
 bations, which exacerbations are induced by the monthly 
 periods, by fatigue and by venereal excess. The first or 
 original symptoms reappear with these relapses, but they 
 are less severe, and the tumor grows again. Metrorrhagia, 
 or more frequently menorrhagia, leucorrhoea, and ulceration 
 of the cervix uteri, accompany the pelvi-peritonitis ; but the 
 metrorrhagia depends directly upon this inflammation, and is 
 really one of its characteristic features. 
 
 After a prolonged duration, pelvi-peritonitis passes into the 
 cachectic stage. Angemia, nervousness and a very painful hys- 
 teralgia belong to this period. From this time forward the 
 hemorrhages are still more abundant, and are also very pain- 
 ful. The tumor becomes hard, irregular and bossolated, and 
 the uterine deviations are very pronounced. 
 
 When the prognosis is favorable, the relapses and the men- 
 orrhagia cease ; the effused fluid is absorbed ; the tumor dimin- 
 ishes ; and very soon there only remain some bands of con- 
 nective tissue which anchor the uterus in its unnatural position, 
 and which, like the false membranes in pleurisy, are often the 
 seat of persistent pains. 
 
 When the cachectic state has set in, these patients are very 
 apt to become tuberculous. Under these circumstances there 
 is a. particular symptom which gives rise to an appearance that 
 
272 THE MEDICAL CLINIC. 
 
 is quite peculiar. Just in proportion as the phthisis is devel- 
 oped the symptoms of pelvi-peritonitis improve ; the pains di- 
 minish and the monthly flow is less copious ; but if, on the 
 contrary, the thoracic trouble is better, the pelvi-peritonitis re- 
 sumes its intensity, the pains and the hemorrhage return as 
 they were before the phthisis had set in, and during the future 
 life of these patients there will be a sort of balancing or alter- 
 nation between these two affections. 
 
 But as in pleurisy with the effusion of serum, the sero- 
 adhesive form of pelvi-peritonitis may terminate in suppuration. 
 With a violent febrile action the patient has excessive pains, 
 whilst the tumor is considerably increased in size. The dis- 
 ease then progresses as we shall see in considering the pur- 
 ulent variety, for the case upon which this lecture is founded 
 is an example of the purulent transformation of the effused 
 fluid in pelvi-peritonitis. 
 
 The Mild Form. — This often begins its course with very 
 acute symptoms resembling those of ordinary peritonitis. 
 These symptoms subside, and we recognize the intra-pelvic 
 tumor and the signs already given as proper to the preced- 
 ing variety ; but at the end of two, three or four weeks there 
 is a very abundant menstruation, which relieves all the symp- 
 toms and terminates the disease. 
 
 The Chronic Form. — This form makes its onset obscurely, 
 and exists for some time without attracting attention, and 
 never presents that array of symptoms which would cause 
 one to think of peritonitis. Once having developed itself, 
 it very much resembles the common form of the disease, 
 having the same aggravations, and the same course and ter- 
 mination. 
 
 The Purulent Form. — Bernutz calls this the regular pelvi- 
 peritonitis. This form usually, but not always, follows labor 
 
PELVI-PERITONITIS. 273 
 
 or abortion. Quite recently we have had a case which came 
 spontaneously during menstruation. 
 
 The debut of this fbrm is violent ; there is a severe chill 
 followed by an increase of temperature which often exceeds 
 104°, with a pulse that is hard and frequent, shrunken fea- 
 tures, a violent pain in the affected part, and nausea and vom- 
 iting. 
 
 In two cases which I have seen, and that were discon- 
 nected from the puerperal state, the pain was so intense 
 that it was absolutely necessary to relieve it by hypodermic 
 injections of morphine. These pains came in paroxysms, 
 which caused the patient to cry aloud, and which resembled 
 those of labor. They were accompanied by rectal and ves- 
 ical tenesmus, and were very much aggravated by the desire 
 to urinate and to go to stool. 
 
 In the first days of this disease, the peritonitis is very 
 likely to become general, and this really constitutes one of its 
 greatest dangers. 
 
 The expression continues to be bad ; there are irregular 
 chills and sweats ; then the tumor shows itself ; it grows much 
 more rapidly and becomes much larger than in the other forms 
 of this disease. 
 
 The abscess imparts to the ' ' touch ' ' and to palpation the 
 signs that we have already described, and which vary with its 
 location, but which usually present the evidences of decided 
 fluctuation. 
 
 Like all other internal abscesses, this suppuration is accom- 
 panied by a peculiar febrile movement, and becomes the sea 
 of an eliminating process. This process may go too far, and 
 give rise to a diffuse peritonitis, or to a very great increase in 
 the size of the tumor. But usually, after great suffering and 
 an aggravation of all the symptoms, the abscess opens itself 
 
 into one of the neighboring cavities, — the peritoneum, the 
 18 
 
274 THE MEDICAL CLINIC. 
 
 bladder, the vagina, the intestine, or, perhaps, either simul- 
 taneously or successively, into several of these cavities. Dur- 
 ing the subacute period of these abscesses we have sometimes 
 observed the occurrence of malignant erysipelas, and of per- 
 nicious paroxysms which resemble those of the purulent di- 
 athesis in puerperal women. 
 
 Death often occurs in this acute stage, either from the 
 violence of the fever, or from a complication of the peritonitis. 
 If the abscess opens freely into the vagina or the rectum, the 
 case generally terminates in a cure. This cure is sometimes 
 rapid ; but more frequently it occurs only after the purulent 
 discharge has continued for some months, and when the general 
 health is quite reestablished. For the reason that the outlet 
 for the pus is not free, the opening into the bladder is less 
 favorable. Possibly it may give rise to the infiltration of the 
 abscess with urine, but I have not observed it. If the open- 
 ing into the intestine consists in a perforation which is too 
 small, or too high in the bowel, as, for example, in the caecum, 
 the pus escapes with difficulty. In such a case the disease is 
 interminable, and the women fall into a cachectic and a hectic 
 condition, as in the case which I have shown you in my clinic. 
 In passing into the intestine, the discharge often provokes a 
 colliquative diarrhoea, which weakens the patient very deci- 
 dedly, and contributes very much to bring about a fatal 
 termination. In certain very bad cases, the intra-peritoneal 
 abscess opens and closes alternately, at intervals varying from 
 a week to several months, and, beset by a thousand dangers, 
 the disease is prolonged for some years. 
 
 The Tuberculous Form. — Like the tuberculous pleurisy, this 
 is distinguished from the chronic form, complicated with 
 phthisis, by a single sign, which is, that the menorrhagia per- 
 sists until it ends in tuberculous pelvi-peritonitis, whilst it 
 ceases in pelvi-peritonitis complicated with phthisis. 
 
PELVI-PERITONITIS. 275 
 
 Diagnosis. — Pelvi-peritonitis is sometimes confounded with 
 abscess of the iliac fossae, with abscess of the broad ligament, 
 and with peri-uterine hematocele. 
 
 As there is in our ward a very good example of hemato- 
 cele, I intend to give yon its pathological history ; and we will 
 therefore reserve, for the present, the study of the differential 
 diagnosis between it and pelvi-peritonitis. 
 
 Concerning inflammation in the iliac fossae and abscess of 
 the broad ligament, they are easily distinguished at first, be- 
 cause, when uncomplicated, they show no signs of peritonitis ; 
 because, in inflammation of the broad ligament, the tumor, 
 which is recognized by the "touch, 1 ' instead of occupying the 
 culs-de-sac of the vagina, is located in the wall of that canal, 
 where it is perceptible ; • because immediately under the anterior 
 abdominal wall that tumor forms a kind of cake, which is not 
 very thick, the limits of which are marked by palpation, and 
 which Bernutz calls the abdominal breast-plate [plastron]. 
 
 In abscesses in the iliac fossae, if they are superficial, the 
 tumor is not perceptible by the vagina, but extends directly 
 toward the horizontal ramus of the pubis. When they are 
 deep-seated and profound, there is retraction of the thigh upon 
 the pelvis, through irritation of the psoas muscle ; very often 
 oedema of the labia majora, and a deep-seated swelling in the 
 external portion of the iliac fossa, which afterward is felt in the 
 lateral walls of the vagina, and toward the horizontal ramus 
 of the os-pubis. 
 
 The differential diagnosis between pelvi-peritonitis and pelvic cellulitis is 
 quite as important, but quite as difficult, in many cases, as it is to separate some 
 cases of pneumonia from pleurisy. Indeed, there can be no doubt that they 
 often coexist. 
 
 In general, however, this, like other forms of serous inflammation, begins 
 with an initiatory chill, which is almost always so violent in degree as to be 
 accompanied by a chattering of the teeth. This symptom is lacking in uncom- 
 plicated pelvic cellulitis until about the time that pus has formed. 
 
 Pelvi-peritonitis is very apt to be accompanied by vomiting and by tym- 
 panitis, which, no matter how limited the lesion itself, soon spreads over the 
 
276 THE MEDICAL CLINIC. 
 
 whole abdomen. These symptoms are seldom found in idiopathic cellular 
 inflammation about the womb and within the pelvis. 
 
 In the former, the increase of heat in the roof of the vagina is a less impor- 
 tant symptom than the swelling. The neck of the womb is surrounded by a 
 hard mass which, as a rule, is more prominent in the posterior cul-de-sac than 
 it is laterally. By conjoined manipulation, this tumor, which is due to the 
 effused serum within the peritoneum at its lowest portion in front, is readily 
 felt behind the symphisis pubis. In pelvic cellulitis, however, the tumor is 
 most often largest laterally, at the site of the broad ligament, whence it may 
 extend along the sides of the vagina far down toward the vulvar outlet. The 
 latter symptom is impossible in uncomplicated pelvi-peritonitis. 
 
 In our work on the Diseases of Women, 4th edition, 1879, at page 448, we 
 have said: " It must be acknowledged, however, that the lines which separate 
 these two disorders are not always distinct. For, whether it be due to the fact 
 that the textures are contiguous, and that these lesions frequently coexist, or 
 that our present means of differentiation are imperfect, it remains that they 
 may be combined without our knowing it, and that we are liable occasionally to 
 mistake one for the other.' ' — L. 
 
 Treatment. — Pelvi-peritonitis is a disease the special pa- 
 thology of which is so recently known that we have no clinical 
 and classical treatment for it. We therefore submit the follow- 
 ing indications to our professional brethren with the promise 
 and hope of aiding in the completion of this important work 
 in therapeutics. 
 
 In the acute stage, the indications for treatment are drawn 
 from the violence of the fever and the intensity of the in- 
 flammation of the pelvic peritoneum. A.conitum, colocynth 
 and cantharis are the three remedies that are most appropri- 
 ate at this period of the disease. 
 
 Aconite is the principal remedy. The old-school physicians 
 prescribe it in this disease in the dose of one to two grammes 
 of the tincture in twenty-four hours ; and we must say very 
 decidedly that, in this case, these strong doses do no harm, 
 and that many of our school employ them in the same man- 
 ner, and with the best results. In very acute and severe cases 
 we do not hesitate to prescribe twenty to thirty drops of the 
 mother tincture, to be taken within twenty-four hours; but, 
 
PELVI-PERITONITIS. 277 
 
 where the attack is milder and not so threatening, the lower 
 dilutions (the first, second and third) have always been suffi- 
 cient. Whatever the dose or the dilution, the aconite should 
 be continued whilst the fever continues to be violent. 
 
 We have already said that the symptoms which indicate 
 this remedy are derived more especially from the character 
 of the fever, and from the serous inflammation. To specify 
 the febrile characteristics which indicate aconite: there is, at 
 the beginning, chill with palor, followed by violent heat with 
 redness of the face, a full and frequent pulse, and excessive 
 thirst. But the most important symptom, because it is 
 especially characteristic of aconite, is anguish with unrest, a 
 sense of impending death, and a fainting condition. These 
 latter symptoms occur during the cold as well as during the 
 hot stage. 
 
 All of these symptoms are shown in the physiological 
 effects of aconite. 
 
 When this medicine is given in poisonous doses, the fol- 
 lowing symptoms, according to Dr. Richard Hughes, will be 
 observed:* "In acute poisoning, the dilated pupils, the pale 
 face, the quick and contracted pulse and the general cold- 
 ness within and without, bespeak an excitation of the vaso- 
 motor nerves throughout the body, analogous to that which 
 results in tetanus. In other words, we have a condition an- 
 swering to the chill of fever, to the cold stage of ague, the 
 collapse of cholera. When the reaction takes place, the con- 
 dition of febrile heat succeeds that of chill ; as Dr. Wood 
 states, ' the circulation, respiration and general temperature 
 are sometimes increased.' This is seen in such a case of 
 poisoning as No. 10, of Dr. Hempel's series, but its power to 
 induce fever is still more marked in the Austrian Provings. , ' , 
 
 * A Manual of Pharmacodynamics, translated into French by Dr. Guerin- 
 M£neville, page 39. Paris, 1875. 
 
278 THE MEDICAL CLINIC. 
 
 In my experiments upon man and upon rabbits, made in 
 conjunction with Dr. Jablonski, and published in E Art Med- 
 ical, 1871, aconite was given in doses of from ten to sixty 
 drops, and we observed, as the first effect, an increase of the 
 temperature and an acceleration of the pulse. 
 
 Aconite affords, therefore, in its physiological action, a 
 picture of a paroxysm of fever from the chill to the heat, 
 and its favorable effect is a still further confirmation of the 
 truth of the law of similars. 
 
 But there are those who will not examine for themselves 
 opinions that have already been pronounced, and who do 
 not confess to being in the wrong when they condemn a doc- 
 trine without having examined it. M. G-ubler is of that 
 class, and his Codex seems to have been undertaken with 
 no other object than to demonstrate the fallacy of the law 
 of similars. His pupil, M. Franceschini, has just published, 
 under the inspiration of his master, a thesis upon aconitine, 
 in which he pretends to show, experimentally, that this sub- 
 stance abolishes the sensibility, diminishes the temperature 
 of the body, and slackens the pulse ; whence he concludes 
 that aconitine cures neuralgias, inflammations and fevers by 
 its contrary effects. 
 
 In the face of these opposite and contradictory results, 
 derived from the experiments of M. Franceschini and those 
 of numerous savants who had already given the history of 
 aconite, shall we clothe ourselves with skepticism when we 
 repeat the axiom, experimentia fallax f No ; but let us say 
 decidedly, with Claude Bernard, that one experiment well 
 made can never be annihilated by another experiment that 
 is well made ; and following this precept, upon which all 
 the sciences of observation are founded, let us search in the 
 experiments of M. Franceschini for the error of which this 
 apparent contradiction is the fruit. 
 
PELVIPERITONITIS. 279 
 
 The experiments by which M. Franceschini believes it 
 possible to demonstrate that, far from causing the well-known 
 pains, the aconitine produces anaesthesia, prove absolutely 
 nothing, because they are so harsh that in a few minutes 
 the animal is put in a state of asphyxia ; and everybody 
 knows that asphyxia, whatever its cause, abolishes all sen- 
 sibility. 
 
 In experiment No. 1, made upon a guinea-pig, the in- 
 jection was given at three o'clock and fifty minutes. Six 
 minutes after the animal is still extremely sensitive to pain- 
 ful impressions, but at four o'clock, id est, ten minutes after 
 the experiment, u the symptoms of asphyxia declared them- 
 selves " (p. 14). 
 
 In the second experiment k w death by asphyxia occurred 
 in about six minutes " (p. 15). 
 
 Candidly, what conclusion can be reached in the study of 
 sensibility from experiments that are conducted in this man- 
 ner? And how can these experiments weaken those which 
 have been carefully made, and which have demonstrated that 
 aconite causes pain, especially a neuralgia of the fifth pair? 
 
 Our young author is not more happy in showing that acon- 
 itine does not cause an elevation of the temperature and of 
 the pulse. 
 
 In the experiment No. 5 (page 34), the rabbit, under the 
 influence of a poisonous dose, showed very plainly all the 
 symptoms of febrile chilliness and of cold, noted by Dr. 
 Richard Hughes. But when the rabbit has resisted the poison, 
 and experienced a reaction, why should we leave him there, 
 and not concern ourselves any further, either with his tem- 
 perature or his pulse ? 
 
 Finally, M. Franceschini is careful to demonstrate for him- 
 self the falsity of his own theory ; for the truth is so powerful 
 that when one acts in good faith he can do nothing against it. 
 
280 THE MEDICAL CLINIC. 
 
 In the clinical part of his essay we find the confirmation of 
 the property which aconite certainly possesses, to elevate the 
 pulse and the temperature also. 
 
 At page 24: is the unfortunate history of a patient poisoned 
 by aconitine, and who, after a great many mishaps, finally 
 began to react. Now, in this case the observer noted a slight 
 increase of heat. But what caused this increase of heat, and 
 what had become of the thermometers of the hospital Beau- 
 jon ? 
 
 The cases given at pages 57 and 58 are more explicit, 
 because the temperature was taken by the thermometer. 
 
 At page 53 the pulse alone was recorded, but the descrip- 
 tion leaves nothing to be desired ; it was a case of rheumatism 
 without fever. An injection of aconitine was given at 10.30, 
 the pulse being 76. Half an hour later the pulse was 86. 
 4 'The pulse-beat is increased; the respiration is accelerated, 
 and the whole skin is more or less heated." It seems as if 
 we had read again the passage which we have already quoted 
 from Dr. Hughes. 
 
 At page 57 there is another case of acute articular rheu- 
 matism. The temperature was 99.6°, the pulse 103, when an 
 injection of aconitine was given at 10.30. At 11 o'clock the 
 temperature was 99.8°, the pulse 108; and at 11.20 (in less 
 than an hour) the temperature was 100.5°! 
 
 Two days later, the temperature being at 99.5°, and the 
 pulse 90, the injections of aconitine were repeated, and in 
 forty minutes the temperature was 99.6°. 
 
 Is it not clear enough, and are we not justified in saying 
 that an experiment which is well made is never deceptive ? 
 It is not the experience which deceives one, but it is the 
 experimenter who may be deceived. 
 
LECTUKE XXI. 
 
 Summary. — The treatment of pelvi-peritonitis, continued. Indications for colo- 
 cynth; case. Indications for cantharis, conium mac. ; pelvi-peritonitis and 
 rheumatism, remedies for; the suppurative stage of; aconite, china, arsen- 
 icum and the chin, sulph. in; hamamelis, thlaspi and sabina, opiates, hot- 
 water irrigation, hygienic care, and a good diet. Puerperal pelvi-peritonitis. 
 
 The Treatment of Pelvi-peritonitis — (Continued). 
 
 Gentlemen : Colocynth is a remedy which belongs exclu- 
 sively to homoeopathy in the treatment of pelvi-peritonitis. 
 Dr. Ludlam" recommends this remedy, especially in inflam- 
 mation of that portion of the peritoneum which covers the 
 ovaries, id est, in pelvi-peritonitis. This indication is drawn 
 directly from the localized action of colocynth upon the ovaries 
 and upon the epididymis in physiological experiments. Dr. 
 Richard Hughes relates that, in a case of poisoning by colo- 
 cynth, autopsy has shown that the intestines were glued together 
 by a fresh formation of lymjph. In this manner the lesions as 
 well as the symptoms show the appropriateness of colocynth in 
 acute pelvi-peritonitis. 
 
 The special symptoms which should guide the physician 
 and fix his choice upon colocynth, are : excessive pains in the 
 abdomen, especially when this pain causes the patients to bend 
 themselves forward ; diarrhoea, rectal and vesical tenesmus and 
 cramps in the legs. 
 
 Here is a case in which colocynth has been very efficacious : 
 
 Case LYII. — Mrs. X , aged thirty-eight, was admitted 
 
 on the 20th of December into ward 2, Xo. 2. 
 
 *Vide Clinical and Didactic Lectures on the Diseases of Women, by R. 
 Ludlam, M.D., etc., 4th edition, p. 137. 
 
282 THE MEDICAL CLINIC. 
 
 Of good 'general health habitually, she has been subject, 
 since her youth, to very copious menstruation. In conse- 
 quence of a fall upon the buttock when she was nineteen years 
 old, she has had an habitual pain in the hypogastrium. She 
 has never had a child, but about eight years ago she had 
 an abortion at the fourth month. 
 
 On the 15th of last November she had just finished the 
 monthly flow, which was as abundant as usual, when, with- 
 out having acted imprudently, she was seized with violent 
 pains in the abdomen, with chilliness, but no vomiting. At 
 the same time a metrorrhagia set in and continued for one 
 day. Then she had fever for five or six days, with constant 
 pains in the hypogastrium. These pains were deep-seated and 
 bruised and tearing in character. 
 
 She remained in bed until the 4th of December, when she 
 was obliged to go and take care of a sick relative. She had no 
 more fever from that time, but the pains which she had experi- 
 enced from the first continued with the same intensity. 
 
 December 8. The menses returned as usual, eight days in 
 advance. They continued until the 12th of the month, but 
 her condition was not in the least improved. 
 
 December 17. The abdominal suffering has increased in 
 violence. She has had such severe pains that she was obliged, 
 on several occasions, to take hypodermic injections of mor- 
 phine. At the same time she had chills, violent fever, vomit- 
 ing and obstinate constipation, and was so ill that we feared a 
 fatal result. We were sent for to visit her on the 20th, and 
 found her with the following symptoms : 
 
 She complains of nausea and of suffering in the abdomen, 
 which is distended, tympanitic, and so sensitive that a slight 
 touch provokes the pain. The pulse is 96, and the temp. 
 101.2°. The expression is bad, and from time to time there 
 are slight chills. Colocyntk, 3d dil., six drops in twelve spoon- 
 fuls of water, one spoonful every hour, with a moderate diet. 
 
 December 21. The patient had some vomiting yesterday. 
 The pains and the fever persist, and there is constipation. The 
 same treatment. 
 
 December 23. The fever is entirely broken, but the pains 
 in the abdomen are quite as severe, and during the night they 
 
THE TREATMENT OF PELV1-PERITONITIS. 283 
 
 are even worse than during the day. She compares them to a 
 gnawing of the tissues, and they force her to cry like one who 
 is having labor pains. The urination is not painful, but the 
 constipation is obstinate. Colocynth, 2d dil., in the same 
 manner. 
 
 December 24. The pains return only at night, but they 
 were so intense that the hospital assistant was called, and he 
 gave her a hypodermic injection of morphine. The general 
 condition is a little better than for some days. She says that 
 there is a reddish-white discharge from the genitals. There is 
 no more nausea, and the appetite has returned. Arsenicum, 
 6th dil. I forbade the use of the morphine. 
 
 December 27. The abdomen is a little less swollen and a 
 little less sensitive ; but the patient has had, during the night, 
 some pains in the belly, which were more violent than ever 
 before. Colocynth, 1st dil. An enema had no effect upon the 
 constipation. 
 
 December 28. During yesterday she was very calm, but in 
 the evening the pains returned. Moreover, she was obliged to 
 urinate often, and with pain. Arsenicum, 6th dil., two drops 
 in twelve teaspoonfuls of water, a teaspoonful every two hours. 
 
 December 29. She is better. Continue the arsenicum, 6th 
 dil., ten drops. 
 
 December 31. After taking an injection she had a stool, 
 then violent diarrhoea, with colic. Arsenicum, 6th dil. 
 
 January 3. The pain has localized itself on the right side, 
 where we find a swelling which is very sensitive to pressure. 
 The menses have appeared to-day. The diarrhoea is less. 
 Chamomilla, 3d dil. 
 
 January 5. The menses stopped last evening. The diar- 
 rhoea is a little better. The vaginal touch discloses a tumor 
 seated in the right lateral cul-de-sac, and which projects into 
 the vagina. Colocynth, 3d dil., and she was permitted to eat a 
 cutlet. 
 
 January 8. For some days the patient has had a return of 
 the sanguineous discharge from the vagina. She has no more 
 chills nor fever. The pains continue, but are less severe ; the 
 abdomen is tympanitic again, but the diarrhoea has ceased. 
 Cantharis, 3d dil. 
 
284 THE MEDICAL CLINIC. 
 
 The pains diminished daily ; at the same time the appetite, 
 the sleep and the strength returned. Although the pains had 
 almost entirely disappeared, yet I did not permit her to make 
 her bed until the 19th of January. 
 
 In the early part of February the menses returned. They 
 were very free, with clots, and were accompanied by colic. 
 They continued for six days. The patient was examined care- 
 fully after the cessation of the flow, but, although the cervix 
 was inclined to the right, there were no traces of the tumor. 
 
 The good effects of colocynth in this case appear to us to 
 be incontestable. Here is a woman who, suffering habitually 
 with the womb, was seized with the first onset of pelvi-peri- 
 tonitis in the month of November ; she recovered imperfectly, 
 wearied herself with the care of the sick, and soon became 
 more seriously ill, after the monthly epoch of December. 
 This is the common history of women attacked with pelvi- 
 peritonitis. The violence of the fever, the vomiting, and the 
 intensity of the pain, comprised a list of formidable symp- 
 toms, which seemed to necessitate, while she was at home, 
 the frequent use of morphine. When she came under our 
 care we prescribed colocynth, and, under the influence of this 
 remedy, the fever left after three days of treatment ; then 
 the pains subsided considerably during the day, but returned 
 at .night with such an intensity that our assistant thought him- 
 self obliged to resort to the hypodermic use of morphine. 
 
 In this case I stopped the palliative treatment, because 
 arsenicum. appeared to me to be indicated, as well for the vio- 
 lence of the abdominal pains as for their nightly aggravation. 
 Under the influence of arsenicum, 6th dil., the pains were 
 mitigated and soon disappeared. 
 
 I should remark that I have kept this patient in bed for 
 about a month. It is very important in case of women at- 
 tacked with pelvi-peritonitis to keep them as quiet as possible. 
 
THE TREATMENT OF PELVI-PERITONITIS. 285 
 
 This patient came very near having a relapse, on account of 
 being obliged to get up quickly while she had the diarrhoea. 
 I was also very careful in making a direct examination, know- 
 ing that the touch is very painful to these patients, and that 
 it may sometimes increase the inflammation of the peritoneum. 
 
 Cantharis seems to us to be especially indicated in this 
 disease by the usus in rnorbis. The good effects obtained 
 from blisters, and the heroic action of cantharides, homceo- 
 pathically given in the treatment of pleurisy, suggest its use 
 in the treatment of pelvi-peritonitis. Some physicians of our 
 school have also advised cantharis in inflammation of the 
 ovaries ; but the Materia Medica does not give us the proper 
 guidance for the use of this remedy in pelvi-peritonitis. Con- 
 sequently we are reduced to the expedient of depending upon 
 imperfect data, which cannot now be supplemented by positive 
 details from the Materia Medica. What is the difficulty in 
 finding the indications for cantharis ? Is it because this rem- 
 edy, in spite of all analogies, does not really correspond to 
 the disease? Is it because of this that I have not obtained 
 from cantharis, in the treatment of pelvi-peritonitis, what I 
 have obtained from it in the treatment of pleurisy? In this 
 last disease, the cantharis is a remedy which is almost always 
 sufficient for the cure of the effusion ; while in inflammation 
 of the pelvic peritoneum, it has had almost no effect. I am 
 accustomed to prescribe colocynth and cantharis in the third 
 dilution, three drops in six ounces of water, one teaspoonful 
 every two hours. 
 
 Some years ago we found the following paragraph in the Clinical Memoirs 
 upon the Diseases of Women, by Bekntjtz & Goupil (New Sydenham Society's 
 Edition, Vol. II, page 165): 
 
 "I ought to add that I have found conium a most valuable special narcotic 
 to the genital organs. I give it so as just to produce slight derangement of 
 vision, and a kind of hallucination. I have, however, seen many cases get 
 quite well without there having been any apparent effect from the administra- 
 tion of the drug; so that I cannot feel certain that the beneficial results which 
 seemed to follow its employment were really due to that.' 1 
 
286 THE MEDICAL CLINK. 
 
 Acting- upon this hint, a careful study of the pathogenesy of conium in its 
 relation to the parts involved in pel vi- peritonitis, and to the implication of the 
 sexual and the menstrual functions in the same disease, revealed the fact that 
 Bernutz had probably cured his cases with it. Experience has now taught us to 
 rely upon it in these cases, especially when they are accompanied by a uterine 
 colic that is directly connected with the escape of a leucorrhoeal flow, or by a 
 menstrual tympanitis resembling that of ordinary peritonitis; by aching pains 
 in the hypogastrium, and forcing-down feelings like those of menstrual colic; 
 pains like after-pains in the lower abdomen, or by pressing upon the uterus and 
 cutting during micturition. It seems to be equally useful in the chronic and in 
 the puerperal forms of the disease. Our preference is for the second decimal 
 dilution. — L. 
 
 We have seen that in the course of pelvi-peritonitis the 
 febrile action, after having yielded more or less completely, 
 was very apt to return under the influence of the develop- 
 ment of the disease, or from some external exciting cause. 
 Whenever, in the course of pelvi-peritonitis, the fever recurs, 
 it will be necessary to return to the treatment proper to the 
 acute stage, and principally to the use of aconite. 
 
 We have long since been satisfied that a considerable share of the cases of 
 pelvi-peritonitis are complicated with rheumatism. Not unfrequently the at- 
 tack comes from a translation of rheumatism directly to the peritoneum. Some- 
 times an idiopathic attack is attributable to exposure to cold and wet, in which 
 case, if there is a coincident arrest of the menses, the whole mischief is very apt 
 to be referred to the stoppage of the flow, and not to the peritoneal lesion. It 
 is very common to mistake the effect for the cause, and many of these cases 
 have been unwittingly cured by bryonia, belladonna, rhus tox., colocynth and 
 macrotin. 
 
 Of late I have given the first decimal trituration of the salicylate of soda in 
 some of these cases, with very decided benefit. It seems to be especially useful 
 where there has been a metastasis of the rheumatic inflammation from the syn- 
 ovial, or from the other serous membranes, to the peritoneum. 1 have some- 
 times given it, also, in the second decimal trituration with excellent effect. 
 
 For the relief of the intra-pelvic pain and distress, especially when it is of a 
 neuralgic or rheumatic character, this salt of soda is one of our best remedies ; 
 but the more acute the case, and the more decided the diminution in the quan- 
 tity of the urine secreted, and the absolute increase in the proportion of uric 
 acid contained in the urine, the better the indication. — L. 
 
 During the suppurative period, whether this fever is a 
 symptom of idiopathic or of adhesive pelvi-peritonitis, tend- 
 ing to suppuration, aconite, china and arsenicum are the priii- 
 
THE TREATMENT OF PELVIPERITONITIS. 287 
 
 cipal remedies : aconite corresponds to the continuous fever, 
 and china to its intermittent or remittent type. In these 
 cases I have sometimes observed the occurrence of true per- 
 nicious paroxysms, and I have not hesitated to prescribe the 
 sulphate of quinia in strong doses. 
 
 Certain physicians attribute to the sulphate of quinia an 
 action which is specific against the purulent diathesis. Dr. 
 Richard Hughes says, literally, that this remedy has the 
 power to prevent the formation of pus. My own experi- 
 ence does not permit me to adopt this 'view, for I have too 
 often seen the sulphate of quinia, given in a strong dose, 
 fail in the treatment of this diathesis to accord to it the least 
 anti-purulent virtue. Besides, these specific or quasi-specific 
 properties which are attributed to remedies are almost always 
 illusory. Remedies do not respond to a certain morbid spe- 
 cies, but to indications which are drawn from the totality of 
 the symptoms and lesions, and from the course of these mor- 
 bid phenomena. The sulphate of quinia is not even a specific 
 for intermittent fever, for it is not rare to encounter cases 
 of this fever that are more or less rebellious to this remedy. 
 
 But if the sulphate of quinia is not specific, it is very often 
 indicated by the intermittent type of the symptoms. Now, 
 in a great number of cases of the purulent diathesis, and of 
 diseases ending in suppuration, the fever assumes, in a more 
 or less perfect manner, the intermittent type. In these de- 
 cided cases, the methodical use of the sulphate of quinine 
 causes a marked improvement, and often a cure. It is this 
 peculiar and precious effect of quinine which has caused the 
 illusion that we combat, and which has induced others to at- 
 tribute to this remedy an anti-purulent property. In order 
 to obtain the effects which it will produce, we must find its 
 proper indications, and remember that the more decidedly 
 the symptoms are intermittent, the more certain the action 
 of this remedy. 
 
288 THE MEDICAL CLINIC. 
 
 In pelvi-peritonitis, when the fever which accompanies the 
 suppuration is continuous, or nearly so, and when the differ- 
 ence between the morning and the evening temperature does 
 not exceed 1.8° F., the aconite continues to be the principal 
 remedy. But when the case is dangerous, you need not fear to 
 give it in strong doses. 
 
 I remember a desperate case in which aconite was given in 
 the dose of five drops of the mother tincture every hour for 
 six hours, and in which all the dangerous symptoms were ar- 
 rested promptly. There had been a relapse of purulent pelvi- 
 peritonitis, with the escape of pus by the rectum and by the 
 bladder. The fever, which had a remittent type during the 
 first few days, had resisted the sulphate of quinia (which was 
 badly borne and brought on vomiting) ; and this fever, with- 
 out having a well-marked type, had several daily paroxysms, 
 the chill and the heat alternating irregularly. At the moment 
 of a chill I found the patient in a condition that was more seri- 
 ous than ever ; the face was pale, and expressive of unrest and 
 anguish ; there was considerable agitation ; fear of approaching 
 death ; vomiting ; tendency to syncope, and icy coldness. All 
 these symptoms recalled those of poisoning by aconite. That 
 remedy, given as I have just told you, caused an improvement 
 which was extremely rapid and permanent. 
 
 China and arsenicum have also been recommended during 
 the suppurative fever. I am not quite familiar with the signs 
 which govern the choice between china and the sulphate of 
 quinia. In my own practice I am in the habit of giving the 
 former to prolong the action of the latter. I prescribe from 
 one to five grammes of the mother tincture to be taken in 
 twenty-four hours. 
 
 As for arsenicum, I have not had occasion to extol it in the 
 acute stage of suppuration. On the contrary, however, it is an 
 
THE TREATMENT OF PELVI-PERITONITIS. 289 
 
 excellent remedy in suppurative pelvi-peritonitis which has be- 
 come chronic. It sustains the patient's strength, favors recon- 
 struction, and helps to retard the suppurative process. In 
 these cases it should be given for months, with an intermission 
 of from four to twenty days. My preference is for the first 
 or second triturations. The arsenical mineral waters act in the 
 same way. 
 
 As we have seen in the last case, arsenicum may also be 
 indicated in other stages of pelvi-peritonitis. 
 
 Bryonia should not be forgotten or overlooked in this connection. What 
 Baehr says of it (Science of Therapeutics, translated by Hempel, Vol. I, p. 515) 
 is certainly true. "Hartmann's assertion that peritonitis cannot be cured with- 
 out aconite, seems to us more applicable to bryonia. It comes into play at the 
 most decisive period in the development of the disease, namely, when we desire 
 to remove the effused fluid as soon as possible. ... In comparing the second 
 stage of peritonitis with the pathogenesis of bryonia, we shall find that, in the 
 majority of cases, this remedy is indicated by its physiological effects upon the 
 healthy. It is almost certain that, under the influence of bryonia, the exuded 
 fluid is reabsorbed without causing any further derangement; hence, that no 
 suppuration will take place. But the medicine should be used consistently; we 
 cannot expect to obtain results in a day that can only be obtained in from ten 
 days to a fortnight." 
 
 Apis mel. is indispensable if pelvic cellulitis complicates the case, and we 
 desire to abort the tendency to all forms of pelvic abscess. If the effusion is 
 lodged in the meshes of the areolar tissue, the apis will do all that is claimed 
 for bryonia when the serum has been poured out as a consequence of peritonitis. 
 But it needs to be given in a low form and frequently repeated. — L. 
 
 In chronic, non-suppurating pelvi-peritonitis, arsenicum is 
 also an important remedy, because it may be used with great 
 advantage against the abundant menorrhagias, which are a 
 cause of debility to the patient. In such a case I give of 
 arsenicum, 3d trit., one grain, twice daily, during the interval 
 of the menses. 
 
 Ilamamelis, thlaspi, sabina, and the other remedies for 
 metrorrhagia should be consulted if the arsenicum fails. 
 
 There are times when the pains are so terribly severe that 
 they cause the patient to scream aloud. In such cases we 
 
 19 
 
290 THE MEDICAL CLINIC. 
 
 should not hesitate to use hypodermic injections of morphine. 
 These injections procure a relief from pain, and some hours of 
 rest, which, even from a curative point of view, constitute a 
 real advantage. But you have seen in our last case that one 
 should not abuse this means of relief. 
 
 Of late we never find it necessary to resort to opiates in these cases. There 
 is an expedient which has the double merit of relieving- pain and of being of 
 direct benefit in curing the inflammation, and that expedient consists in the 
 use of very warm or hot water, in the form of a vaginal irrigation. It is 
 always available, and will assuage the pain as promptly and more efficiently 
 than morphine. Its use can be repeated as often as necessary without any 
 harmful results; nor does it in the least interfere with the action of the appro- 
 priate internal remedies. Moreover, it is quite as useful in pelvic cellulitis and 
 in hematocele as it is in pelvi-peritonitis ; and, since these affections may merge, 
 or are apt to be mistaken for each other, this surely is no small advantage. 
 
 To apply these injections (first recommended by Emmet), the patient should 
 lie upon her back with the hips raised. She should be undressed, and go regu- 
 larly to bed. Then place an old-fashioned English bed-pan beneath the hips, 
 or bring them to the edge of the bed, and so arrange the rubber cloth beneath 
 them that the water may flow into a basin or bucket upon the floor. The stream 
 can be thrown by a syphon of plain rubber tubing, or by a syringe with a con- 
 stant current. The temperature of the water, of which from two quarts to two 
 gallons may be used at one time, may be gradually increased from 98° to 108°. 
 The operation may be repeated as often as necessary without any bad effects. 
 — L. 
 
 Proper hygienic care is very important in the treatment of 
 this disease. In the acute stage the most absolute rest should 
 be enjoined. In the chronic stage these patients should avoid 
 fatigue, and venereal excesses especially ; they should be re- 
 minded that each menstrual epoch may be an occasion for 
 resorting to the same absolute rest that is proper and necessary 
 in the acute stage. 
 
 A good diet, life in the country, the use of waters contain- 
 ing chlorinated soda, and warm salt baths, especially if they 
 contain sea-water, will very decidedly aid in the reestablish- 
 ment of health and the complete cure of the patient. 
 
PUERPERAL PELVI-PEEITONITIS. 291 
 
 Puerperal Pelvi-Peritonitis. 
 
 There is one form of pelvi-peritonitis occurring in lying-in women that 
 sometimes gives the physician a deal of trouble. It is that in which there is 
 an inflammation of the portion of the pelvic peritoneum which covers the 
 bladder. Outside of the puerperal state, this disease is variously denominated 
 peri- cystitis, epi- cystitis, and ante-uterine pelvi-peritonitis. 
 
 This is a local or circumscribed peritonitis, which is not usually septic, pyse- 
 mic or symptomatic, and which sets in some days after delivery. The flow of 
 milk is apt to be arrested, but not so with the lochia. The liability to an attack 
 seems to bear no especial relation to the severity of the labor, although it may 
 follow a traumatic injury and irritation of the lower segment of the womb and 
 of the cervix uteri. It occurs both in primiparse and in pluriparee. One of my 
 private patients has had it in her three successive labors. 
 
 The commonly received view that peri-cystitis always follows general peri- 
 tonitis, cystic, uterine, or cellular inflammation, will answer for the ordinary 
 form of the disease; but it is not true of the puerperal variety, — nor is it often 
 due in childbed to an extension of endo-metritis, or of salpingitis, to the peri- 
 toneal cavity. It is almost always an idiopathic affection. It may develop in 
 such a manner as to involve the remaining coats of the bladder, and finally result 
 in chronic cystitis. It is not a dangerous affection, providing it does not end in 
 the perforation of the bladder, and in the extravasation of the urine, in which 
 case it might cause death from diffuse peritonitis, or from urinsemia and septicae- 
 mia. 
 
 Its most common cause is the accumulation of urine in the bladder during 
 the early period of the lying-in. Naturally enough the vesico-uterine excava- 
 tion is more shallow in puerperal than in non-puerperal women. This is es- 
 pecially true for the first week or ten days after delivery, when its depth and 
 situation are very much changed. Under these circumstances a comparatively 
 small quantity of urine, retained in the bladder, may produce a mechanical 
 effect that would not otherwise be felt, or be capable of doing the least mis- 
 chief. 
 
 If this accumulation continues, whether it be through the oversight of the 
 doctor, the carelessness of the nurse, or because the semi- an aesthetic condition 
 of the soft parts after labor renders them more tolerant than usual, and makes 
 the patient indifferent thereto, the effect is the same. The fundus uteri is forced 
 away from the symphysis pubis, and the angle of its lateral deviation is very 
 much increased. Its involution is arrested, and this is the prime condition for 
 inflammation, either in the womb itself or in some of the neighboring organs. 
 
 In a considerable share of cases the uterus and its appendages escape, and 
 the bladder becomes the seat of the difficulty. One of the first symptoms is an 
 inability of the patient to void her urine. The labor may have been natural, 
 and she may have done well in every respect for four or five days, or even for a 
 week, after her delivery. Being able to pass the urine voluntarily, meanwhile, 
 attention has not been directed to the bladder. Then, the physician and the 
 nurse may have neglected to make any further inquiries concerning it, and if 
 the patient has not had the usual desire to urinate for some hours, or even for a 
 
292 THE MEDICAL CLINIC. 
 
 day and night, there will be an over-distension that may act both as a cause and 
 an effect. 
 
 The attack usually begins with a chill, which is not always so severe in 
 degree as in the onset of the other forms of peritonitis. This chill is very apt 
 to repeat itself. It is not usually followed by a very high fever, for, unless there 
 are some septic complications, the patient's temperature averages about 100°, 
 the highest figure being 102° or 102.5°. The chill, partaking more of the na- 
 ture of a rigor, does not produce so profound an impression as it does in the 
 case of the non-puerperal variety of pelvi-peritonitis. The pulse is not so slow 
 as in the normal retardation during the puerperal convalescence, nor is it usually 
 so rapid as in the diffuse form of peritonitis, or of metro- peritonitis of childbed. 
 In this respect its distinctive diagnostic quality may be lost. 
 
 The kind and degree of pain varies in different cases. Sometimes it is 
 brought on and increased by the inaction of the bladder and the retention of a 
 considerable amount of urine. In this case it is sharp and lancinating, and is 
 accompanied by an irresistible desire to urinate. Exceptionally this may be 
 followed by involuntary urination. Again there is no suffering until the bladder 
 has been emptied with the ca.theter, when its contraction causes a pain that may 
 continue for some time after the water has been discharged. One of my hos- 
 pital patients described this pain as very similar to that which is sometimes felt 
 in cases of stone, when the bladder has closed firmly upon the calculus. These 
 pains may change their location from time to time, or they may radiate, like a 
 neuralgia, to either inguinal region, or upward toward the umbilicus. They are 
 very much increased by motion, by downward pressure over the pubic region, 
 and by upward pressure toward the symphysis, when the index finger is passed 
 per vaginam. They are generally relieved by having the limbs drawn up. The 
 meteorism is usually not so pronounced as in other cases of pelvi-peritonitis. 
 
 As a rule, there is no exudation, and consequently there is no intra-pelvic 
 tumor, in this circumscribed form of puerperal peritonitis. The roof of the 
 vagina is natural, or nearly so, unless it may happen that the womb has dropped 
 very low on account of its faulty involution. In extremely rare cases, however, 
 it is possible that an effusion which might be poured out from the inflamed 
 peritoneum around the bladder and above the anterior cul-de-sac, might float 
 backward, and be found in the lowest part of the peritoneal cavity, at Doug- 
 las's pouch, and behind the cervix uteri. 
 
 Treatment. — The first indication is to direct that the urine shall be drawn 
 regularly every four hours during the day and night. This should be carefully 
 and not roughly done. The patient should not be allowed to strain in the 
 attempt to force the flow, nor to worry about passing it naturally now and then 
 without the instrument. Nor should she be teased or disgusted with diluent 
 drinks and such expedients as are designed to stimulate a free secretion of urine, 
 for the fault is not with the kidneys. The bowels also should be kept open, or 
 in a laxative state, for, if she has difficulty at stool, or with constipation, the 
 worst results may happen to the bladder. 
 
 The more recent the date of the labor, if there are no septic or pyaemic 
 complications, the better the indications for aconite and arnica, the good effects 
 of which remedies are shown every day in our puerperal clinic. 
 
 Dr. Jousset's recommendation of cantharis, 3d dil., in pleurisy (see page 
 

 PUERPERAL PELVI-PERITONITIS. 293 
 
 12*), is a very valuable one; but in this form of peritonitis we, also, have some- 
 times found the cantharis to have very little effect. 
 
 For the best of clinical reasons, we have great confidence in the internal 
 employment of terebinthina in puerperal peritonitis. It is closely related in its 
 effects upon the urinary organs to cantharis, and, like it, is also possessed of a 
 wonderful influence upon the serous membranes. But, in our judgment, it is 
 far better adapted to the peculiar condition of the blood, and to the state of 
 vitality of lying-in women, which modifies the puerperal inflammations (even 
 when there is no septic or pysemic infection), than cantharis. This condition is 
 very analogous to that which is met with in typhoid and low hemorrhagic states, 
 as in typhilitis and dysentery. And we have prescribed it in this puerperal peri- 
 cystitis with the same excellent results that we have several times had from its 
 employment in peri- typhilitis. The abdominal and vesical symptoms given in 
 the provings confirm its indication. Our habit is to order it in the second tritu- 
 ration. 
 
 Bryonia, bell., rhus tox. ihlaspi, collinsonia can., are useful remedies under 
 the indications already given. 
 
 We append the notes of a case of this form of pelvi-peritonitis which are 
 condensed from the clinical records of the Hahnemann Hospital for 1879. — L. 
 
 Case 7043. — A. H , American, a multipara, aged thirty- 
 three, was taken in labor on the 12th of March, 1879, at 9.30 
 p.m. An anaesthetic was administered, and at 3 a.m. of the 13th 
 of March, the os uteri being fully dilated, the delivery was com- 
 pleted. The child presented by the vertex in the first position, 
 and was a living male child weighing six pounds. The cir- 
 cumference of the foetal head was fourteen inches, the cord 
 was twenty-one inches long, and the placenta weighed twenty- 
 four ounces. 
 
 Previous to labor, the average temperature of this patient 
 was 97.6°, and her average pulse was 88. 
 
 First day. Morning temp. 98.4°, and the pulse 75. Acon- 
 ite, 3d dil., and arnica, 3d dil. 
 
 Evening temp. 98.4°, pulse 77. The after-pains have been 
 quite severe ; the urine has been drawn with a catheter. Con- 
 tinue the aconite and the arnica. 
 
 Second day. Morning temp. 97.4°, and the pulse 70. Se- 
 vere after-pains. The same remedies continued. 
 
 Evening temp. 97.8°, pulse 75. The after-pains continue. 
 Aconite and arnica. 
 
 *See, also, Jousset's Elements de Medecine Pratique, Vol. II, page 278. 
 
294 THE MEDICAL CLINIC. 
 
 Third day. Morning temp. 98.2°, pulse 78. The after- 
 pains are less severe, and she feels almost well. Aconite and 
 arnica. 
 
 Evening temp. 101.4°, pulse 110. She had a chill this 
 evening, with pains in the temples that are worse on motion. 
 The skin is moist. Bryonia, 6th dil. 
 
 Fourth day. Morning temp. 101.8°, pulse 102. The milk 
 is freely secreted. She has sharp, shooting pains in the region 
 of the bladder, and great thirst. Bryonia, 3d dil., and veratrum 
 vir., 2d dil., in hourly alternation. 
 
 Evening temp. 102.6°, pulse 128. She has had another 
 slight chill ; is thirsty and restless ; has severe pains in the 
 uterus. Continue the same remedies. 
 
 Fifth day. Morning temp. 99.2°, pulse 95. She rested 
 well during the night ; this morning she is much more com- 
 fortable, but still she has considerable pain when passing the 
 urine. Arsenicum, 6th dil. 
 
 Evening temp. 102.8°, pulse 110. She has sharp, shooting 
 pains behind the symphysis pubis, which come and go sud- 
 denly ; the nij)ples are chapped ; the face is congested, and 
 she has a throbbing headache. She also complains of excruci- 
 ating pains while urinating, and is very thirsty. There is 
 some tympanitis. Belladonna, 3d dil , every hour. 
 
 Sixth day. Morning temp. 100°, pulse 96. She is very 
 much better. The pains have nearly ceased. Belladonna. 
 
 Evening temp. 102.4°, pulse 100. The patient has had 
 another slight chill this afternoon, and now feels very chilly 
 when turning in the bed. She has had no appetite since her 
 confinement. Veratrum vir., 3d dil , and milk punch. 
 
 Seventh day. Morning temp. 99°, pulse 90. Her tongue is 
 coated and flabby, and shows the indentation of the teeth. 
 Merc, sol., 3d trit. 
 
 Evening temp. 100.8°, pulse 98. She has sharp pains in 
 the pubic region, which are aggravated by motion, and is very 
 thirsty. Bryonia, 6th dil. 
 
 Eighth day. Morning temp. 98.6°, pulse 84. She did not 
 sleep well, is free from pain, but is very weak ; the urine is re- 
 tained, the tongue is still coated, and shows the imprint of the 
 teeth. Merc. sol. 
 
PUERPERAL PELVI-PERITONITIS. 295 
 
 Evening temp. 99.6°, pulse 90. There is still retention of 
 urine, with much burning about the meatus and along the 
 course of the urethra ; these pains come and go quickly. Bel- 
 ladonna, 3d dil. This evening she has, in addition to the other 
 symptoms, darting pains along the inner border of the crest of 
 the ilium, which are constantly increasing in severity. There 
 are no head symptoms, but she is quite thirsty. The skin is 
 moist. Bryonia. 
 
 Ninth day. Morning temp. 98.2°, pulse 89. She has 
 sharp pains in the left temple, and her bowels have not moved. 
 She has had no offensive lochia, and very little hemorrhage. 
 She lies with her limbs fixed ; the abdomen is not tympanitic, 
 but there is some tenderness in the right inguinal region. She 
 perspired freely all night. The urine is still retained. China, 
 3d dil., every two hours. 
 
 Evening temp. 100°, pulse 100. She had burning pains 
 in the meatus this afternoon, which were relieved by belladonna^. 
 She now complains of a severe pain in the right iliac region, 
 which shoots across the abdomen into the thigh and groin. 
 Bryonia, 3d dil. 
 
 Tenth day. Morning temp. 99.4°, pulse 90. The patient 
 rested well last night, but this morning she has some pain, be- 
 ginning along the crest of the ilium on the right side, and shoot- 
 ing across the abdomen, as before. Locally, the right side of 
 the vesical region is swollen and sensitive. The right leg is re- 
 tracted. Her tongue is coated white, and flabby ; there is no 
 appetite, and the urine has to be drawn. Bryonia, 3d dil. 
 
 Evening temp. 100.6°, pulse 93. She has been more com- 
 fortable to-day ; the bowels moved a little after an injection. 
 The same remedy continued. 
 
 Eleventh day. Morning temp. 99.2°, pulse 90. Rested 
 well last night ; has considerable pain, however, to-day, in the 
 meatus, shooting upward, and pains extending upward and 
 across the abdomen. Bryonia and cantharis, in the 3d dil., 
 alternately. 
 
 Evening temp. 99.8°, pulse 93. She has the most dis- 
 tressing pains when there is any accumulation of urine ; other- 
 wise she is quite comfortable. 
 
 Twelfth day. Morning temp. 98.8°, pulse 86. Bryonia 
 
296 THE MEDICAL CLINIC. 
 
 was given through the night, and she rested very well, but she 
 still complains a little of the burning pains in the meatus ; the 
 appetite is improving ; the lochia have almost disappeared. 
 Cantharis, 3d dil., continued. 
 
 Evening temp. 99.4°, pulse 83. She still complains ol 
 pain along the course of the right ureter ; cannot straighten 
 her limbs or turn upon either side without pain. .Bryonia, 
 3d dil. 
 
 Thirteenth day. Morning temp. 98.2°, pulse 83. There 
 is no pain unless she turns upon her side or moves about, but 
 there is a burning pain before and after urination ; she has con 
 siderable thirst, some appetite, and her tongue is not so badly 
 coated ; the lochia are very scanty. Mere, sol., 3d trit. 
 
 Evening temp. 99.2°, pulse 85. She feels that she is im- 
 proving, although there is great tenderness in the bladder, and 
 the urine is dark in color ; Prof. Ludlam directed that the urine 
 should be tested for albumen. Bryonia, as before. 
 
 Fourteenth day. Morning temp. 98°, pulse 76. She is 
 gradually improving ; there are no new symptoms ; the tongue 
 is somewhat coated yet, and there are indications for mere, sol., 
 which was given again. 
 
 Evening temp. 99.2°, pulse 80. The patient has nothing 
 to complain of except great weakness ; she is drowsy and stupid, 
 and had no appetite for her supper. 
 
 Fifteenth day. Morning temp. 98.4°, pulse 81. Had a 
 good night, and feels better this morning ; the proper tests be- 
 ing applied, no albumen was found in the urine. Continue the 
 mere, sol., three times a day. 
 
 Evening temp. 98.8°, pulse 75. She complains of slight 
 pain before the urine is withdrawn, extending across the abdo- 
 men from right to left. Lycopodium, 3d dil. 
 
 On the morning of the sixteenth day she was put upon rner- 
 cwius sol. , 3d trit. , which was continued with good effect for 
 three days. 
 
 Nineteenth day. Morning temp. 98.8°, pulse 96. This 
 morning the patient has some headache, is thirsty, and the 
 right breast is painful. Bryonia, 3d dil. 
 
 Evening temp. 99.2°, pulse 86. The bowels moved to- 
 
PUERPERAL PELVI-PERITONITIS. 297 
 
 day, and there is a great deal of soreness. The urine was 
 passed spontaneously. The same remedy. 
 
 Twentieth day. Morning temp. 98°, pulse 83. She com- 
 plains of soreness in the bowels, and there is a slight tympani- 
 tis. Belladonna, 3d dil. 
 
 Evening temp. 99.4°, pulse 90. The same symptoms and 
 the same remedy. 
 
 Twenty-first day. Morning temp. 98°, pulse 83. She 
 thinks the soreness across her bowels is less severe, but feels 
 as if everything would be pressed out of the pelvis ; she has 
 some pain in her back and head. Merc, sol., 3d dil. 
 
 Evening temp. 99.6°, pulse 90. There is some pain in 
 the back of the head. Nux vomica, 3d dil. 
 
 Twenty-second day. Morning temp. 97.8°, pulse 76. She 
 complains again of a dull pain after urinating; the urine is 
 very red, and there is a desire to pass it very often, but the 
 amount is scanty ; her feet are cold, and she perspires a great 
 deal. Veratrum alb., 3d dil. 
 
 Evening temp. 99.6°, pulse 85. She feels much better 
 to-night in some respects, but whenever she attempts to sit up 
 in the bed, the same pressure in the pelvis returns. At his 
 
 clinic Prof. L failed to find any evidence of peritoneal 
 
 effusion. Verat. vir., 3d dil. 
 
 Twenty-third day. Morning temp. 98.4°, pulse 80. The 
 patient rested very well and ate some breakfast ; she has the 
 same sensation, when sitting up, as yesterday, but the pain on 
 urinating is less. Apis met., 3d trit. 
 
 Evening temp. 99.2°, pulse 77. The same symptoms and 
 same remedy. 
 
 Twenty-fourth day. Morning temp. 97.8°, pulse 77. This 
 morning she has stitching pains in her back and hips when she 
 breathes. Bryonia, 3d dil., every hour. 
 
 Evening temp. 101°, pulse 94. She has had pain all day 
 in the region of the uterus and the bladder ; some thirst, and 
 no appetite ; there is great tenderness over the bladder. Ar- 
 senicum, 3d trit. 
 
 Twenty-fifth day. Morning temp. 100°, pulse 93. The 
 patient rested well ; has some pain after vomiting ; there is 
 less soreness, and some appetite. Arsenicum, 3d trit. 
 
298 THE MEDICAL CLINIC. 
 
 Evening temp. 100.8°, pulse 100. She has had stitching 
 pains through the abdomen, and much thirst. Bryonia, 3d dil. 
 
 Twenty-sixth day. Morning temp. 100.6°, pulse 98. She 
 still has stitching pains in the left side, below the ribs, when 
 she breathes, and some pain connected with urination. Can- 
 tharis, 3d dil. 
 
 Evening temp. 103.4°, pulse 110. She has had three 
 slight chills to-day, a throbbing headache through the tem- 
 ples and some pains in the abdomen, as in the morning ; the 
 bowels were moved by an enema ; she has no appetite. Bel- 
 ladonna, 3d dil. 
 
 Twenty-seventh day. Morning temp. 98.6°, pulse 93. Has 
 slept pretty well ; has some pain in the right side. Bell., as 
 before. 
 
 Evening temp. 101.2°, pulse 98. There are no new symp- 
 toms. 
 
 Twenty-eighth day. Morning temp. 98°, pulse 80. ~No 
 appetite, and some nausea ; she rested pretty well, but has 
 been chilly for an hour, and still has the burning, dull pain 
 after urination. Apis mel., 3d trit. 
 
 Evening temp. 99.2°, pulse 94. She is about the same; 
 bowels were moved with an enema. The same remedy. 
 
 Twenty-ninth day. Morning temp. 98.6°, pulse 88. She 
 rested well, and is better this morning. Apis mel. 
 
 Evening temp. 102.2°, pulse 114. She has had a chill 
 this morning ; she was very thirsty during the chill which was 
 accompanied by a frontal headache ; there are catching pains 
 in both lumbar regions. Bryonia, 3d dil. 
 
 Thirtieth day. Morning temp. 102.4°, pulse 116. She had 
 another chill at ten o'clock last evening, which continued for 
 nearly two hours. She is now very thirsty and feels very weak ; 
 has some nausea, but was able to retain her breakfast. Yerat, 
 vir., 3d dil. 
 
 Evening temp. 103°, pulse 116. Another chill this morn- 
 ing, after which she slept a little and perspired some. There 
 was nausea and vomiting during the chill. 
 
 At six in the evening she had another slight chill. She 
 now has frontal headache, considerable thirst, and there is 
 great tenderness over the region of both kidneys, and pain and 
 
PUERPERAL PELVI-PEKITONITIS. 299 
 
 soreness in them when trying to move. No more trouble with 
 the bladder. China. 
 
 Thirty-first day. Morning temp. 100.4°, pulse 96. She 
 has rested well all night, and thinks there is a little less sore- 
 ness in the lumbar region. Apis. 
 
 Evening temp. 101.8°, pulse 100. Some pain in her back 
 all day, and frontal and occipital headache. She perspires a 
 great deal. China. 
 
 Thirty-second day. Morning temp. 99.4°, pulse 89. She 
 has rested well, but is very sore across her back, and can 
 scarcely move in the bed. Apis. 
 
 Evening temp. 101.2°, pulse 98. Had* another chill at one 
 o'clock, lasting over an hour, with thirst and nausea during 
 the paroxysm. There is pain in the lumbar region. Bella- 
 donna. 
 
 Thirty-third day. Morning temp. 101.2°, pulse 98. She 
 slept well, and has less pain and soreness. Apis. 
 
 Evening temp. 101.8°, pulse 102. She had another chill 
 about one o'clock this afternoon. Chin, sulph. 
 
 Thirty-fourth day. Morning temp. 98°, pulse 98. Rested 
 well, perspires during sleep, and has less soreness ; appetite 
 not very good. Apis and china. 
 
 Evening temp. 9s°, pulse 87. No complaint of any kind. 
 China. 
 
 Thirty fifth day. Morning temp. 96.8°, pulse 68. She 
 has buzzing noises in her head, but complains of no pain. 
 Apis and china. 
 
 Evening temp. 97.6°, pulse 78. The same symptoms. No 
 appetite. 
 
 Thirty-sixth day. Morning temp. 96.4°, pulse 78. She 
 has cold feet, and perspires during sleep ; there is very little 
 pain or soreness now. Apis and china. 
 
 Evening temp. 98.2°, pulse 73. There is a little pain in 
 her left side. China. 
 
 This woman improved slowly and steadily, with one slight 
 relapse, under apis and china chiefly, until the fifty-first day, 
 when she was discharged from the hospital in good condition. 
 
LECTURE XXII. 
 
 Summary. — Peri-uterine hematocele; hematocele and pseudo-hematocele; 
 hematocele from rupture; hematocele from retention; vicarious hemor- 
 rhage. Case: menorrhagic hematocele. Case: differential diagnosis from 
 pelviperitonitis, and from uterine fibroids. Case: treatment, aconite, colo- 
 cynth, arnica, belladonna and digitalis. 
 
 Peri-uterine Hematocele. 
 
 Gentlemen : The clinical history of hemorrhages within 
 the pelvis, and of tumors that may result from them, is still 
 
 very imperfectly known. However, the facts collected by the 
 French gynecologists, more especially by Bercmtz and Goupil, 
 are now very numerous. Bernutz, in particular, has examined 
 them very critically and minutely*, and his labors will assist us 
 in tracing the clinical history of these peculiar hemorrhages. 
 
 For the present we shall pass over the subject of the pseudo- 
 hematocele described by ITuguier, which has its seat in the 
 cellular tissue of the broad ligament and of the pelvis. Its 
 special pathology varies so much that, unless we could show 
 you a patient who was ill with this form of the disease, it 
 would be useless to burthen your minds at present with its 
 details. 
 
 Some authors have recognized two varieties of hematocele, in one of which 
 the effusion is poured into the peritoneal cavity, and in the other it escapes into 
 the cellular tissue, that is, within the pelvis and around the internal generative 
 organs. The first of these is styled the true, the intra-peritoneal, the encysted, 
 or the peri-uterine hematocele; the latter, the false, the -pseudo, — the extra-peri- 
 toneal, or the non-encysted hematocele. Some writers call the latter a thrombus. 
 By drawing a parallel between the recto-vaginal fold of the peritoneum in 
 women, and the tunica vaginalis testis in men, Dr. Bernutz concludes and in- 
 sists that true hematocele can only take place within the peritoneum. — L. 
 
 * Vide the New Dictionary of Practical Medicine and Surgery, Vol. XVII. 
 
PERI-UTERINE HEMATOCELE. 301 
 
 For ourselves, we consider that, from the moment in which 
 there is a hemorrhage into the serous cavity of the lower pelvis 
 the case is one of peri-uterine hematocele. We do not wait 
 until the blood has become coagulated and encysted by an inci- 
 dental peritonitis before we give it the name of hematocele. 
 
 We know that the word hematocele means a blood-tumor, 
 and that, properly speaking, there is no tumor while the blood 
 remains fluid, and non-encysted. But we prefer to be less 
 literal than to use two different names to specify the same 
 lesion with a few hours' interval, when in fact a hemorrhage in 
 the morning may be encysted and form a tumor which merits 
 the name of hematocele in the evening. 
 
 From a clinical point of view, and as a teacher who should 
 give his pupils a clear idea of the disease which he describes, I 
 shall adopt the following classification of peri-uterine hemato- 
 cele, viz: (1) Hematocele from rupture • (2) Hematocele from 
 menstrual retention, and (3) Menorrhagic hematocele, or the 
 catamenial hematocele of Trousseau. Possibly there are cases 
 that could not be included in this classification, but they are 
 either too rare or too imperfectly understood for me to men- 
 tion them, nor would it be proper to do so in a special clinic. 
 
 The intra-peritoneal hemorrhage in this disease has been attributed to 
 various sources. Thus Bernutz ascribes it to menorrhagia with a regurgitant 
 flow of the menses through the oviduct; NeUaton, to the rupture of a Graafian 
 follicle, and the gravitation of blood into the retro-uterine pouch ; Virchow, to 
 the rupture of the newly-formed vessels in the false membranes that have 
 resulted from a local peritonitis; Peuch, Bichat and Devalz, to a rupture of the 
 utero-ovarian vascular plexus; Tilt and Genouville insist that it comes from the 
 ovary; Trousseau and Tardieu, to a sanguineous exhalation from the peritoneum; 
 Tyler Smith, to an ovarian or Fallopian menstruation, which is vicarious in 
 character; and Gallard, to the escape or dropping of the ovum into the peritoneal 
 cavity, or, in other words, to the detachment of the ovum in extra-uterine 
 gestation. — L. 
 
 I. HEMATOCELE FROM RUPTURE. 
 
 This form results most frequently from a rupture of the 
 tubo-ovarian veins ; but occasionally from a rupture of the 
 
302 THE MEDICAL CLINIC. 
 
 Fallopian tube, or of the ovary itself. It is characterized by 
 an excessive pain which is located in one of the iliac fossae, by 
 the fainting condition which is proper to all internal hemor- 
 rhages, and, if death does not follow at once, by the very rapid 
 development of an alarming peritonitis. 
 
 In this variety, properly speaking, we do not find the 
 tumor, but a distension of the abdomen, from the accumulation 
 of blood and from the early symptoms of peritonitis. It is 
 only in case that life is sufficiently prolonged that the clot 
 becomes encysted, the tumor forms, and, in the proper sense 
 of the word, hematocele exists. 
 
 This is a very important distinction. Cases of hematocele in which the 
 affection has taken on the sub-acute or the chronic form, and in which a large 
 sized, semi-solid tumor has been formed, do not belong to this class. Being 
 accompanied from the first by symptoms of a collapse that is due to a concealed 
 intra-peritoneal hemorrhage, such cases are almost always rapidly fatal. They 
 do not, as a rule, live long enough to permit the development of the secondary 
 peritonitis that furnishes the cyst, or pouch, in which the effused blood is solidi- 
 fied when the hematomatous tumor is formed. — L. 
 
 The two following varieties are more frequently met with, 
 and they are, in all respects, of more practical interest. 
 
 II. HEMATOCELE FKOM RETENTION. 
 
 This is the title which Bernutz gives to hemorrhage within 
 the lower pelvis, caused by partial or complete obliteration of 
 the generative intestine, which interferes with the escape of 
 the menses. In the first class, he specifies imperforate hymen 
 and obliteration of the vagina and of the cervix ; in the second, 
 strictures of the neck of the womb. In these cases, the blood, 
 which has accumulated in the uterus, overflows through the 
 Fallopian tube, and discharges itself into the peritoneal cavity. 
 
 This mode of origin is literally true in case of complete re- 
 tention, and we do not have need to copy the illustration of 
 Barlow, contained in the Monthly Journal for 1841, in order to 
 
PERI-UTERINE HEMATOCELE. 303 
 
 understand how the blood, which is contained in the uterine 
 cavity by a constriction of the cervix, or by atresia of the 
 vagina, may accumulate therein each month until it shall finish 
 by dilating the tubes and flowing through them into the cavity 
 of the peritoneum. 
 
 But is M. Bernutz quite positive that the cases of hemato- 
 cele, which follow a total suppression of the menses for one 
 or more months, are due to the same cause ? Has it been 
 demonstrated that all these patients have a stricture of the 
 cervix X Certainly not. Besides, in these cases, there are no 
 symptoms of an accumulation of blood in the uterine cavity. 
 The clinical truth is at once more simple and more obscure. A 
 woman who has had a suppression, more or less prolonged, and 
 who is not pregnant, is seized,, at the time when the menses 
 should appear, with decided symptoms of peritonitis and the 
 rapid formation of an hematocele. 
 
 Now, in these cases, we do not believe it possible to ex- 
 plain the symptoms by the retention of blood in the uterus and 
 by its passage, through the Fallopian tubes, into the peritoneum. 
 Our reasons are, first, because the hematocele has not been pre- 
 ceded by the signs of retention ; and secondly, because the nar- 
 rowing of the cervix, when it exists, is not always sufficient to 
 explain such a retention. In fact, it is quite common to meet 
 with cases of cervical stricture that cause the most frightful 
 dysmenorrhea without ever producing hematocele. 
 
 There are exceptional cases, however, in which the hematocele evidently 
 results from a partial or complete stenosis of the cervix uteri. We have had 
 one of these under our observation for two years past. The facts were as fol- 
 lows : Case — Mrs. , aged twenty-eight, a slender, delicate woman, who had 
 
 been married for six years, but without offspring, and with no history of an 
 abortion, consulted us for the relief of a very severe headache to which she had 
 been subject much of the time since her first menstruation at the fifteenth year. 
 Of late, the headache 1 had become decidedly menstrual, anticipating the flow 
 some twelve to twenty-four hours, and being always somewhat relieved by it. 
 But the monthly discharge was so scanty and escaped with such a stillicidium, 
 
304 THE MEDICAL CLINIC. 
 
 that she felt satisfied that the retention must have something to do with her 
 suffering. She had long been subject to hemorrhoids. 
 
 I gave her remedies for some time, but without effect, and finally obtained 
 permission to make a careful internal examination of the uterine cervix. She 
 would not consent to this until she had satisfied herself that quite recently, in- 
 deed at her last period, she had felt something wrong and unusual within the 
 pelvis. I felt the conical cervix crowded forward toward the symphysis pubis 
 by a retro-uterine tumor, that was of irregular form and doughy to the touch. 
 Around its outline the tissues were very tender. Unfortunately, I could not 
 know how long this state of things had existed. 
 
 The tumor was bi-lobular, with a kind of sulcus between the lobes that 
 could easily be felt by the rectal touch. This sulcus, indeed, corresponded in 
 shape, size and direction with the rectum itself. She had had a great deal of 
 sacral pain, and of dragging in the hips and the loins, but the bowels were 
 regular. The sacral distress was usually very severe at the month. 
 
 There was an almost complete stenosis of the uterine cervix, for only the 
 smallest sized sound could be passed through the internal os uteri. With the 
 absence of the signs of pelvic cellulitis, and of an uterine fibroid, the case was 
 diagnosticated as one of menstrual hematocele, due to an overflow of blood from 
 the uterine cavity. 
 
 A careful dilatation of the uterine canal was begun and continued through- 
 out the inter-menstrual period. When the month came around the flow was 
 much more free, and she had very little headache. The strictest quarantine 
 and rest were enjoined for a week during the period, and then the careful dila- 
 tation of the cervix was resumed. In three months the menstrual trouble and 
 the headache had vanished, and through a free coffee-ground discharge from 
 the rectum the tumor had almost entirely passed away also. For a twelve- 
 month now she has been quite well. — L. 
 
 We are led to believe, therefore, that in these cases there is 
 an exhalation of blood within the peritoneum itself, as there 
 may be a nasal, or gastric, or pulmonary hemorrhage in case of 
 suppression of the menses ; in short, that this may be a veri- 
 table vicarious hemorrhage. Case LVIII is an example of 
 hematocele by retention, but one in which it is impossible 
 to find any obstacle whatever to the escape of the blood 
 from the uterus in the natural way. 
 
 Concerning the German idea which is revived in the theory 
 of pachy-meningitis [hematoma of the dura-mater], and which 
 holds that the false membranes precede the hemorrhage, and 
 that this hemorrhage is due to the rupture of newly formed 
 vessels in the false membrane, the study of the symptoms is 
 
PERI-UTERINE HEMATOCELE. 305 
 
 not in the least favorable to this theory ; for in that case it 
 would be necessary that the signs of pelvi-peritonitis should 
 precede, for a long time, those of the hemorrhage, which is 
 not true. 
 
 If the ordinary form of pelvi-peritonitis is common, and in many cases 
 latent, as we believe it to be, and if adhesions may form without an acute ill- 
 ness, as they so often do in pleurisy, hemorrhagic peritonitis and hemorrhagic 
 pleurisy should be much more frequent than they really are, providing Virchow's 
 theory that the hemorrhage in hematocele depends upon a rupture of the deli- 
 cate vessels in the neo-membranes were true. — L. 
 
 Whatever else may be said, this variety of hematocele 
 has a beginning and a course which are characteristic. 
 
 After a suppression of the menses, which are more or less 
 prolonged, and at the moment of their appearance, there is an 
 acute pain in the center of the hypogastrium, with all the 
 symptoms of a violent peritonitis, a chill, intense fever, 
 pinched features and vomiting, which is sometimes intracta- 
 ble. This is what Bernutz calls a dramatic debut. The encyst- 
 ment of the blood takes place very rapidly, and the tumor may 
 sometimes form within thirty-six hours. This encystment is 
 due to the peritonitis occasioned by the contact of the blood 
 with the serous membrane. The process results in the forma- 
 tion of a sort of a pathological diaphragm, which is formed 
 by the adhesions between the intestinal loops, the genital 
 organs and the abdominal walls. Bernutz calls this formation 
 a diaphragm, because it falls with each inspiration, and forces 
 the blood into the vaginal culs-de-sac. 
 
 The tumor which is formed by the hematocele is large, 
 
 and sometimes extends from the posterior cul-de-sac of the 
 
 vagina as high as the umbilicus. It does not change its 
 
 volume appreciably from one monthly period to another ; but 
 
 from settling more and more into the lower pelvis, it may 
 
 seem to diminish at its upper part. It is the largest in one 
 
 of the iliac fossae ; but it may send a prolongation into the 
 20 
 
306 THE MEDICAL CLINIC. 
 
 other one, and it always extends itself more or less in the 
 median line. The uterine cervix is crowded forward and up- 
 ward toward the pubis, and the rectum is compressed and 
 more or less displaced. 
 
 This tumor has a doughy consistence ; later it has a solid 
 portion, with a consistence like that of a fibrous body, and 
 also a portion which is soft and fluctuating. 
 
 The author has given an excellent description of this tumor. We have only 
 to add that in some cases these hematomata do perceptibly diminish in size from 
 time to time. If in our practice we can prevent a repetition of the flow, espe- 
 cially in menorrhagic cases, they will shrink as they become more solid, until 
 finally they are removed by absorption, or by their discharge through some of 
 the pelvic outlets. This fact may be confirmed by means of a careful bi-manual 
 examination repeated now and then. 
 
 Exceptionally, also, and more especially when Nature is preparing a means of 
 escape for their contents, there is such a degree of cellulitis about these tumors 
 as causes them to feel very hard to the touch, and a local examination of them 
 just at this time, through the vagina or the rectum, or both, may lead to their 
 being mistaken for fibromata, or for some form of malignant growth. — L. 
 
 The symptoms of peritonitis subside, and from day to day 
 there is considerable improvement. The pulse, however, re- 
 mains frequent, and the features present the cachectic appear- 
 ance that is proper to hemorrhages. At the next monthly 
 return all the symptoms may reappear, the expression and 
 pains are as bad as they were before, the tumor increases 
 decidedly, and death may follow, on account of the peritonitis 
 having become diffused. At other times the blood-cyst be- 
 comes the seat of a suppurative fever, and internal inflamma- 
 tion, and, as in pelvi-peritonitis with suppuration, the abscess 
 may open into the peritoneum, the rectum, the vagina, or the 
 bladder. If it opens into the peritoneum, the case rapidly ter- 
 minates in death ; if into the vagina or the rectum, it results 
 in a cure ; if the opening is too small, or located too high in 
 the intestine, or if it opens into the bladder, the disease will 
 pass into a state of chronic suppuration with hectic fever. 
 Among these different openings, therefore, the most favorable 
 
PEKI-TJTEEINE HEMATOCELE. 307 
 
 is that which communicates with the vagina. You have, how- 
 ever, seen one of our cases in which an opening into the 
 rectum was followed by a prompt cure. These various ter- 
 minations sometimes happen only after the third or fourth 
 menstrual period. 
 
 In the most fortunate of these cases the termination ar- 
 rives through an absorption of the blood-cyst, and this retro- 
 gressive process also begins during the menstrual epoch, and 
 has a very rapid course. We shall cite 'an example of Peri- 
 uterine peritoneal hematocele. 
 
 Case LVIII. — Madame C- , a cloth dresser, aged thirty- 
 three years, was admitted to the hospital Saint-Jacques on the 
 21st of May, and discharged on the 21st of June, 1872. 
 
 This woman, who has had two children, is of general good 
 health ; her periods are rather scanty and too frequent. 
 
 On the 17th of May, at the beginning of the monthly now, 
 she was taken suddenly with a violent pain in the left groin, 
 which compelled her to go to bed. During the night she had 
 severe bilious vomiting and three solid stools, but no fever. 
 
 May 18 and 19. She was much better, and wanted to go to 
 work again. 
 
 May 20. The pain returned, and was more severe than at 
 first. She entered the hospital on the 21st. 
 
 'The next morning the patient presented the following symp- 
 toms : slight fever, pulse 96, temp. 100.4°; the face is very 
 pale ; the abdomen is distended and sensitive, especially in the 
 left iliac fossa ; palpation discloses a swelling, which extends 
 from the anterior spine of the left ilium to the margin of the 
 womb. This swelling is more and more pronounced until it 
 reaches the inferior part of the hypogastrium, where it forms a 
 hard, non-fluctuating mass, and is absolutely dull on percussion. 
 Urination is not difficult. 
 
 In the evening the fever was very much increased, the pulse 
 120, temp. 105.4°. Aconite, 2d dil., twenty centigrammes in 
 200 grammes of water, a teaspoonful every two hours. 
 
308 THE MEDICAL CLINIC. 
 
 May 23. The fever persists ; the morning temp, was 102.5°, 
 the evening temp. 103.25°. The same treatment. 
 
 May 24. The fever has diminished somewhat ; morning 
 temp. 101.6° ; evening temp. 102.8°. By the vaginal touch we 
 discover a hard tumor forcing itself into the left posterolateral 
 cul-de-sac of the vagina. 
 
 May 25, 26 and 27. Her condition is the same, the evening 
 temperature being always one degree or more higher than in 
 the morning. 
 
 May 28. The fever has subsided ; the abdomen is not so 
 distended, and is no longer painful. The pufhness has dimin- 
 ished, so that we can recognize the hematic tumor more dis- 
 tinctly. By the touch, we still find the tumor in the left cul-de- 
 sac, and the cervix is raised and pushed forward. The aconite 
 was continued, and the patient ordered to be better nourished. 
 
 June 10. There are no more functional troubles. The 
 tumor is very circumscribed, and wedded to the left side of the 
 womb. Arnica, 6th dil., was given until the 15th, when it was 
 substituted by belladonna, 3d dil. The patient left on the 21st, 
 still having a hematic tumor. The cervix is pushed forward 
 against the symphysis pubis. 
 
 We saw this woman four years later, and there were no 
 signs of the tumor. 
 
 III. MENOERHAGIC HEMATOCELE. 
 
 This form, which is the most frequent of all, happens in the 
 case of those women who, for one cause or another, are sub- 
 ject to very copious menstruation. Trousseau styled this vari- 
 ety of hematocele tubal, because he believed that the mucous 
 membrane lining the Fallopian tube was the exclusive seat of 
 the hemorrhage. Bernutz thought, and properly too, that the 
 increased exhalation of blood which causes this kind of hemato- 
 cele took place from the uterine mucous membrane, as well as 
 from that lining of the tube, and that the reflux of the blood 
 was from the uterus into the peritoneal cavity. 
 
 In this form of the disease the symptoms of peritonitis are 
 
PERI-UTERINE HEMATOCELE. 309 
 
 much less intense. Indeed, in some cases they are so slight 
 that Trousseau has denied the coexistence of peritonitis. 
 
 During an attack of metrorrhagia there is a severe pain 
 within the lower pelvis ; this pain is accompanied by a slight 
 fever, whilst the metrorrhagia is arrested, or at least the flow 
 of blood is considerably diminished. At the end of some days 
 the symptoms improve so decidedly that women often believe 
 themselves cured, and begin to resume their usual habits. But 
 the pains reappear ; the external hemorrhage returns, increases, 
 and prolongs itself indefinitely. 
 
 As in the preceding form, each catamenial epoch is the 
 occasion of an exacerbation of the disease, and becomes the 
 departure for similar results : increased growth of the tumor, 
 a possible rupture of the cyst into the peritoneum, etc., and 
 of the same modes of termination, absorption, suppuration 
 or discharge into the neighboring cavities. 
 
 In his excellent monograph (De V Hematocele Retro- Uterine, Paris, 1860), 
 Voisin reports several cases that were due to the indulgence of coitus during 
 menstruation ; and other writers have attributed it to a violent shock or fright 
 during sexual intercourse, to external abdominal injuries, to lifting and strain- 
 ing, and to too early exercise after an abortion. 
 
 It has been suggested that the menstrual blood, after having been retained 
 in utero for a greater or less length of time, might be very poisonous when 
 brought into contact with the peritoneum. Pure, healthy blood, it is said, 
 would not induce peritonitis; but if the blood was depraved, either in the gen- 
 eral circulation, or when it came into the peritoneal cavity from some special 
 source, it would be very likely to cause a septic infection, as well as a serious 
 inflammation. — L. 
 
 In the twenty-five cases which are included in the thesis 
 of Auguste Voisin, the longest period required for the re- 
 sorption of the hematocele was eight months. Yelpeau ob- 
 served a case in which the absorption of the clot required 
 eighteen months. The following case offers an example of a 
 much longer duration ; and we can see no reason why this 
 duration might not be indefinitely prolonged, or why the 
 
310 THE MEDICAL CLINIC. 
 
 blood-cyst might not continue as a tumor during the life of 
 these patients. We believe, however, that this would be pos- 
 sible only after the change of life, for the menstrual return 
 is frequently the occasion of a new development in, and of 
 a change in, the blood-cyst. 
 
 Here follows a case in which two years and a-half from 
 the commencement of the disease there still exists an hemato- 
 cele, in the form of a tumor, which is as large as the head of 
 an adult : 
 
 Case LIX. — Miss D , now eighteen years old, had, at 
 
 the age of fifteen, the form and all the appearances of a young 
 girl who had passed through puberty, but the menses had not 
 yet appeared. From that time, each month, at a fixed date, 
 she had all the preliminary signs of menstruation — malaise, 
 swelling of the breasts, pains in the loins and the lower abdo- 
 men — but without any sanguineous flow from the vulva, and 
 with no sign of the accumulation of blood in the uterine cavity. 
 After some months of this imperfect ovulation, and when this 
 peculiar crisis was upon her, the young girl was taken sud- 
 denly with all the symptoms of a violent peritonitis. At the 
 same time there appeared a hard, round tumor, which grew 
 rapidly, and which reached beyond the umbilicus. 
 
 There had been no flow of blood from the vulva ; the symp- 
 toms of peritonitis disappeared ; the patient recovered, but 
 continued to have an abdominal tumor which was as large as the 
 head of an adult. This tumor presented no appreciable change 
 in its volume, and became so indolent that the patient could 
 walk and resume her usual habits. Six months after the debut 
 of the peritonitis, the menses appeared for the first time, and 
 have since been irregular, somewhat free and painful. The 
 tumor has not been modified bv the establishment of the 
 monthly flow. 
 
 Six weeks ago this patient was taken with sudden pains 
 in the tumor, and I was consulted in her case. 
 
 She had every appearance of health. I only observed 
 
PERI-UTERINE HEMATOCELE. 311 
 
 that her hips were not as broad as they usually are in women, 
 and that the abdomen seemed retracted. There was a tumor of 
 the size already given. It was round, smooth, and occupied 
 the median line just below the umbilicus, and a part of the 
 left iliac fossa. I could not detect any fluctuation, and it had 
 the consistence of a fibrous body. The tumor was painful 
 to the touch only on the left and inferior portion. The vaginal 
 touch shows that the patient is a virgin ; it is difficult and 
 very painful ; the vagina is narrow ; the cervix is in contact 
 with the rectum, instead of being toward the symphysis pubis, 
 and the complaints of the patient prevent me from finding 
 its orifice. The rectal touch discloses but little, for the tumor 
 occupies principally the anterior face of the uterus. 
 
 Differential Diagnosis. — Now that we have given the 
 prominent features in the clinical history of hematocele, it 
 will be possible for us to establish rules for the differential 
 diagnosis between these tumors and pelvi-peritonitis. 
 
 If we consider the general symptoms exclusively, the 
 purulent form of pelvi-peritonitis may be confounded with 
 hematocele from retention, and adhesive pelvi-peritonitis with 
 the menorrhagic hematocele. 
 
 In hematocele from retention, as also in purulent pelvi- 
 peritonitis, we find an abrupt invasion, with all the symptoms 
 of peritonitis. This is very natural, for in both cases there 
 is a violent inflammation of the serous membrane within the 
 lower pelvis. However, there are three differences in the 
 totality of the symptoms. The first is that hematocele, like 
 a peritonitis which is due to a perforation, begins very abruptly ; 
 the second is that the hematocele occurs during the menstrual 
 epoch, whilst pelvi-peritonitis may set in at another time; 
 and the third difference is that, after a frightful onset, hemato- 
 cele, when it does not terminate in death from the first at- 
 
312 THE MEDICAL CLINIC. 
 
 tack, takes a course which decreases steadily until the next 
 monthly period, while purulent pelvi-peritonitis has its periods 
 of being better and worse at irregular intervals. 
 
 In its general symptoms the adhesive pelvi-peritonitis bears 
 a strong resemblance to menorrhagic hematocele. In both 
 cases the symptoms correspond with those of a mild attack 
 of peritonitis. Hematocele always preserves its character as 
 an affection with an abrupt onset and a regular course, im- 
 proving after each menstrual period, and not becoming worse 
 until the next regular epoch. But as the symptoms are less 
 pronounced than in the form of hematocele which is due to 
 retention, the symptom derived from their course alone is 
 more difficult to understand. 
 
 The principal diagnostic sign is derived from the coinci- 
 dence of peritonitis with menorrhagia, which menorrhagia sub- 
 sides at first, then returns more or less decidedly, and con- 
 tinues almost indefinitely. This peculiarity of the brusque 
 onset of a peritonitis within the true }3elvis, with a men- 
 orrhagia, is jxitliognomonic of hematocele. 
 
 But the local symptoms derived from the examination of 
 the tumor will furnish us other differential signs which are 
 of great value. 
 
 These are the signs which are afforded by the tumor itself 
 in a case of hematocele : the tumor is formed rapidly, and im- 
 mediately attains the size which it will continue to have until 
 the next menstrual return. This tumor mav be of consider- 
 able size, sometimes reaching almost to the umbilicus ; or it 
 may descend deeply between the rectum and vagina, and al- 
 most always occupies the two iliac fossae and the hypogas- 
 trium. 
 
 The form of this tumor is irregularly rounded, usually pre- 
 senting a large protuberance in one of the iliac fossae, another 
 
PERI-UTERINE HEMATOCELE. 313 
 
 in the hypogastrium and a third in the opposite iliac fossa. 
 This form has been compared to that of a clover leaf; the 
 pedicle of the clover dips down into the lower pelvis, of which 
 it forms a cast like metal in a mold. 
 
 If the hemorrhage happens to occur when the rectum is loaded with faeces, 
 the tumor may be molded into such a form as afterward to exempt the patient 
 from rectal tenesmus, which usually is one of the most distressing symptoms in 
 retro-uterine hematocele. And strangury may also be lacking as a symptom if, 
 during the solidification and encystment of the tumor, the patient has invari- 
 ably lain upon her back. — L. 
 
 The consistency of the tumor is no less characteristic ; at 
 first it is of a doughy softness, then of an elastic resistance 
 which, according to Bernutz, is quite peculiar ; later its texture 
 ceases to be homogeneous, and we recognize some small bodies 
 which are mixed with liquid ; still later the tumor consists of 
 two parts, one of which is round, hard, elastic, and which, in 
 the case under consideration, was mistaken for a fibrous body ; 
 and of a fluctuating portion, which, when the patients recover, 
 lessens from day to day. 
 
 In certain cases it is very important to differentiate the hematic tumor from 
 an ovarian cyst. In so doing we should remember that the cyst of the ovary is 
 of comparatively .slow growth; that it is seldom accompanied by menorrhagia, 
 or by symptoms of hemorrhage, or of peritonitis; that the tumor is most largely 
 fluid, and that, whether the cyst be compound or single, its fluid portion in- 
 creases from time to time. All of these signs are reversed in pelvic hematocele. 
 
 The diagnosis between the two is, however, more difficult if the ovarian cyst 
 is small and accompanied by pelvi-peritonitis. For in this case it may be bound 
 down and strangulated by adhesions, and as it fills it may cause such a bulging 
 and prolapse of the retro-uterine pouch as shall give it a very strong resem- 
 blance to a large hematic tumor. We should, indeed, remember the possible 
 distensibility of the pouch at the Douglas cul-de-sac, as described by Phillips, 
 Barnes and others, in every such emergency. 
 
 In a very marked case of this kind to which I was called some years ago by 
 my colleague, Dr. A. E. Small, the pelvis was almost completely filled with one 
 lobe of an enormous multilocular ovarian cyst, which was so adherent as to be 
 immovable, and which had forced itself downward until it approached the 
 vulva. The poor victim soon died of an intractable dysentery, and a careful 
 autopsy showed the tumor to have been anchored and compressed by very firm 
 and vascular adhesions extending everywhere throughout the pelvis. In this 
 case the abdominal cysts were also very large. The specimen is preserved in 
 my cabinet. — L. 
 
314 THE MEDICAL CLINIC. 
 
 The hematomatoiis tumor differs from the tumor of pelvi- 
 peritonitis, which is smaller, circumscribed, or at least less 
 prominent in either of the iliac fossse, decidedly fluctuating 
 in the suppurative form of pelvi-peritonitis, presenting in both 
 a special development which we have described at length, and 
 which in adhesive peritonitis, at least, is characteristic. 
 
 It is much easier to recognize and to differentiate this tumor if we have 
 known the condition of the parts involved almost immediately before its forma- 
 tion. If the occurrence of the swelling was coincident with the general attack, 
 and took place, as it were, suddenly, the case would be clear enough; for in 
 simple pelvi-peritonitis, and in pelvic cellulitis also, the effusion is not by any 
 means so rapid. — L. 
 
 It remains to distinguish true from false hematocele or 
 from hematocele of the broad ligament, and also from uterine 
 fibroids. 
 
 Pseudo-hematocele is almost always contingent upon extra- 
 uterine pregnancy ; indeed, only two cases of pseudo-hemato- 
 cele have been reported which are independent of that con- 
 dition. 
 
 As in the true hematocele, the onset is abrupt, and occurs 
 at the catamenial period ; it is not accompanied by symptoms 
 of genuine peritonitis, but by a pain in the hypogastrium, 
 which is very much like that which occurs in case of inflam- 
 mation of the broad ligament. The blood-tumor is entirely 
 lateral and not prominent in the abdomen, whilst it descends 
 very low in the vagina, from the walls of which, so to speak, 
 its body is composed [Bernutz]. 
 
 It is necessary to differentiate very carefullv between uter- 
 ine fibroids and hematocele, because these two affections have 
 often been confounded. This mistake happened to Malgaigne, 
 to Stoltz, and quite recently to the specialist who wanted to 
 operate on our patient. In the case of which we are speaking, 
 the diagnosis turned partly upon the symptoms of the tumor, 
 which it would be useless to recapitulate, but chiefly upon the 
 
PERI-UTERINE HEMATOCELE. 315 
 
 incidental history. For example, we cannot understand how, 
 in this case, one should have taken for a fibroid tumor one 
 which, in a few months, had attained the size of the foetal head, 
 and which at the beginning had presented all the signs of a 
 violent peritonitis. 
 
 Here are the details of this case : 
 
 Case LX. — Madame J , aged thirty-four, was admitted 
 
 into the private ward on the 9th of February, and discharged 
 on the 27th of March. 
 
 This woman had enjoyed good health until the month of 
 September. At that time the menses were suppressed without 
 apparent cause. But from that moment she has had, every 
 month, nausea and general malaise, which continued for some 
 days, but without any sign of the accumulation of blood in the 
 uterus. 
 
 On the 11th of December last, just when she should have 
 had her courses, she was taken with chills, intense fever, very 
 violent pains in the abdomen, and some vomiting. She was 
 obliged to go to bed, and her physician treated her for peri- 
 tonitis. 
 
 At the beginning of January she discovered that the abdo- 
 men was enlarged. The tumor which she found was chiefly 
 on the right side, and was very slightly sensitive to pressure. 
 At the same time she lost her appetite, and her strength 
 diminished rapidly. Then, for the first time, she entered our 
 wards. 
 
 Examination of the Tumor.- — This tumor has the volume of 
 the foetal head at term. It presents two distinct parts : one, 
 and the largest, is round, smooth, hard and elastic, with the 
 consistence of a fibrous body, and located in the right iliac 
 fossa; the other, which is smaller, is decidedly fluctuating, and 
 occupies the middle region. 
 
 By the touch we find that the right and the posterior culs- 
 de-sac of the vagina are filled with a resisting tumor, and the 
 cervix uteri is carried forward and to the left side. 
 
 In the month of January the courses returned, but they 
 were slight and very painful. The size of the tumor was not 
 
316 THE MEDICAL CLINIC. 
 
 changed. The patient went home again because we would not 
 consent to an operation. 
 
 An exploratory puncture was made into the tumor about 
 the last of January, and half a glass of blackish blood was 
 withdrawn. 
 
 Some days later she was seized with chills and nausea, and 
 on the 9th of February she returned to the hospital with a 
 very intense fever. 
 
 In the hypogastriuin, and along the mesian line, we recog- 
 nize a half-solid, half-fluctuating tumor which extends into the 
 right iliac region. The touch also discloses a tumor in the 
 right posterior and lateral culs-de-sac. By the rectal touch we 
 can make out the superior limit of this tumor. Aconite, in the 
 mother tincture, five drops in 200 grammes of water, one tea- 
 spoonful every two hours. 
 
 February 10. Yesterday, during the day, the patient passed, 
 per rectum, a quantity of black blood mixed with pus. The 
 tumor seems to have settled somewhat. The same treatment. 
 
 February 15. She goes regularly to stool, and each time 
 passes a large quantity of black blood. The diminution in the 
 size of the tumor is perceptible. The same treatment. 
 
 February 20. The improvement continues, and the fever 
 is completely broken. The appetite and strength are return- 
 ing. Belladonna, 6th dil., two drops in 200 grammes of 
 water, four teaspoonfuls daily. 
 
 February 24. The tumor is still becoming smaller. The 
 stools contain some granulated blood. On account of a slight 
 fever, the aconite, in the mother tincture, was resumed. 
 
 February 26. Where the tumor was located we now recog- 
 nize a deep-seated, dough-like deposit. Cantharis, 6th dil., 
 two drops. 
 
 The patient had no longer any especial symptoms. The 
 sanguineous discharge had ceased. There was no further sign 
 of a peri-uterine tumor, and she had grown fleshy. She left 
 the hospital on the 27th of March. 
 
 The size and shape of the tumor, and the sensation of 
 elastic hardness upon palpation had completely deceived the 
 surgeon who had diagnosticated it to be a uterine fibroid, and 
 
PEKI-UTERINE HEMATOCELE. 317 
 
 who had decided upon its extirpation. This mistake, which 
 might have been so serious for the patient, would not have 
 happened if our confrere had been careful with regard to 
 the early history of the case, for a uterine fibroid never 
 reaches such a great size in a few months ; and besides, the 
 formation of such a neoplasm is not accompanied by symp- 
 toms of subacute peritonitis. I will add that the direct ex- 
 amination of the tumor showed me that it was composed of 
 two parts, one of which was solid, and another, and a smaller 
 one, which was liquid. Kow, fibroids never present this pe- 
 culiarity.* The surgeon, perhaps, thought that we had been 
 deceived by a false sensation of fluctuation ; but the patient 
 returned to her home and called another surgeon, who, for 
 the sake of clearing up the diagnosis, practiced the explora- 
 tory puncture, or tapping, and who, by drawing off half a 
 glass of blood, demonstrated the existence of a peri-uterine 
 hematocele. 
 
 The results of this puncture were very fortunate for the 
 patient. A slight inflammation of the cyst followed, which 
 resulted in an opening into the rectum, and, as we have 
 already seen, in the complete cure of the disease ; but is 
 this not the place to recall the maxim, felicior quam pru- 
 dentior? For, instead of being moderate in degree, the in- 
 flammation might have been violent, or the opening, instead 
 of discharging the contents of the tumor through the rectum, 
 might have let them into the peritoneal cavity ; and in either 
 case a rapid death would have resulted from the surgical 
 interference. 
 
 Two practical conclusions may be drawn from this case : 
 (1) That, in making a diagnosis, it is indispensable to study 
 the whole history of the case, and (2) that, unless there is 
 a very clear indication for it, we should never touch an 
 hematocele surgically. 
 
 * Excepting in rare cases of their cystic degeneration. — L. 
 
318 THE MEDICAL CLINIC. 
 
 This case is a very instructive one. The celebrated Malgaigne, of Paris, and 
 the no less distinguished Stoltz, of Strasbourg, each mistook a pelvic hemato- 
 cele for an uterine fibroid. The former did not discover his error until (in 1850) 
 he had made an incision into the os uteri with the intention of enucleating the 
 tumor; and Stoltz was so confident of his diagnosis that he made his patient's 
 case the subject of several lectures upon fibrous tumors of the uterus. In the 
 latter case the existence of the hematocele was not discovered until the autopsy 
 was made. 
 
 Bernutz and Goupil could not decide, in a case at the Hotel Dieu, whether 
 it was an hematic tumor or a uterine fibroid; and several cases are on record in 
 which a large hematocele was mistaken for an ovarian cyst. Indeed, in one 
 case, recorded in the Transactions of the London Obstetrical Society, the opera- 
 tion for ovariotomy was actually begun under a misapprehension of this sort. 
 
 The great N61aton, mistaking a pelvic abscess for a pelvic hematocele, 
 punctured the tumor through the posterior wall of the vagina, and discharged 
 an immense quantity of pus instead of blood. 
 
 Since it is only the ignorant quack who (in his own estimation) is perfect in 
 diagnosis, the inference to be drawn from these and similar cases, of which there 
 is no lack, is, that it is impossible always to know and to discriminate between 
 the different kinds of pelvic tumors. By means of the aspirator, however, we 
 can usually arrive at a more correct diagnosis in most cases than the most dis- 
 tinguished physicians and surgeons could once do without it. — L. 
 
 There is one more reflection which concerns the etiology 
 and mechanism of pelvic hemorrhage in this particular case. 
 The formation of this hematocele was preceded by an arrest 
 of the menses for three months. Its onset came with the 
 return of the monthly epoch, but was not accompanied by 
 menorrhagia. How, therefore, shall we accept the opinion 
 of Bernutz, who holds that the blood, being retained in the 
 uterus through a mechanical obstacle to its natural outlet, 
 escapes through the Fallopian tubes into the peritoneal cavity? 
 
 This woman had reached her thirty-fourth year without 
 any serious derangement of the menstrual function. How 
 could it happen that, suddenly, without being pregnant, and 
 independently of uterine disease, there should be an insur- 
 mountable obstacle to the proper menstrual discharge, and that 
 this obstacle should first cause the blood to be retained in the 
 womb, and afterward produce the hematocele by its escape 
 through the tubes into the cavity of the peritoneum i 
 
PERI-UTERINE HEMATOCELE. 319 
 
 I do not hesitate to say that, in this case, the hemorrhage 
 occurred directly within the peritoneum, and that the hemato- 
 cele should be regarded as a deviation of the monthly dis- 
 charge. 
 
 The treatment of hematocele is included in three principal 
 indications, viz : (1) To limit and to overcome the serous in- 
 flammation ; (2) to favor the absorption of the effused blood, 
 and (3) to prevent a repetition of the hemorrhage. 
 
 The remedies indicated for the peritonitis are aconite and 
 colocynth. We reiterate what we have already said of them 
 in the treatment of pelvi-peritonitis. The indications are the 
 same, and we have nothing especial to add to what was said in 
 the last lecture. 
 
 Can the absorption of the effused blood be hastened by 
 remedies 2 We should not be too positive upon this point ; 
 for it is hard to say whether the diminution and disappearance 
 of an hematoma, which takes place naturally when it is not 
 interfered with, is hastened beyond a certain degree by the 
 administration of medicine. However, we advise the use of 
 arnica and belladonna, which appear to have favored the ab- 
 sorption of the effusion in case LVIII. 
 
 The whole attention of the physician should be given to 
 counteract the possibility of another hemorrhage, and to apply- 
 ing the best means for its prevention. The relapsing tendency 
 of the lesion shows itself with the return of the monthly cycle. 
 During this period, therefore, the woman should be subjected 
 to the most rigorous laws of hygiene. Absolute rest in the 
 horizontal position is the rule, and aconite may be given to 
 prevent the hemorrhagic congestion. Twenty drops of the 
 tincture should be given in this case during twenty-four hours. 
 
320 THE MEDICAL CLINIC. 
 
 Digitalis is also indicated on account of its anti-hemor- 
 rliagic properties, and especially because of its action upon the 
 uterus ; but I do not know the signs which would lead you to 
 prefer it to aconite. 
 
 At the moment of the hemorrhage arnica is the principal 
 remedy ; but hamamelis, thlaspi bursa pastoris, secale cornutum 
 and other remedies for metrorrhagia may be indicated. At 
 this period, also, the local application of ice to the lower abdo- 
 men is sometimes of great service. 
 
 We must insist upon what we haye already said of terebinthina as a remedy 
 for pelvi-peritonitis.* As an anti-hemorrhagic remedy, which is especially 
 adapted to inflammation of the serous membrane about and within the pelvis , 
 and to the peri- enteritis of the large intestine, it is better suited than any other 
 to the conditions that are found in pelvic hematocele. Its power to relieve the 
 peculiar pain and the extreme suffering that are incident to this disease, to 
 abort the suppurative process in serous membranes, and to tide the patient over 
 the whole difficulty, is very remarkable. It is especially appropriate to cases in 
 which, from an alteration of its quality, the blood is likely to exude or to exhale 
 into a serous cavity; cases of vicarious or deviated menstruation, which cause 
 the effusion within the peritoneum, and to cases that are septic or typhoid in 
 their character. — L. 
 
 If the blood-cyst is distended by a fresh hemorrhage, and 
 the violence of the pain causes you to fear a rupture thereof, 
 Nelaton advises to puncture it. This operation should be 
 made from the vagina. This, indeed, is the only case in which 
 you would have a warrant to interfere surgically, for otherwise 
 the puncture is usually followed by violent inflammation of 
 the cyst and the death of the patient. 
 
 In our day the hematic cyst can be tapped with the aspirator much more 
 safely than was possible with the old-fashioned trocar. But still the operation 
 is not devoid of danger, and is strongly contra-indicated in certain conditions. 
 Thus it would not be safe or expedient while the effused blood continues in a 
 fluid state, without being encysted, nor while the size of the tumor continues 
 gradually to diminish and the patient's condition to improve, nor if the source- 
 of the hemorrhage, being catamenial and dysmenorrhceal or obstructive, still, 
 remains to reproduce the difficulty. Most authorities have regarded it as an. 
 "extreme resource." 
 
 * See Treatment of Pelvi-peritonitis, page 293. 
 
PERI-UTERINE HEMATOCELE. 321 
 
 But if the tumor has existed for a long time, and shows little or no disposi- 
 tion to be absorbed and to disappear; if the original cause of the hemorrhage in 
 such cases is no longer in operation; if there is a very large accumulation, which 
 is not too recent, but which causes great pain and pressure, with forcing pains 
 like those of labor; if there are rigors and signs of suppurative fever; if the 
 symptoms are those of septic infection, or typhoid in character, with a hyper- 
 thermic condition, there should be no delay in evacuating the tumor. I am 
 opposed to putting it off very long, for when properly used it gives great relief 
 and expedites the cure. 
 
 Some authorities, remembering that Nature most frequently discharges 
 these tumors through the rectum when they are not interfered with, insist that 
 they should be tapped from the rectal side. But this is not important. We 
 select the most dependent part of the pouch, and discharge it with a large -sized 
 aspirator needle. 
 
 Dr. Meadows says that: "In performing the operation of tapping we should 
 be careful to thrust the trocar in far enough; in two of my cases the first tap- 
 ping proved abortive, and I have no doubt that the reason of it was that I did 
 not puncture deep enough. It is probable that some coagulation of the effused 
 blood takes place circumferentially ; this coagulated layer may in some places 
 be very thick, and we must make allowance for that. At any rate, if it be a 
 case fit for tapping, we need not be afraid of going pretty deep, and we ought 
 certainly to push on until fluid is reached."— L. 
 
 Finally, if the hematocele becomes the seat of the inflam- 
 matory process, we should by all possible means limit that 
 inflammation. Aconite, colocynth, cantharis, will be indicated 
 as they were in the onset. Collodion and sometimes ice are 
 very useful in arresting the violent and persistent symptoms. 
 In this way the inflammation may safely pass to ulceration of 
 the cyst at its inferior portion and its opening into the vagina 
 or the rectum, with the result of a complete cure of the 
 disease, as you have witnessed in Case LX. 
 
 There is a great dearth of well- authenticated cases of this disease in our 
 literature. We insert the following communication, therefore, from our friend 
 and fellow gynecologist, Dr. T. G-. Comstock, of St. Louis, with a great deal of 
 pleasure, more especially because he is a truthful witness, and the case has never 
 before been in type. — L. 
 
 Case. — In July, 1878, Mrs. S , a patient of Dr. Bah- 
 
 renburg, was taken quite suddenly ill with slight hemorrhages 
 and bearing-down pains, accompanied with tenderness in the 
 pelvic region, loss of appetite, with faintness, exhaustion, and 
 also more or less difficulty at times in passing water. Such 
 21 
 
322 THE MEDICAL CLINIC. 
 
 were her subjective symptoms for some days previous to my 
 being called in consultation. This was during the excessive 
 hot weather in St. Louis, a period that is never to be forgotten. 
 
 When I first saw the lady, after conversing with her, and 
 before making any physical examination, it occurred to me that 
 she had symptoms of peritonitis. Dr. B. had suggested to me 
 that he thought she was suffering from retroversion. I found 
 the patient quite anxious, with a pulse at 98 and a temperature 
 of 101°, and upon a digital examination, the cervix uteri directed 
 anteriorly, and behind it a swelling in the retro-uterine space. 
 This swelling, which was sensitive, and though prominent was 
 rather flattened yet seemingly fluctuating, made me at once 
 suspicious of the existence of an hematocele. The patient was 
 the mother of several children, and her attack followed a men- 
 strual period. 
 
 I advised perfect rest and quietude, vaginal injections of 
 warm water, aconite to be given internally, and, at bed- time, 
 McMunn's elixir of opium. 
 
 The patient's condition remained much the same for several 
 days, and by repeated vaginal examinations I found that the 
 tumor was increasing, and that my opinion as to the diagnosis 
 was being confirmed. 
 
 At the expiration of eight days, as the patient seemed suf- 
 fering much with wandering and bearing-down pains, and feel- 
 ing as if "she must pass something from the vagina," I ad- 
 vised instrumental interference, in order to evacuate the con- 
 tents of the swelling. Dr. Walker was called in consultation, 
 who agreed with me as to the existence of the swelling, but, 
 with Dr. Bahrenburg, was disposed to regard it as containing 
 pus, or, in other words, they thought that it was a pelvic ab- 
 scess. This opinion was based upon the fact that the lady had 
 complained at times of slight rigors, followed by an elevation 
 of temperature, as indicated by the thermometer. Dr. Walker, 
 however, advised the evacuation of the tumor. 
 
 With the assistance, therefore, of Drs. Walker and Bahren- 
 burg, I proceeded to make the operation. Placing the patient 
 upon her left side, with the knees drawn up to the abdomen, I 
 introduced the perineal retractor of Simon (an instrument some- 
 thing like Sim's speculum), and drawing back the perineum, 
 
PERI-ITTERINE HEMATOCELE. 323 
 
 so as to expose the most depending point of the swelling 
 in the posterior wall of the vagina, then placing the sharp point 
 of the cannla of Dieulafoy's aspirator first in a solution of 
 carbolic acid, I carefully punctured the swelling, introducing 
 the canula into the Douglas cul-de-sac, where the fluid was col- 
 lected. Immediately the air-pump of the aspirator was filled 
 with blood. At this operation I drew off some fi.ve ounces of 
 blood, and completed the operation by injecting a few drops 
 of a weak solution of carbolic acid into the sac. 
 
 The patient bore the operation well, ■ and after being re- 
 placed in bed expressed herself as feeling greatly relieved. 
 
 About six days after the first operation, I visited her, and, 
 finding the swelling again prominent, I operated a second time, 
 and drew off several ounces of blood, the last ounce being per- 
 haps not so red as at first, but having more or less lymph 
 mixed with it. 
 
 The patient made a slow convalescence, but did not ma- 
 terially suffer after the last operation. Some ten days after- 
 ward she had a discharge from the rectum of pus that was 
 slightly sanguineous, as if from the evacuation of an abscess. 
 This continued to flow for several days, and she finally made a 
 perfect recovery. 
 
 The writer's experience includes six cases of hematocele, 
 and all of them have opened spontaneously either into the 
 vagina or the rectum. One case was after labor at term. All 
 of these cases recovered, but usually it was after great suffer- 
 ing. In all of the six cases the patients were strong and 
 healthy subjects. 
 
 I should advise, generally, in such cases, the expectant 
 method of treatment. In the case above mentioned operative 
 interference was resorted to simply to relieve the great pains 
 of which the patient complained. — Comstock. 
 
LECTURE XXIII. 
 
 Summary. — Eczema: Definition. It is a symptomatic affection; eczema rubrum 
 (pseudo-exantheinatic); seat; scrofulous eczema, case; dartrous eczema, 
 case; arthritic eczema, case; treatment: Rhus toxicodendron and vemix; 
 pathogenesy and indications: cantharis, arsenicum; case; plumbago, meze- 
 reum, dulcamara, viola tricolor, sepia, sulphur, mineral waters. External 
 treatment. 
 
 Eczema. 
 
 Gentlemen : Eczema is a cutaneous affection characterized 
 by the eruption of vesicles or vesico-pustules, sometimes by the 
 formation of fissures, by the exudation of a serous, sero-puru- 
 lent or viscous liquid, and by the formation of crusts. 
 
 Not excepting hysteria, there is no disease which has been so variously de- 
 fined as this. In a prize essay on Eczema, its Pathology and Homoeopathic 
 Treatment, by H. C. Jessen, M.D., there is a quotation of definitions from 
 twelve distinguished authors and specialists, no two of which definitions are 
 alike. Dr. Jousset defines it as being invariably a moist eruption; but Dr. Jes- 
 sen believes that it also may appear as a dry eruption, where the formation of 
 vesicles and the exudation of serum are so slight that there is no sensible moist- 
 ure, but only an exfoliation of scales instead of the formation of crusts. This 
 latter view agrees with our own observation and experience. — L. 
 
 This affection is always accompanied by itching, and by 
 a burning sensation, from which it derives its name. 
 
 When we say that eczema is an affection, we declare that 
 it is always symptomatic, and that one should always search 
 for the disease with which it is associated. 
 
 We take especial pleasure in commending what the author has said of the 
 constitutional origin of eczema; for in our day there is a strong tendency to 
 regard it as a purely local affection. Perhaps this bias comes from a misappli- 
 cation of Rindfleisch's remark that eczema is an analogue of catarrh of the 
 mucous membranes. (He did not say, as some of our writers have made him 
 say, that it was a real catarrh of the skin.) 
 
 But, nevertheless, in our judgment, Dr. Jousset's statement needs some 
 
ECZEMA. 325 
 
 qualification. For while, as a rule, eczema depends upon constitutional causes, 
 and is, therefore, a sympathetic affection, it certainly may arise from local irri- 
 tants. Hebra has shown that the topical application of croton oil will always 
 produce a genuine typical eczema. — L. 
 
 We are pleased that M. Bazin has followed the precepts of 
 our school in trying to recognize the peculiar character of each 
 of the varieties of eczema, and of their relation to a definite dis- 
 ease. And, if dazzled by the eclat of symptomatology, which 
 holds that every symptom should carry the imprint and stamp 
 of the disease to which it belongs, M. Bazin is sometimes too 
 hasty in his conclusions upon so difficult a subject ; if some of 
 his distinctions are not really tenable, he should console him- 
 self by thinking that he has undoubtedly restored certain ques- 
 tions in dermatology to their proper ground, and that what he 
 has not completed will certainly be achieved by his successors. 
 He has built upon the solid ground of essentials in disease ; 
 and while his work may be improved it cannot be overthrown. 
 
 We admit with M. Bazin that eczema may show itself in 
 three different diseases, viz : in dartrous affections, gout and 
 scrofula ; and we add that this affection can also be caused by 
 poisons or by medicines. Rhus toxicodendron, rhus vernix, 
 mercury, arsenic, croton oil, and cantharides, are veritable ecze- 
 matogenes, and they really are the best remedies for this affec- 
 tion. In connection with the treatment we shall see that there 
 is one eczema of sumac, another of cantharides, another of mer- 
 cury, and another of arsenic ; but as these differences have an 
 especial relation to therapeutics, we shall not insist upon them 
 for the present. 
 
 In very exceptional cases, — and it is a fact which is almost never mentioned 
 by dermatologists, — eczema is associated with diabetes mellitus. We recently 
 reported a case of the kind to the Clinical Society of the Hahnemann Hospital 
 (see the U. S. Medical Investigator for March 15, 1879, or the North American 
 Journal of Homeopathy for May, 1879). The case was that of a woman aged 
 forty-three. The eruption, which spread over the genitals and the nates, would 
 almost disappear and then break out again without apparent cause. There was 
 no incontinence of urine, and no vaginitis. The patient was of a very cleanly 
 
326 THE MEDICAL CLINIC. 
 
 habit. She was also a victim to the most intractable neuralgia. The urine 
 contained a considerable quantity of sugar. 
 
 In this connection, also, the following extract from Hebra is worthy of re- 
 membrance (Lehrbuch der Hautkrankheiten Von F. Hebra und M. Kaposi, 
 1874, Band 1, page 28): "In the diagnosis of skin diseases in women we must 
 never forget to examine the genital functions; and we must not be satisfied with 
 mere superficial questions, but the examination must be thorough, manual and 
 even instrumental, if necessary; for the uterus and ovaries in women, like the 
 stomach, liver and kidneys in both sexes, often prove to be affected simulta- 
 neously with the skin; and from a thorough investigation of these organs only, 
 in many cases, is it possible to make a correct diagnosis of an affection of the 
 skin.' 1 
 
 In Dr. Fr^dault's work, Des Hemorrhoides, Paris, 1868, page 155, the 
 author says: "A large number of cases of very serious eczema of the face that 
 I have seen have been associated with hemorrhoids. Some writers cited by 
 Montegre had recognized this relation long ago.' 1 — L. 
 
 In all the varieties of eczema there is a first period of in- 
 flammation and a period of desiccation. From the beginning 
 there is an eruption of vesicles upon a red base which is more 
 or less swollen. These vesicles consist in a lifting of the epi- 
 dermis, and contain, at least for the first few days, a serum 
 which afterward becomes more or less purulent. The vesicles 
 are more or less pointed, more or less numerous, and coales- 
 cent. They break spontaneously, and the affection becomes 
 humid. At this time the surface resembles the wound pro- 
 duced by a blister. The liquid, which varies with the different 
 kinds of eczema, dries, and forms crusts that are always moist 
 and yellowish, and which vary in thickness. 
 
 In the second stage the vesicles, or vesico-pustules, cease to 
 form ; the surface dries, and the eczema resembles either 
 psoriasis or pityriasis. The skin is then covered with dry, 
 scaly crusts, leaving, when they fall, a surface that is dry, 
 smooth and reddish, and which looks as if it had been var- 
 nished. The desquamation becomes less and less abundant, 
 the skin becomes pale and assumes its normal state, but for a 
 long time a brownish tint persists as the last vestige of the 
 disease. 
 
ECZEMA. 327 
 
 The eczema in its first stage (inflammatory eczema) is de- 
 nominated eczema rubrurn. There are some varieties in which 
 the eczema is so widespread and diffused that it resembles 
 erysipelas ; this is the pseudo-exanthematic eczema. The febrile 
 action is more or less intense, and Hardy reports a case that 
 terminated fatally. 
 
 Eczema im-petiginoides is that form in which, little by lit- 
 tle, the vesicles are replaced by pustules. For that matter, 
 Hardy considers impetigo as a form of eczema. 
 
 The eczema fissurum is that variety in which the vesicles 
 are replaced by fissures and cracks in the epidermis. 
 
 Finally, we also distinguish the disease according to its 
 seat or location, as an eczema of the face, of the hairy parts, 
 of the ears, of the extremities, of the breasts, and of the geni- 
 tal organs. 
 
 Scrofulous eczema is the variety which is the most charac- 
 teristic of all that have been admitted by Bazin. 
 
 It is almost always of the impetiginous form, and is dis- 
 tinguished from other kinds by the presence of pustules of 
 an abundant secretion, and by humid, thick, yellow crusts. 
 
 Here we have, according to Bazin, the common character 
 of scrofulous herpes, a peculiarity which exists in the highest 
 degree in eczema, id est, u the tenacity, the persistence in the 
 same place ; the regular order which they (the vesicles) follow 
 in their propagation, extending themselves generally from 
 the head and superior parts of the body to the inferior parts ; 
 their prompt distribution upon different portions of the body ; 
 the mode of development of the inflammatory process, which 
 is essentially secretory and suppurative ; the participation of 
 the glands and follicles, and often also of the subcutaneous 
 cellular tissue in this inflammatory process ; the implication 
 
328 THE MEDICAL CLINIC. 
 
 of the lymphatic glands in the neighborhood ; the absence 
 of pain and of itching, at least of the violent and constant 
 pruritus, which is increased by the warmth of the bed, and 
 which often causes the patient to tear the skin with his finger- 
 nails ; and finally the marks which they leave after them." 
 {Lectures upon Scrofula, page 176.) 
 
 To resume : the decided moisture of the eruption, a pruritus 
 which is relatively slight, and especially the swelling of the 
 lymphatic glands, constitute the chief characteristics of scrofu- 
 lous eczema. 
 
 The dartrous eczema and arthritic eczema are much more 
 difficult to distinguish from each other. The characteristic 
 symptoms given by M. Bazin, of which we shall speak di- 
 rectly, have been very seriously criticised by certain renowned 
 dermatologists, nevertheless we give the peculiarities assigned 
 by M. Bazin to these two varieties of eczema. 
 
 Dartrous eczema, which Bazin calls herpetic, presents for 
 its proper symptom certain anatomical features which are more 
 distinct than with the other kinds ; that is to say, in this vari- 
 ety only the elementary lesion is characterized by a vesicle 
 upon an inflamed base. Besides, this form of eczema is 
 usually symmetrical. But we should not accept this last 
 symptom in its literal sense ; for when eczema shows itself 
 upon both ears, or upon both feet, for example, it is almost 
 always more fully developed upon one side than upon the 
 other. I will add that we have also observed cases of eczema 
 in which the eruption was located upon the ears, and in which 
 the lesion was perfectly symmetrical, in gouty and scrofulous 
 subjects. The third peculiarity of the dartrous eczema, and 
 one that is more marked than the symmetry of the eruption, 
 is the character of the liquid discharge. At a certain stage, 
 dartrous eczema is characterized by a serous exudation that 
 
ECZEMA. 329 
 
 is extremely abundant. This exudation stains the linen of a 
 grayish tint, and stiffens it in a manner that is quite peculiar. 
 This peculiarity of the discharge is not, however, constant, 
 for it pertains only to one stage of the disease ; but while it 
 does exist, it has a real diagnostic value. 
 
 The dartrous eczema causes the most atrocious itching of 
 all the varieties of this affection. It has also a tendency to 
 relapse and to become general. 
 
 Here is a case of dartrous eczema : 
 
 Case LXI. — Miss V , aged thirteen and a half years. 
 
 The mother of this young girl is scrofulous. Her maternal 
 aunt is herpetic and asthmatic. This patient, who has not yet 
 menstruated, has enjoyed very good health until now. She is 
 well developed, and shows no signs of scrofula. 
 
 The eczema, which is seated upon the dorsal surface of the 
 great toes of both feet and in the spaces between them, began a 
 month ago with itching and a decided redness of the skin. The 
 eruption consisted of vesicles located upon a red and inflamed 
 base. It yielded an effusion of a grayish-white fluid, which 
 stiffened the linen, and there are a few thin crusts which are 
 brownish, and which consequently contain a little blood. 
 
 The pruritus is continual and severe ; the affection is most 
 marked on the left foot ; upon the right foot it continues to 
 be imperfectly developed ; it occupies exactly the same loca- 
 tion on both feet. The fold of the groin shows no signs of 
 glandular swelling. 
 
 This patient took cantkaris, 12th dil., four globules in 100 
 grammes of water, four times a day. The external treatment 
 for the first few days consisted of the application of starch 
 poultices (cataplasmes defecule). 
 
 She improved rapidly under the influence of this treat- 
 ment. The eruption dried as the itching ceased. The dry 
 potato starch was applied instead of the poultices. 
 
 December 11. The disease has taken a new turn. The 
 patient complains of having had, last evening, a very severe 
 itching, while at the same time new vesicles have appeared at 
 the root of the great toe. Arsenicum, 12th dil., was substi- 
 tuted for cantharis, to be given in the same manner. 
 
330 THE MEDICAL CLINIC. 
 
 December 14. The arsenicum having had no effect, can- 
 tkaris, 6th dil., was given, and the poultices were reapplied. 
 
 December 18. The vesicles on the dorsal surface of the 
 toes have disappeared, and the crusts on the plantar surface of 
 the toes are not so thick as they were. The exudation has di- 
 minished ; the itching is not so severe. Cantharis, 6th dil. , 
 two drops each day. 
 
 December 20. The itching has returned and is much worse 
 than before. The same medicine was continued, and the foot 
 is to be enveloped with gummed silk. 
 
 December 24. There is much less inflammation ; the base, 
 upon which there are still some vesicles, is not so red as be- 
 fore, but there is quite an abundant effusion of serum. Can- 
 tharis, 6th dil. 
 
 December 27. There is a great improvement ; the crusts 
 are falling, and the exudation is diminishing. The same medi- 
 cine was continued until she left the hospital. 
 
 The arthritic eczema is distinguished from the preceding 
 by the lack of distinctness in its physical signs, and by its 
 being less regular in its' course. There are papules which are 
 mixed with vesicles ; the patch is usually rounded in outline, 
 not symmetrical ; it rests upon a violet-colored base, and is ac- 
 companied by a varicose condition of the skin. Arthritic 
 eczema is much more dry than the other kinds of eczema ; 
 it is very persistent, and it never becomes general like the 
 herpetic eczema. When it disappears, it is often replaced 
 by another gouty affection, as, for example, of the heart, of 
 the great vessels, of the stomach, etc.; and, finally, it some- 
 times leaves cicatrices, a thing which does not often happen 
 as a sequel to the other varieties of eczema. 
 
 Now, gentlemen, these distinctions, which are not always 
 found in practice, are more easy to make in a book than at the 
 bedside of the sick; and I do not hesitate to say that the 
 cleverest physicians are sometimes very much puzzled when 
 they are compelled to make a differential diagnosis between 
 the dartrous and the gouty eczema. 
 
ECZEMA. 331 
 
 Of the symptoms given by Bazin, not one of them is abso- 
 lute. Thus, in gouty subjects we have a symmetrical eczema. 
 Moreover, the violet base and the varicose condition of the 
 skin are observed especially in the eczema of the inferior ex- 
 tremities, and they are more frequently the sign of a variety of 
 the location of the disease than of a nosological difference. 
 
 These difficulties, which we are the first to recognize in the 
 distinction of the dartrous from the gouty eczema, cannot bring 
 us to the legitimate conclusion that such a distinction has no 
 real practical existence. Much less can we confound gout and 
 herpes under the name of uriccemia (Gigot-Suard de V Herjpe- 
 tisme, p. 170). But if the signs of the eruption are not always 
 sufficient to establish the differential diagnosis between gouty 
 and dartrous eczema, the totality of the symptoms presented 
 by the patient will always decide which we have to deal with ; 
 and this is quite as important a point for the prognosis as it is 
 for the treatment. 
 
 Case LXII. — Madame Vovet, aged fifty-eight years, was 
 admitted on the 2d of December, and left the hospital on the 
 28th of February. She occupied bed JSTo. 1 of ward 1. 
 
 This woman presented all the signs of the gouty constitu- 
 tion. Twelve years ago she began to have pains in the finger- 
 joints. These pains returned, and were dull and lancinating 
 nearly all the day, and were accompanied with slight swelling. 
 From that time the fingers became deformed. The deformity 
 is now very marked, and* the fingers cannot be extended with- 
 out difficulty. 
 
 The knees have also been the seat of pains, but they were 
 much less intense in degree. The joints are not deformed, 
 neither are there any concretions upon them. This woman is 
 also subject to hemorrhoids, and to varicose veins of both legs. 
 
 For ten years she has had a great deal of itching in the 
 region of the neck and of the arms. This itching is always 
 accompanied by a redness of the skin, but without any erup- 
 tion. The pruritus was not constant ; it . lasted eight days, 
 
332 THE MEDICAL CLINIC. 
 
 disappeared, and then came again. The temperature of the 
 weather had no effect upon its return. 
 
 She has had the eczema upon both legs, for which she 
 entered the hospital, for a year. When it began, the skin be- 
 came red, principally on the internal surface of the legs. At 
 that time some vesicles appeared, but there was no exudation. 
 
 The eruption is seated upon the anterior surface of the two 
 limbs, and principally the right one, occupying the middle two- 
 thirds of the member ; the surface is red and violet-colored ; 
 the exudation is slight, and forms into pretty thick yellowish 
 crusts. The whole extremity is the seat of itching and of burn- 
 ing pains. 
 
 December 2. Plvmbago, 3d trit., twenty centigrammes in 
 200 grammes of water, four tablespoonfuls daily. Poultices of 
 starch to be applied externally. 
 
 December 4. The crusts have fallen and exposed a dark- 
 red surface, very wet, and surrounded with dilated veins. 
 The same treatment. 
 
 December 13. The itching is excessively severe. Some of 
 the vesicles have broken, and left little red and ulcerated 
 patches. The exudation is slight. Arsenicum, 3d trit., twenty 
 centigrammes during the day, and the starch cataplasm. 
 
 December IT. The patient complains of a burning sensa- 
 tion, especially in the left leg. Arsenicum,, 2d trit., twenty 
 centigrammes. 
 
 December 21. The vesicles have completely disappeared. 
 There remains a large red and brilliant surface, with here and 
 there some small ulcerations that give rise to an insufferable 
 itching. Arsenicum, 2d trit., twenty centigrammes. The limb 
 to be enveloped with gummed silk. , 
 
 December 29. The redness of the skin has considerably 
 diminished, but the itching persists. 
 
 January 1. The limb is enveloped in rubber-cloth, and the 
 same medicine is to be continued. 
 
 January 6. The condition of the leg is better. There is 
 little pain ; some crusts are forming, and the exudation con- 
 tinues. Plumb, euro])., 3d dii.* 
 
 * This remedy, the plumbago europeans, or leadroot, is not to be found in 
 most of our works on the Materia Medica. Dr. Jessen says that it grows in the 
 
ECZEMA. 333 
 
 January 12. Continue the same remedy. To stop the itch- 
 ing, the limb was bathed with the following solution : plumb, 
 europ., one gramme; water, fifty grammes; glycerine, fifty 
 grammes. 
 
 January 14. ~No improvement. The crusts are quite as 
 numerous. The itching is still worse. Rhus vernix in the 
 mother tincture, ten drops during the day, and the rubber-cloth 
 to be kept upon the leg. 
 
 January 18. The redness of the leg is much less marked ; 
 the crusts begin to fall, leaving a reddish, brilliant surface ; the 
 itching has diminished. The same remedy. 
 
 January 23. The improvement continues. There is almost 
 no exudation. Same medicine. 
 
 February 2. The itching is less severe. The leg presents 
 only some red points, which are not the seat of any exudation. 
 The same medicine. 
 
 February 6. /Sepia, 1st trit., twenty centigrammes. 
 
 February 13. There is a slight extension of the inflamma- 
 tion upon the external surface of the leg. The same medicine 
 was continued, and a local application, consisting of the follow- 
 ing solution, was ordered : glycerine, 100 grammes ; alcohol, 
 twenty-five grammes; sepia, 1st trit., one gramme. 
 
 February 20. The inflammation has almost entirely dis- 
 appeared. At certain points the skin has resumed its normal 
 color. The same treatment, including the rubber-cloth about 
 the limb, was continued. 
 
 February 25. The skin has recovered its elasticity and its 
 usual color ; it is still the seat of a very slight itching. The 
 same medicine was taken up to the day of her discharge. 
 
 Treatment. — M. Bazin, who understands homoeopathy, and 
 who believes that the nature and species of the disease should 
 serve as the principal basis for the choice of the remedy, 
 
 southern part of Europe and in South America. The fresh root is acrid and 
 vesicatory. It stimulates the secretion of the salivary fluids, and is a popular 
 remedy for the toothache. In large doses it is poisonous, causing symptoms 
 that resemble cholera, hemoptysis, etc. Lebrech and Wittman have given it in 
 very small doses in hemoptysis with benefit. It is a remedy that deserves to be 
 studied, and we only wish that the author of these lectures had said more about 
 it— L. 
 
334 THE MEDICAL CLINIC. 
 
 teaches that there is one kind of treatment that is proper for 
 herpetic eczema, another for the arthritic, and a third for the 
 scrofulous variety. We are far from believing that the thera- 
 peutics of eczema is so simple a matter, and think that here, 
 as in all other therapeutic questions, physicians should be 
 guided in the choice of a remedy by the totality of the symp- 
 toms presented by the patient. 
 
 We have seen that a large number of medicines have the 
 power to produce a true eczema upon the skin. It is by the 
 use of these substances that we shall establish the treatment 
 of this affection. 
 
 Rhus toxicodendron is one of the substances which pro- 
 duces in the healthy person the most exact symptoms of 
 eczema. "The result of the absorption of emanations from 
 the sumac takes place in a few hours, and sometimes only after 
 several days. It consists in itching, swelling, redness, pains 
 and pustules more or less vesicular upon the region which has 
 been in contact with the vegetable particles, and even upon 
 those parts in which there has been no contact, as upon the 
 face, the scrotum, the eyelids, etc. The observations of Fon- 
 tana, Gonon, Amouroux, Yan Mons, and the experiments of 
 Orfila, tend to prove that the most active principle of the rhus 
 toxicodendron is that which is disengaged in the form of gas, 
 when it does not receive the direct rays of the sun." (Cazin, 
 Des Plantes medieinales indigenes, pp. 1033 et 1034.) 
 
 It is easy to find in the description of this independent 
 author, who is not suspected of being a homceopathist, quite 
 a faithful image of eczema in its inflammatory stage. 
 
 u The celebrated Fontana reports having touched at three 
 different times, with an interval of several days, some leaves 
 of the toxicodendron, from which he experienced certain 
 troublesome symptoms. Four or five days later, the eyelids, 
 the tips of the ears, and the face generally, became swollen, 
 
ECZEMA. 335 
 
 and appeared as if filled with a watery fluid. The spaces which 
 separate the fingers became red, and covered with little vesicles 
 that were filled with a transparent humor; the epidermis fell 
 in little scales, and there was a terrible smarting for fifteen 
 days, with an insufferable itching, which continued fifteen days 
 more; the pulse was very much excited." (Orfila, Toxicologie, 
 page 133.) 
 
 Lavini, twenty-five days after the application of two drops 
 of the juice of the rhus toxicodendron on^ the first phalanx of 
 the finger, had the following symtoms : ' 'A great heat in the 
 mouth and in the fauces ; rapidly increasing swelling of the 
 left jaw, of the upper lip, and of the eyelids, the following night ; 
 great swelling of the forearms, which increased to double 
 their natural size ; skin leathery, with insufferable pruritus and 
 great heat. Four days after there appeared upon the hands, 
 and especially upon the forearm, some pustules very much like 
 those of the itch / some of these pustules in breaking exuded 
 a limpid humor, which by inoculation upon the forearm re- 
 produced other pustules." (Loc. cit., page 133.) 
 
 Now, these "pustules," which are so similar to those of 
 the itch, and from which a limpid humor escapes, are true 
 vesicles. 
 
 The rhus toxicodendron is, then, the homoeopathic remedy 
 par excellence for the eczema rubrum ; and the more nearly this 
 disease resembles erysipelas the better will be the indica- 
 tion for the rhus toxicodendron. 
 
 The vesicular eruption upon a red patch, with internal 
 pruritus followed by pains in the thighs after the patient 
 has scratched them, is the marked indication for the rhus 
 toxicodendron, whether the eczema be dartrous or gouty. 
 Agitation and a febrile state strengthen this indication. 
 
336 THE MEDICAL CLINIC. 
 
 The rhus radicans, which, according to Bosc, is only the 
 rhus toxicodendron of an older growth, and the rhus vernix, 
 have the same properties as the rhus toxicodendron. Dr. 
 Cretin has contributed very decidedly to popularize the use 
 of the rhus vernix in the treatment of eczema. He pre- 
 scribes it in the mother tincture, in the dose of twenty drops 
 during the day. 
 
 Cantharis, which, according to Dr. Richard Hughes, can 
 produce pustules upon the skin by its dynamic action only, 
 is a remedy that is very analogous to rhus. I always use 
 it in the dartrous eczema during the inflammatory stage, 
 and I have made numerous cures with it. I have prescribed 
 this remedy in from the sixth to the twelfth dilution. 
 
 Arsenicum is also a remedy for eczema, as we learn from 
 the following passage taken from Hahnemann: " Whitish, 
 pointed pimples, containing a watery liquid at their summit, 
 which come on with decided itching like the stinging of a 
 gnat, on the hands, between the fingers, upon the lower 
 abdomen ; scratching causes the liquid to escape and the 
 itching to cease." (Symptom 1046.) Burning, itching, and 
 desquamation, are the other symptoms noted by Hahnemann. 
 Imbert-Grourbeyre has published a monograph upon the ar- 
 senical eruptions, which I recommend you to consult, and 
 which demonstrates the power of arsenic to cause eczema. 
 
 As for the effects of this medicine in eczema, we have 
 only to refer to the practice of the old-school physicians 
 everywhere to be assured that arsenic and arsenical waters 
 are considered by them as a kind of specific for this disease. 
 
 The indications that lead us to prefer arsenicum to other 
 remedies for eczema, are : its chronic nature, its period of 
 dry desquamation, and the burning pruritus. It is, therefore, 
 a remedy which we give after the rhus or cantharis. 
 
ECZEMA. 337 
 
 Here is a case of arthritic eczema taken from my private 
 case-book, in which arsenicum finished the cure which was 
 begun by the cantharis and rhus vernix : 
 
 Case LXIII. — M. F , a man of forty-eight years, of a 
 
 very robust constitution, was seized within two years with a 
 symmetrical eczema of both the ears. M. Bazin had diagnos- 
 ticated the case as arthritic eczema, because the patient had 
 been subject to headache and to hemorrhoids. The alkaline 
 treatment did no good ; a season at Royat produced an aggra- 
 vation, and the patient consulted me on the 17th of October, 
 1873. 
 
 Both the ears were attacked, the right one more than the 
 left ; they are thick, very red, stiff and very humid ; they re- 
 semble the surface of a blister. I prescribed cantharis, 12th 
 dil., six globules in 200 grammes of water, two spoonfuls 
 daily ; and for the protection of the excoriated surfaces a lini- 
 ment composed of ten grammes of water, one of glycerine 
 and two drops of the tincture of cantharis. 
 
 October 25. He is a little better, but he made such com- 
 plaint of the liniment that it has not been used except at long 
 intervals. I prescribed powdered starch for the excoriated sur- 
 faces. Cantharis, 6th dil. , two drops in 200 grammes of water, 
 two spoonfuls daily. 
 
 November 4. The patient does not get on very well. Stop 
 the liniment entirely, and give mezereum, 2d dil., twenty centi- 
 grammes in 200 grammes of water, two spoonfuls daily. 
 
 November 13. The mezereum has not succeeded. Re- 
 sumed cantharis, 12th dil. and 30th dil., which was continued 
 until January, 1874. The patient improved decidedly. The 
 surface is dry, but the ears are thick and stiff. Arsenicum, 
 12th dil., to be taken as the cantharis. Arsenicum, 6th dil., 
 and afterward in the 3d trit., was continued until the 16th of 
 February, when, because the acute stage returned, cantharis, 
 12th dil. and 6th dil. were given again. 
 
 April 8. The cantharis constantly improved the acute stage 
 of the disease, but without effecting a radical cure. I then pre- 
 scribed rhus vernix in the mother tincture, four drops daily; 
 sulphur, 12th dil., having been given without result. 
 22 
 
338 THE MEDICAL CLINIC. 
 
 The rhus vernix was continued all the summer, except dur- 
 ing an interval of a fortnight, when plumbago was tried, with- 
 out any benefit, and on the 15th of September the eczema pre- 
 sented no longer the fiery redness or the exudation, but had 
 become perfectly dry. I then returned to arsenicum, 1st trit., 
 twenty centigrammes in 200 grammes of water, two spoonfuls 
 daily. 
 
 October 14. He has taken the arsenicum for a month, and 
 is very much improved. Wishing to hasten the cure a little, I 
 ordered thirty, instead of twenty, centigrammes of the first trit- 
 uration. The patient experienced nausea, diarrhoea, thirst, and 
 burning pains in the stomach, and I suspended the remedy. 
 
 October 28. Arsenicum, 30th dil., at intervals, until Janu- 
 ary, 1875, when the affection seemed to be cured. 
 
 During the winter the eczema returned, but in a very slight 
 form. Arsenic, 1st trit., in the dose of five centigrammes, suf- 
 ficed to arrest it. This man remained entirely well during the 
 summer of 1875 and the winter of 1876. 
 
 In the monograph to which we have already referred, our neighbor, Dr. H. 
 C. Jessen, has compiled a curious and suggestive table, showing the comparative 
 frequency with which twenty of our most prominent writers on eczema have 
 prescribed each of the fifty remedies mentioned by them. Rhus tox. and arsen- 
 icum were advised by all; sulphur, by nineteen; mercurius sol., by seventeen; 
 graphites and sepia, by sixteen; dulcamara, calcarea carb. and clematis erecti, 
 by fifteen, and so on through the list. — L. 
 
 My friend, Dr. Fredault, has called the attention of the pro- 
 fession to the employment of plumbago in the treatment of 
 humid eczema, and that remedy has been somewhat suc- 
 cessful ; but the indications for it are not very definite. 
 
 According to Cazin, plumbago is a rubefacient and vesi- 
 cant of a decided character. When used for the itch, it some- 
 times causes general eruptions, and a young girl who had tried 
 it was, so to speak, skinned alive. 
 
 This brings us to speak of mezereum, dulcamara and viola 
 tricolor, which are especially indicated in the eczema impetigi- 
 noides, so common among scrofulous persons. The same is 
 also true of sepia. 
 
ECZEMA. 339 
 
 Mezereum, daphne mezereum, has been studied by Hahne- 
 mann, but it was traditionally used in the treatment of scrofula, 
 and its* external employment was, and still is, very common for 
 blistering purposes. According to Cazin, this is its effect upon 
 the skin : ' ' Its action is slow ; it produces rubefaction only at 
 the end of twenty-four hours, and vesication after forty-eight 
 hours. It causes an insupportable itching, sl papular eruption, 
 and an inflammation around the part upon which it is applied. 
 This wet exudation escaped twice daily, and abundantly, until 
 eight or ten double compresses were saturated. The secretion 
 is truly marvelous in its abundance. The surface which is at- 
 tacked swells and forms a great many little outlets for the 
 escape of the serum. One of the advantages of these issues is 
 that the skin returns to its natural state without leaving cica- 
 trices of any sort." (Cazin, loc. cit., page 370.) 
 
 Hahnemann speaks of a pruritus which is aggravated by 
 scratching and by taking off the clothes ; and also of an erup- 
 tion of pustules and of diffuse, itching pimples with desquama- 
 tion over the whole body. (Chronic Diseases, Yol. II, page 
 563.) 
 
 The extreme abundance of tl>e serous exudation caused by 
 mezereum is also an indication for this remedy in the acute 
 stage of the dartrous eczema. 
 
 Dulcamara. — Bertrand of Grenie, and Carrere of Gardes, 
 extol this plant in the treatment of eczema, and Cazin reports 
 the radical cure of a case of scrofulous eczema of the right leg 
 by the internal use of a strong decoction of the twigs of the 
 dulcamara. 
 
 This author cites only two symptoms as pathogenetic effects 
 of the dulcamara which are related to eczema, id est, a ting- 
 ling in different parts of the body, and sometimes a pruritus of 
 the genital organs (loc. cit., page 403). 
 
 In Hahnemann's Chronic Diseases we find principally the 
 
340 THE MEDICAL CLINIC. 
 
 symptoms of urticaria, with nightly aggravations ; but the fol- 
 lowing symptoms may be related to eczema : herpetic crusts 
 upon the whole body (356), exudative eruptions u]5on the 
 cheek (94) ; and Hahnemann notes expressly the herpetic erup- 
 tions with glandular swelling (page 198). Jahr copies Hahne- 
 mann, and adds: "Eruption of itching pustules, which pass on 
 to suppuration and become incrusted, especially upon the in- 
 ferior extremities, upon the posterior part of the body." 
 
 It is easy to recognize in these pathogenetic signs the pic- 
 ture of the impetiginous eczema, which is proper to scrofulous 
 subjects. In these cases we are accustomed to alternate the 
 dulcamara with the viola tricolor, and to employ them in 
 from the first to the third dilutions. 
 
 Viola tricolor. — This is also a traditional remedy against 
 scrofula, the eczema impetiginoides of scrofulous subjects, and 
 especially for that variety which is so frequently met with in 
 infants, commonly called milk-crust. Strack, of Mayence, 
 gave it in powder put into milk in cases of milk-crust. He 
 pretends that at the end of four days, when taken by healthy 
 persons, the face becomes covered with thick crusts. (Cazin, 
 page 809.) 
 
 Jahr gives, as pathogenetic symptoms, miliary eruption 
 all over the body, crusts upon the face, with burning itching, 
 especially at night, and the exudation of a viscous yellow pus, 
 with swelling of the glands of the neck. 
 
 Dr. Richard Hughes declares that he has never needed 
 any other remedy for milk-crust, and that he has given it 
 with success in the impetigo of adults. He uses the sixth 
 dilution in the first case, and the first decimal for the latter. 
 
 But I repeat that my principal remedy for the impetiginous 
 eczema of scrofulous persons is dulcamara. 
 
 Exceptionally this and other favorite remedies for milk-crust will fail, be- 
 cause of a slight syphilitic taint. In such cases we have had the best results 
 from mercurius jodatus in the third decimal trituration. — L. 
 
ECZEMA. 341 
 
 Case LXIV. — Eczema Impetiginoides. — Miss Mary G- , 
 
 aged sixteen, admitted on the 26th of December, 1875. This 
 young girl, who has not yet menstruated regularly, seems to 
 be endowed with a vigorous constitution, but she has a scrofu- 
 lous appearance. For four or five years past she has been sub- 
 ject to herpetic eruptions, which continue for a month or two, 
 disappear, and then return again at certain intervals. There 
 are no hereditary antecedents. Her father was accidentally 
 killed, and her mother is still living and in good health. 
 
 The affection of the skin, for which she is admitted into our 
 wards, began about two months ago. It is located upon both 
 sides of the head, upon the ears in the mastoid region, and ex- 
 tends for some distance upon the sides of the neck. There are 
 very few vesicles ; but the region occupied by the eczema is 
 covered with thick vellow crusts, beneath which the skin looks 
 as if it were injected. 
 
 The local symptoms are limited to a slight itching. The 
 neighboring glands are swollen, but not painful. 
 
 The general condition of the patient is good. The menses 
 have appeared for the first time, but they are not quite natural. 
 Plumbago europ., 3d dil., was prescribed. 
 
 December 27. ~No change in the local condition. Rhus 
 ■vemix, mother tincture, 10 drops during the day. 
 
 January 6. Rhus vemix, 12 drops. 
 
 January 14. The patient seems a little better. The crusts 
 are less numerous and not so thick. In a small part of the 
 region occupied by the eruption the skin has resumed its nat- 
 ural color. Rhus vemix, 15 drops during the day. 
 
 January 21. The improvement of the last few days does 
 not continue. The same remedy. 
 
 January 24. The rhus vernix having done no good, we 
 decided to give dulcamara, 3d dil., 2 drops each day. 
 
 February 1. There is a very decided improvement to-day. 
 The crusts, which had increased, are falling. The itching is 
 less acute. Dulcamara, 2d dil., as before. 
 
 February 5. The eruption is stationary. Viola tricolor, 3d 
 dil., two drops daily. 
 
 February 11. Dulcamara, 3d dil., was resumed. 
 
 February 17. Under the influence of the last remedy the 
 
342 THE MEDICAL CLINIC. 
 
 exudation upon the skin ceased ; the skin is more supple and 
 less dry. Dulcamara^ 2d dil. 
 
 February 20. The marked improvement, which commenced 
 some days ago, continues ; there is no longer a new formation 
 of crusts; the skin is less red and dry. Dulcamara, 1st dil., 
 two drops daily. 
 
 February 23. The itching, which has persisted until now, 
 has ceased ; the glandular swellings have disappeared. Dul- 
 camara, mother tincture, five drops during the day. 
 
 February 25. The same remedy. 
 
 February 28. The condition of the patient is very satis- 
 factory ; the skin recovers little by little its normal color and 
 elasticity. The same remedy. 
 
 The treatment by dulcamara having been changed for 
 another, the patient became worse. A month ago a new erup- 
 tion of the impetigo appeared, which has yielded to calcarea 
 carhonica in alternation with orpiment. The regular establish- 
 ment of the menses seems to have finished the cure of this case. 
 
 Sepia is a remedy that belongs exclusively to our homoeo- 
 pathic literature. Its pathogenesy yields the following symp- 
 toms : Pruritus, with vesicles upon a red base on all parts 
 of the body, — face, eyelids, hands, feet, axillce, the vulva, arms, 
 ears and hairy scalp. According to Dr. Cretin, sepia corre- 
 sponds especially to the crusts, and to eczema complicated 
 with lichen ; but my own clinical experience leads me to 
 conclude that it is particularly useful in scrofulous eczema. 
 
 Sulphur. — I very seldom prescribe this remedy in eczema 
 proper, but reserve it for prurigo and for those affections 
 which are apt to follow the suppression of an eruption. 
 
 Considering that the provings of natrum muriaticum are so rich in the 
 symptoms of eczema, it is a little odd that its use is not more general in the 
 treatment of this affection. One of the worst cases of eczema that we ever saw 
 was in a lad of fourteen years, who was brought to the meeting of the Illinois 
 Homoeopathic Medical Association, in May, 1865, by the late Dr. M. D. Coe. 
 Three years before the boy had contracted the habit of eating large quantities 
 of common table salt, and there was no doubt that in his case the eruption, 
 which was very extensive and severe, was due to this cause. I have seen two 
 other cases that were milder in degree, but which evidently had their root in 
 this same kind of a, pica or false appetite. — L. 
 
ECZEMA. 343 
 
 Shall I say something to you of the use of mineral waters 
 in this affection ? The practice of Bazin seems not to be 
 very successful, for I often see his patients who have taken 
 these waters upon his prescription but without any benefit. 
 Gigot-Suard has made some very thorough experiments with 
 a view to reach the especial indications for the Cauteret waters 
 in eczema, but I cannot detail them in a clinical lecture, nor 
 call your attention to a sufficient number of cases to make it 
 worth your while to study them. It is enough to know that 
 we may cure this disease without having recourse to mineral 
 waters. 
 
 One word, in closing, upon the external treatment of ec- 
 zema. Generally, I am entirely opposed to this treatment ; 
 and, after having tried for several years the practice of apply- 
 ing the same remedy locally that was being given internally, 
 I have come to renounce it altogether — not as being harmful, 
 but useless ; but while it is useless and sometimes dangerous 
 to treat eczema by topical applications, it also is sometimes 
 well to resort to such local measures as will soothe the inci- 
 dental suffering, although they are not curative. Baths of 
 starch water, and simple poultices, allay the inflammation in 
 the acute stage of eczema, soothe the patient, and are not 
 harmful by reason of interfering with the internal treatment. 
 
 There are cases of eczema in which the too frequent bathing of the parts 
 for the sake of cleanliness is very injurious. Water is sometimes almost poison- 
 ous, and should be kept away and the crusts allowed to dry and drop off. — L. 
 
 In some cases the pruritus causes a torture from which 
 it is absolutely imperative to free the patient. The applica- 
 tion of an impervious covering, either of caoutchouc, or of a 
 similar tissue, has been of great service in our hands, and 
 has procured for our patients the desired relief. This prac- 
 tice, borrowed from the Hospital Saint Louis, is entirely in- 
 offensive, and does not in any way interfere with the action 
 of our homoeopathic remedies. 
 
LECTUKE XXIV. 
 
 Summary. — Typhoid fever of a benign form, case. The ordinary form, case. 
 The diagnosis of typhoid fever; prodroma; thermometric tracings in typhoid 
 and Inflammatory fevers, variola, pneumonia, and acute phthisis. Value of 
 the thermic record; it gives a startling picture of the ensemble of the dis- 
 ease. The diagnostic value of these records, and their confirmation of the 
 doctrine of critical days. Bilious and mucous fevers are nosological errors. 
 The acute catarrh of the stomach is nothing more than the old theory of 
 universal gastritis proposed by Broussais. The pretended gastric symptoms 
 belong to stomatitis, an affection which is common to the most varied dis- 
 eases. The ordinary form of typhoid fever prolonged, case. Importance of 
 this form. 
 
 Typhoid Fever. 
 
 • 
 
 Gentlemen : Since the beginning of January we have had 
 three cases of typhoid fever in our wards. The first was an ex- 
 ample of the benign type, and was entirely cured by the four- 
 teenth day of the disease ; the second was of the common form, 
 and reached the apyrexia on the twentieth day ; and the third 
 is a good illustration of the common form very much pro- 
 longed. This last patient had a decided remission of all the 
 symptoms on the twenty-sixth day; on the thirtieth day the 
 fever returned and continued until the fortieth day. We shall 
 take advantage of these three cases to give you some practical 
 rules concerning the diagnosis and treatment of typhoid fever. 
 
 In the first place, we will call your attention to the history 
 of the young girl who was attacked with the benign form of 
 this disease. 
 
 Case LXV.— This young girl, of very good health formerly, 
 had lived in Paris but two months. She took her bed on the 
 31st of December, but for ten days previous had had the pro- 
 droma of her disease, id est, anorexia, bleeding from the nose, 
 
TYPHOID FEVER. 345 
 
 a general malaise, extreme lassitude and a pain in the posterior 
 cervical region. These symptoms anticipated the benign type 
 of typhoid fever with which she has been seized. 
 
 To-day there is a moderate degree of prostration. She com- 
 plains of a severe headache, especially in the frontal region, of 
 vertigo and of singing noises in the ears. 
 
 The mind is almost intact, the ideas being only slightly con- 
 fused. The hearing is considerably diminished. There is com- 
 plete anorexia. The tongue is covered with a light and whitish 
 coating in the middle, but the tip and borders are red. 
 
 The patient has no diarrhoea; the abdomen is distended 
 and very sensitive, and we can very readily detect a gurgling 
 in the right iliac fossa. 
 
 Muriatic acid, 3d dil., was prescribed, of which three drops 
 were to be put in 200 grammes of water, one teaspoonful to be 
 taken every three hours during the day, ■ and belladonna, 3d 
 dil., in the same manner during the night. The diet to be 
 strict. 
 
 January 5, seventh day. , The night has been somewhat 
 disturbed. She has had a slight delirium. On the skin of 
 the abdomen there are some red lenticular spots, which disap- 
 pear under pressure by the finger. The same treatment. The 
 morning temp. 101.3°, pulse 96; evening temp. 102.9°, pulse 
 112. 
 
 January 6, eighth day. The patient has been more tranquil 
 than during the previous night. The spots are more numerous 
 than they were yesterday. By auscultation of the lungs we find 
 only sibilant rales, which are very numerous. The same treat- 
 ment. The morning temp. 101.8°, pulse 96; evening temp. 
 102.9°, pulse 104. 
 
 January 7, ninth day. The patient had some diarrhoea this 
 morning. The headache has entirely disappeared. The pulse 
 is strong and dicrotous. The same treatment. Morning temp. 
 100.4°, pulse 88; evening temp. 101.8°, pulse 100. 
 
 January 8, tenth day. The general state of the patient is 
 very good. She answers questions which are addressed to her, 
 and is not nearly as deaf as she has been before. The same 
 treatment, with the addition of some porridge. Morning temp. 
 99.7°, pulse 96; evening temp. 101.1°, pulse 96. 
 
34:6 THE MEDICAL CLINIC. 
 
 January 9, eleventh day. There is complete anorexia this 
 morning; the thermometer indicates only 97.5°, the pulse is 
 84; evening temp. 101.1°, pulse 96. 
 
 January 10, twelfth day. She continues to improve; the 
 appetite has returned. Morning temp. 99°, pulse b8 ; evening 
 temp. 102.2°, pulse 100. The same treatment, including the 
 porridge. 
 
 January 11, thirteenth day. Morning temp. 99.1°, pulse 
 84; evening temp. 98.6°, pulse 96. China, 6th dil. 
 
 January 12, fourteenth day. The fever is entirely broken ; 
 the tongue is moist and quite clean. China, 6th dil. 
 
 January 13. The patient continues to improve. The china 
 was continued until January 23, when she left, after having 
 been in the hospital about twenty days. A remarkable pro- 
 duction of head-lice coincided with this cure. 
 
 We come now to our second case, which is one of typhoid 
 fever of the common type. 
 
 Case LXYI. — B , aged twenty-five, was admitted on 
 
 the 12th of January, and discharged on the 14th of February. 
 (Men's ward, JNo. 4.) 
 
 This young man has complained since the 1st of January 
 of a general malaise, extreme lassitude, and headache with loss 
 of appetite. These were the symptoms which he had prior to 
 the 7th of January, when he was forced to take to his bed. 
 
 Three or four days ago he had a severe chill, and several 
 times during the day, yesterday, he had slight attacks of nose- 
 bleed. 
 
 To-day he complains of a violent headache, but has no pain 
 in the abdomen ; the appetite is entirely gone ; the tongue is 
 white in the middle and red at the tip and borders. 
 
 January 12, sixth day. In the evening the thermometer 
 marked 101.8°, and the pulse 104. Muriatic acid, 3d dil., 
 three drops during the day; broth. 
 
 January 13, seventh day. Morning temp. 101.1°, pulse 
 96; evening temp. 101.8°, pulse 96; the night has been 
 quite calm ; this morning some rose-colored lenticular spots, 
 which disappear on pressure by the finger, were observed upon 
 the surface of the abdomen. The same treatment. 
 
TYPHOID FEVER. 347 
 
 January 14, eighth day. Morning temp. 101.5°, pulse 80 ; 
 evening temp. 103.6°, pulse 96. He was slightly agitated dur- 
 ing the night ; the general condition, however, is good ; he 
 has had some fits of coughing, but auscultation reveals noth- 
 ing abnormal. The same treatment. 
 
 January 15, ninth day. Morning temp. 101.8, pulse 84; 
 evening temp. 103.6°, pulse 96. The patient complains very 
 much of headache. Muriatic acid, 3d dil., and belladonna, 
 3d dil., alternately. 
 
 January 16, tenth day. Morning temp. 101.5°, pulse 84; 
 evening temp. 102.5°, pulse 100. The patient declares himself 
 decidedly better. 
 
 January 17, eleventh day. Morning temp. 101.5°, pulse 
 96 ; evening temp. 103.3°, pulse 96. He has some diarrhoea; 
 the abdomen is sunken and slightly painful to pressure. The 
 same treatment. 
 
 January 18, twelfth day. Morning temp. 100.4°, pulse 84; 
 evening temp. 101.5°, pulse 84. The diarrhoea continues, there 
 is some stupor, and the patient responds with difficulty to ques- 
 tions which are put to him. The same treatment. 
 
 January 19, thirteenth day. Morning temp. 100.4°, pulse 
 84; evening temp. 102.2°, pulse 88. Same treatment. 
 
 January 20, fourteenth day. Morning temp. 99.7°, pulse 84 ; 
 evening temp. 102.2°, pulse 92. The diarrhoea has diminished 
 somewhat ; the stools are liquid and of a foetid odor. The same 
 treatment ; porridge. 
 
 January 21, fifteenth day. Morning temp. 99.7°, pulse 68; 
 evening temp. 102.5°, pulse 84. This morning the patient had 
 a slight epistaxis. On account of a slight fever, of the re- 
 mittent type, which he has had for two days, he was given 
 china, 6th dil., two drops during the day. 
 
 January 22, sixteenth day. Morning temp. 99.7°, pulse 68 ; 
 evening temp. 102.4°, pulse 84. The diarrhoea has almost en- 
 tirely ceased ; the general condition of the patient is good. 
 The same treatment. 
 
 January 23, seventeenth day. Morning temp. 99.5°, pulse 
 68; evening temp. 101.8°, pulse 88. The evening paroxysm 
 persisting despite the china, I ga^e chininum suljph., 1st trit., 
 twenty centigrammes, during the day. He was also allowed 
 an egg. 
 
348 THE MEDICAL CLINIC. 
 
 January 24, eighteenth day. Morning temp. 99°, pulse 
 68 ; evening temp. 100.4°, pulse 88. The fever continues to 
 subside daily, and the patient begins to have a little appetite. 
 The same treatment, with a little meat. 
 
 January 26, twentieth day. The evening paroxysm has 
 disappeared ; medication was suspended, and the patient was 
 allowed to eat some porridge and an egg. 
 
 January 30. He continues to improve, but still has a little 
 headache. Belladonna, 30th dil., twice daily. 
 
 February 5. The belladonna has cured the headache. The 
 patient gained his strength rapidly, and left on the 14th of the 
 month. 
 
 A physician, belonging at that time to the hospital service, 
 had decided that this was a case of gastric catarrh. Some of 
 you questioned the correctness of the diagnosis when it was 
 said that the young girl who convalesced on the fourteenth day 
 had typhoid fever ; and on that occasion something was said of 
 mucous fever. It is, therefore, important that I should tell you 
 upon what signs I based my diagnosis of typhoid fever in these 
 two cases ; and also that I should once more speak of certain 
 names and titles of disease which have no scientific value. 
 Mucous, gastric and bilious fevers and gastric catarrh are 
 names which frequently cover up but do not conceal an in- 
 different diagnosis. 
 
 Formerly the differential diagnosis of typhoid fever at its 
 onset was chiefly based upon the existence of prodromata that 
 were lacking in other continued and eruptive fevers which 
 resembled it, and also in the ephemeral and inflammatory 
 fevers and in variola. The malaise, the headache, the sad- 
 ness, the diminution of strength and of spirits, a troubled 
 sleep, loss of appetite, and especially epistaxis and a tendency 
 to diarrhoea, are the symptoms which, continuing for from eight 
 days to a fortnight, constitute the prodroma of typhoid fever. 
 ~Now the ephemeral and inflammatory fevers and variola have 
 
TYPHOID FEVER. 349 
 
 only the most insignificant premonitory symptoms, for the 
 fever usually begins abruptly. 
 
 The brusque onset which is almost always wanting in ty- 
 phoid fever is, therefore, a good differential sign. The condi- 
 tion of the skin, the stomatitis, with a tongue which is whitish 
 in the middle and red at the tip, were symptoms that we have 
 sought for carefully, and of which we have taken the precise 
 signification in difficult cases. 
 
 But, we must say, emphatically, that where the prodroma 
 were absent, id est, in serious cases, the diagnosis in the begin- 
 ning was often very difficult. 
 
 Only a few years ago it was really very embarrassing", in many cases of this 
 fever, not to be able to make a certain diagnosis for the first week or two. When 
 we were in college a venerated professor told us that the best way of recognizing 
 it was to give the patient a moderate cathartic, and if it operated excessively, 
 the case was almost certain to be one of typhoid fever. — L. 
 
 At the present day the diagnosis of typhoid fever is stamped 
 by the thermometer with a mathematical certainty. The exact 
 record of the temperature gives us such a correct idea of the 
 febrile movement that we can recognize, without difficulty and 
 without the possibility of error, the most delicate shades of 
 this affection ; and you are aware that it is upon these shadings 
 that our differential diagnosis must always depend. Without 
 doubt, we have known for a long time that the febrile action 
 was more brusque in its onset, and that it reached more 
 promptly its maximum of intensity in inflammatory fever and 
 in variola than in typhoid fever ; but whilst the frequency of 
 the pulse has been our only measure of the fever, the differ- 
 ences in the course of this affection were not always perfectly 
 recognizable, and consequently the differential diagnosis was 
 wanting in certainty. Observations with the thermometer 
 have taught us the exact character of the febrile heat in 
 the different fevers, and for the purposes of differential diag- 
 nosis these qualities may be stated in the two following propo- 
 
350 THE MEDICAL CLINIC. 
 
 sitions : in inflammatory fevers, variola, and pneumonia, the 
 highest degree of temperature, say 104°, at the least, is reached 
 by a continuous ascension during the first days. But in ty- 
 phoid fever that degree is attained only after the fourth day, 
 and by an ascent which is composed of a morning remission 
 and an evening exacerbation. 
 
 Thus you will observe that an ascension which is abrupt, 
 rapid, without very decided morning and evening alternations, 
 characterizes the febrile movement of an inflammatory fever, 
 of variola and of pneumonia. A progressive ascension, in 
 which the heat of each morning is above that of the preceding 
 morning, but below that of the preceding evening, so that the 
 curve represents a stairway, is proper to typhoid fever. It is, 
 therefore, easy when we have the thermic tracings of the on- 
 set of the disease to make the differential diagnosis between 
 typhoid fever, variola and pneumonia. 
 
 There is one other disease with which typhoid fever is very 
 easily confounded, and that is acute phthisis. In this disease 
 the thermic record will not settle the question of its symptom- 
 atology, because the fever of acute phthisis has a remittent 
 type. 
 
 To conclude, the typhoid fever is the only disease in which 
 the thermic chart shows a period of regular ascent during from 
 four to five days ; followed by a period of regular oscillation, 
 which varies from nine to twenty days, and which terminates 
 by a descending oscillation of several days more. The thermic 
 chart will, therefore, suffice completely in the diagnosis of 
 typhoid fever. 
 
 This is very plain and very true; for excepting in case of internal hemor- 
 rhage, and of the various puerperal diseases, there are no affections in which 
 the value of the clinical thermometer as an aid in diagnosis is better illustrated 
 
TYPHOID FEVER. 351 
 
 than in typhoid fever. Its application to the study and treatment of this fever 
 alone marks an era in practical medicine. — L.* 
 
 We should remark, gentlemen, that modern researches 
 upon the temperature of fevers, and the tracings bj which 
 they are expressed, have the great advantage of embodying, 
 and of presenting in an image which is perfectly recognizable, 
 the characters and the totality of the febrile movement, so 
 that a glance upon the chart permits the mind to seize in- 
 stantly the nature, the different complications, the .gravity and 
 the duration of the disease. 
 
 The author has overlooked a peculiar advantage to be derived from clinical 
 thermometry in this and in other forms of disease. Not only is this mode of 
 recording our cases, so far as it goes, more accurate than any other, and there- 
 fore an indispensable and invaluable aid to clinical experience, but it offers a 
 means of reference to cases that we have had, and that others have had, in 
 former years and elsewhere, as a guide and a study in the future. A collection 
 of such records in typhoid fever would furnish a safeguard against the mischief 
 of trusting to memory, or even to the old-fashioned written reports, when we 
 come to refer to our experience in its treatment. — L. 
 
 Another advantage of these thermometric studies is, that 
 they permit us ' to make such clear and precise distinctions 
 between the fevers which belong to similar diseases. Thus 
 it is, for example, with the fever which is proper to a local 
 inflammation, with that which belongs to the typhoid fever, 
 and with that which accompanies small-pox. General pa- 
 thology is therefore right in teaching us that these symptoms 
 receive a peculiar character from the diseases upon which 
 they are secondary ; and this grand law, upon which all symp- 
 tomatology rests, is singularly confirmed by modern studies 
 in clinical thermometry. 
 
 This study of heat in fevers gives an unexpected confir- 
 mation of the old doctrine of critical days. 
 
 *See an essay on the Temperature and the Pulse in Puerperality ; being an 
 analysis of Fifty Cases treated in the Puerperal Wards of the Hahnemann Hos- 
 pital, of Chicago, by R. Ludlam, M.D., etc., in the Transactions of the Ameri- 
 can Institute of Homoeopathy, for 1878, p. 489. 
 
352 THE MEDICAL CLINIC. 
 
 According to the tradition which is the most accredited, the 
 critical days are the 4th, 7th, 11th, 14th, 17th and the 20th 
 day, or the 21st, according to some authors. You will observe 
 that these days happen sometimes in the middle, sometimes at 
 the end, of each week. Now, the reading of a large number of 
 thermic charts will prove to you that the defervescence, as the 
 modern barbarians style it, occurs usually on the 4th or the 7th 
 day in pneumonia ; that the chief modifications of temperature 
 in typhoid fever have almost always occurred on critical days. 
 
 Jaccoud says that "the chief thermic modifications which 
 mark the passage from one period to the other correspond to 
 the middle or to the end of a week, the time being counted 
 from the first day of the disease. This singular coincidence is 
 a rule which is very rarely broken." {Clinique, page 584.) 
 
 By the use of clinical thermometry in typhoid fever we are also notified of 
 accidental complications, such, for example, as hemorrhage from the bowels, 
 peritonitis, perforation of the bowels, meningitis, the formation of abscesses, 
 etc. The reader will find a very interesting and thorough exposition of this sub- 
 ject, most carefully and beautifully illustrated, in Vol. II of Lorain's great 
 work, De la Temperature du corps humain et de ses variations dans les diverses 
 maladies, Paris, 1877. — L. 
 
 Are not the middle and the end of the week precisely the 
 critical days, and why should we call this coincidence ' c singu- 
 lar," or be astonished at it? Experience has shown that dis- 
 eases have definite conditions, which are characterized by a 
 totality of symptoms and of determinate lesions, and that they 
 are subject to a proper evolution. If each disease has its own 
 evolution, wherefore should we be astonished that its course 
 has a certain regularity, for it is the contrary that would be 
 ' ' singular. ' ' 
 
 Our second patient, B , came to us during the remis- 
 sion at the end of the first week with a temperature of 102° ; 
 the first half of the second week was marked by an aggrava- 
 tion, 103.3°; the second remission was in the middle of the 
 
TYPHOID FEVEK. 353 
 
 second week, 100.4°; there was a new aggravation at the end 
 of the second week, and at the middle of the third, 102.6°; 
 then a final remission in the middle of the third week, or the 
 seventeenth day of the disease. 
 
 The young girl, who was attacked with the benign form of 
 the fever, was admitted during the aggravation at the com- 
 mencement of the second week (103°) ; there was a remission 
 on the 10th and 11th days, an aggravation on the 12th, and 
 decided convalescence on the 14th day. The gradually ascend- 
 ing course of the febrile curve, and the duration of the pro- 
 dramata, made it impossible to mistake the typhoid fever in 
 these two cases ; and the accuracy of the diagnosis was con- 
 firmed by the appearance of the lenticular spots. 
 
 The exceptionally short duration of fourteen days in ty- 
 phoid fever is a fact admitted by all authors, but we believe 
 that we have much more frequently observed it since we 
 adopted the homoeopathic treatment. It is certain that this 
 duration is very short ; but, whilst it may last fourteen, and, 
 sometimes, only eleven, days in the benign form of this fe- 
 ver, nevertheless the essential peculiarity of this type is the 
 moderate intensity of the fever and not its period of duration, 
 for we have often seen cases of this kind that required three 
 weeks for their development. 
 
 These are the cases of abortive typhoid which, with the 
 synocha, comprise the mucous and bilious fevers of the vul- 
 gum jpecus who abound in the lower ranks of the profession. 
 Practitioners who have forgotten the little they learned at col- 
 lege, where they were victimized by the necessity of preparing 
 for their examinations, instead of learning their true import, 
 are too ready to pick up the commonplace title instead of 
 making a careful diagnosis, and will not readily abandon 
 such vague and unscientific terms as bilious fever and mu- 
 
354 THE MEDICAL CLINIC. 
 
 cous fever. In this manner these, unfortunate phrases are 
 becoming more and more common. There is no such thing 
 as mucous fever. There are only three continued fevers (at 
 least in Paris), the ephemeral, the synochal and the typhoid 
 fevers. Before any other continued fever can be added to 
 this nosological group, its existence must be actually demon- 
 strated ; and where are the observations, where the descrip- 
 tions, where the researches in symtomatology which establish 
 the mucous fever as a distinct species, and which settle the 
 differential diagnosis between this disease and the snyochal 
 and typhoid fevers ? Such records do not exist, and it is, 
 therefore, useless to encumber our literature with expressions 
 that are improper, and which only serve to deceive and mis- 
 lead. 
 
 I know that the opponents of the doctrine of fever, as it 
 was held by the French physicians in the first half of the 
 present century, included in their ranks some who were more 
 influential than those who talk in our day of mucous fever. 
 They taught that the synocha, cases which we style abort- 
 ive typhoid fever, and ephemeral fevers, should be classed 
 with catarrhal inflammation of the stomach, and that they 
 are examples of acute gastric catarrh. These followers of 
 Broussais have tried to found their opinion on certain gastric 
 symptoms which are almost always present in the continued 
 fevers. The redness and the coating of the tongue, id est, 
 the stomatitis, the anorexia, the nausea, the vomiting, the 
 pain at the pit of the stomach, the sub-icteric hue of the 
 naso-labial groove, constitute so many signs of the lesion of 
 the digestive organs, and should be considered a certain 
 proof of a catarrhal inflammation of the stomach, whence 
 the conclusion that the synochal and ephemeral fevers are 
 forms of gastric catarrh. 
 
TYPHOID FEVEK. 355 
 
 We have given, in all their force, the arguments of our 
 opponents : let us see what they are worth. 
 
 The symptoms upon which the theory of gastric catarrh 
 is founded are common to all fevers ; and typhoid fever, es- 
 pecially, shows them in a very marked degree. 
 
 The stomatitis, with coating of the gums and the tongue, 
 exists in the eruptive fevers, and even in the intermittent 
 fevers, and vomiting is a frequent symptom at their onset. 
 Shall we say, therefore, that the typhoid, eruptive and inter- 
 mittent fevers are only attacks of acute catarrh of the stomach i 
 Let us be cautious, for we shall find the same symptoms of 
 stomatitis and of gastric distress, and in a high degree, in 
 angina, in pneumonia, in erysipelas, and, in a word, in all 
 febrile affections. Shall we say that all these diseases origi- 
 nated in acute catarrh of the stomach ? Why should we oppose 
 the doctrine of Broussais, if we are going to recognize once 
 more a universal gastritis % 
 
 I will add that these conditions of the mouth and tongue, 
 the saburral state of the ancients, which M. Davasse has so 
 well described, and which he has properly referred to an 
 inflammation of the mucous membrane of the tongue and of 
 the gums, are so slightly related to a gastritis that an inflam- 
 mation developed by a carious tooth, or by a burn, may cause 
 them, and that the least inflammation of the tonsils is accom- 
 panied by a very decided coating of the tongue. 
 
 This is actually true, for these coatings of the tongue, far 
 from representing a bilious condition, or a saburral or gastric 
 state, are produced by an inflammation of the mucous mem- 
 brane of the tongue, and by the epithelial desquamation which 
 necessarily follows it. This dead epithelium imbibes some 
 thing from all the liquids which pass the mouth, and shows the 
 most varied colors, from white to brown through all the shades 
 of yellow, and it is necessary to be thoroughly incrusted with 
 
356 THE MEDICAL CLINIC. 
 
 the doctrines of Galen in order to find in this yellow color the 
 proof of a bilious affection, and to take the tongue as the 
 mirror of the stomach. 
 
 Thus, on the one side, all the febrile diseases present the 
 symptoms upon which it has been attempted to found the 
 existence of an acute catarrh of the stomach ; on the other, 
 the coatings of the tongue prove only one thing, viz : that 
 the inflammation is in the mouth and not in the stomach. 
 The first argument shows the fallacy of the theory of acute 
 gastric catarrh ; in fact, it is absurd to maintain that diseases 
 which are so different are all due to gastritis. The second 
 argument upsets the basis of the theory by proving that the 
 pretended gastric symptoms are only buccal and not gastric. 
 Let us therefore return, unequivocally, to the adoption of a 
 system of fevers which is an honor to French medicine, while 
 at the same time it is a model of clearness and precision. 
 
 The author's emphasis commends his argument. If any set of physicians 
 should be interested in accurate diagnosis, it is the members of our school of 
 practice. An intelligent prescription presupposes and necessitates, so far as 
 possible, an intelligent idea of the case in point. A loose and shambling diagno- 
 sis cannot ripen into a trustworthy clinical experience. There was a time when 
 our patients would rely upon us to carry almost any kind of a case to a success- 
 ful issue without asking what the disease really was, and in what it differed 
 from something else; but that day has passed, and general terms, like those 
 which Dr. Jousset criticises, will not always satisfy them (nor should they) that 
 we know just what we are about. — L. 
 
 Here we have a case of ordinary typhoid fever of a very 
 prolonged type: 
 
 Case LXYII. — M. Rodou, aged fifteen years, was admitted 
 to 'No. 4: of the men's ward on the 31st of January, and dis- 
 charged on the 30th of March. 
 
 This young man has usually had very good health, and has 
 never been out of Paris. 
 
 On the 24th of January he was taken with a very severe 
 headache, a general malaise, and a weakness in all the limbs ; 
 
TYPHOID FEVER. 357 
 
 but he continued to work until the 27th, when he took to his 
 bed. From that time he had noises in the ears and some diar- 
 rhoea, but no epistaxis. The diarrhoea continues ; there is 
 complete anorexia ; the tongue is covered with a whitish coat, 
 and red at the margins ; pressure in the right iliac fossa does 
 not provoke pain ; there are no spots upon the . abdomen, but 
 auscultation detects some sibilant rales in the thorax. 
 
 The diagnosis was not doubtful, and we gave muriatic acid, 
 3d dil., three drops in 200 grammes of water, one tablespoon- 
 ful every three hours during the day, and belladonna, 3d dil., 
 in the same manner for the night. A, plain diet was also 
 ordered. 
 
 January 31, fifth day. Evening temp. 102.2°, pulse 100. 
 The same treatment. 
 
 February 1, sixth day. Morning temp. 103°, pulse 104. 
 The night has not been very much disturbed ; this morning the 
 prostration of strength is very marked. Evening temp. 104.7°, 
 pulse 108. The same treatment; broth. 
 
 February 2, seventh day. Morning temp. 103.3°, pulse, 
 100. The diarrhoea persists ; the stools are watery and of a 
 putrid odor. Evening temp. 104°, pulse 104. The same treat- 
 ment. 
 
 February 3, eighth day. Morning temp. 102.5°, pulse 96. 
 There was a slight delirium during the night ; the general con- 
 dition, however, is pretty good. Evening temp. 104°, pulse 
 104. The same treatment. 
 
 February 4, ninth day. Morning temp. 103°, pulse 96. 
 Some rose-colored, lenticular spots are seen upon the abdomen. 
 Evening temp. 103.3°, pulse 104. The same treatment. 
 
 February 5, tenth day. Morning temp. 100.2°, pulse 96. He 
 has had some fits of coughing ; there are sibilant rales all over 
 the chest. Evening temp. 103.3°, pulse 104. The same treat- 
 ment. 
 
 February 6, eleventh day. Morning temp. 102.2°, pulse 96. 
 The diarrhoea has considerably diminished, and the tongue looks 
 better. Evening temp. 103.6°, pulse 104. The same treatment, 
 
 February 7, twelfth day. Morning temp. 102.2°, pulse 100 ; 
 evening temp. 103.3°, pulse 104. The same treatment. 
 
 February 8, thirteenth day. Morning temp. 100.4°, pulse 
 
358 THE MEDICAL CLINIC. 
 
 92. The patient is doing well ; the diarrhoea has ceased, and 
 the appetite returned. Evening temp. 102.5°, pulse 100. The 
 same treatment. 
 
 February 9, fourteenth day. Morning temp. 100.8°, pulse 
 84; evening temp. 101.5°, pulse 83. The fever having very 
 much diminished, he was permitted to have some soup. 
 
 February 10, fifteenth day. The improvement continues, 
 and an egg is allowed him. Morning temp. 100.4°, pulse 84; 
 evening temp. 101.8°, pulse 92. The same treatment. 
 
 February 11, sixteenth day. Morning temp. 100.4°, pulse 
 92; evening temp. 102.5°, pulse 100. Another egg. 
 
 February 12, seventeenth day. Morning temp. 99°, pulse 
 92; evening temp. 102.2°, pulse 100. The same treatment. 
 
 February 13, eighteenth day. Morning temp. 98.6°, pulse 
 92; evening temp. 101.8°, pulse 100. The fever having be- 
 come intermittent, twenty centigrammes of chininum sulph.. 
 3d trit., was prescribed. 
 
 February 14, nineteenth day. Morning temp. 97.8°, pulse 
 84; evening temp. 101.5°, pulse 88. Chininum sulph. , 1st trit. 
 
 February 15, twentieth day. Morning temp. 97.8°, pulse 
 76 ; evening temp. 101°, pulse 88. The fever has diminished ; 
 the patient is gaining strength ; he is to have a little meat, with 
 the same treatment. 
 
 February 16, twenty-first day. Morning temp. 98.25°, pulse 
 80; evening temp. 100.75°, pulse 62. 
 
 February 17, twenty-second day. Morning temp. 98.25°, 
 pulse 72; evening temp. 100.5°, pulse 88. The temperature is 
 almost normal, and the general condition is excellent. All 
 medication was suspended. 
 
 February 20, twenty-fifth day. The patient has a little diar- 
 rhoea. Phosphoric acid, 3d dil. 
 
 Although the patient had no fever for six days, it returned 
 on the 23d of February. 
 
 February 24, twenty-ninth day. Last evening he had a 
 very intense fever. Through deceiving the nurse he had grati- 
 fied his appetite by eating some cakes which had been brought 
 to him. Morning temp. 103.6°, pulse 108; evening temp. 
 104.75°, pulse 112. Arsenicum, 6th dil., two drops in 200 
 
TYPHOID FEVER. 359. 
 
 grammes of water, a tablespoonful every three hours, with a 
 strict diet. 
 
 February 25, thirtieth day. His general condition is very 
 bad ; there is considerable prostration, with complete an- 
 orexia. Morning temp. 103.25°, pulse 108; evening temp. 
 104.75°, pulse 112. The same remedy. 
 
 February 26, thirty-first day. Morning temp. 103°, pulse 
 112; evening temp. 104.5°, pulse 108. The patient is no bet- 
 ter, but has all the signs of a relapse. There is stupor and 
 diarrhoea, with gurgling in the right iliac fossa. Muriatic acid, 
 3d dil., and belladonna, 3d dil., to be given ^s they were in the 
 onset. 
 
 February 27, thirty-second day. A new eruption of the 
 lenticular spots has appeared upon the abdomen. The same 
 remedy. 
 
 March 1, thirty-third day. The patient is very ill to-day, 
 and has been delirious all night. Arsen. metal, 3d trit., and 
 rhus tox., 3d dil. 
 
 March 3, thirty-fifth day. The general condition is better, 
 and the diarrhoea has ceased. The same treatment. 
 
 March 7, thirty-ninth day. The improvement continues ; 
 the tongue, which was dry and rough, is becoming moist. 
 The same treatment. 
 
 March 9, forty-first day. The patient is fully convalescent. 
 
 Now, gentlemen, we are happy in having had the oppor- 
 tunity of illustrating the protracted form of ordinary typhoid 
 fever. This form, which is still too frequent, exposes the 
 patient to the risk of deceiving even the most experienced phy- 
 sician. It is necessary to distinguish it with care from cases of 
 the ordinary type, in which the fever continues long after the 
 third week, because of the development of an enteritis, of a 
 broncho-pneumonia, or of some other affection that may be 
 consecutive upon the typhoid fever. When the common form 
 of this disease is really prolonged, it is characterized by the 
 fact that the disease begins its course the second time ; the 
 lenticular spots often reappear ; and certainly the intestinal 
 affection recommences and runs anew through all its stages. 
 
LEGTITEE XXY. 
 
 Summary. — Typhoid fever, continued; the different varieties of; clinical im- 
 portance of this subject; necessity of a careful diagnosis of the forms of 
 this fever, even for the homoeopathic physician; treatment; indications 
 for belladonna and for the muriatic and phosphoric acids, arsenicum, ipecac. 
 and baptisia. These fevers never cut themselves short; regimen. Dr. 
 Small's experience. The meningo-encephalitis of typhoid fever. 
 
 Typhoid Fever — (Continued). 
 
 Gentlemen: I cannot permit this occasion to pass without 
 insisting upon the clinical importance of recognizing the differ- 
 ent forms of typhoid fever. In our Elements de medecine 
 pratique (Yol. I, page 220) we have recognized three forms of 
 typhoid fever : the benign form (latent, abortive) ; the common 
 form, which includes three varieties, viz: the common form, 
 properly so called ; the common form prolonged ; and the com- 
 mon putrid. You have seen in this clinic cases of the first two 
 varieties. The putrid form of typhoid fever is frequent in 
 certain epidemics. It is characterized by a considerable febrile 
 heat, an early prostration and stupor — which are more intense 
 than in the other kinds — and by a tendency to gangrene and 
 to hemorrhages. This is the putrid fever of the ancients, and 
 the adynamic of Pinel. Finally, the third form of typhoid 
 fever is that which is malignant, and of which there are three 
 types, viz: the foudroyante, or the ataxic, of many authors; 
 the hemorrhagic, or the petechial ; and the slow nervous form, 
 which was described by Huxham. 
 
 There is a great difference between this classification pro- 
 posed by the organic pathologists and that of the modern 
 humoralists. The former have divided typhoid fever into 
 
TYPHOID FEVER. 361 
 
 three kinds, according to the predominance of certain cere- 
 bral, pulmonary, or abdominal affections ; and hence they 
 speak of cerebral, pulmonary and abdominal typhoids. Now, 
 typhoid fever, in most cases, is either successively or at the 
 same time cerebral, abdominal and pulmonary. We cannot, 
 therefore, accept as a principle for the classification of the 
 forms of a disease, a basis which is so variable as the predomi- 
 nance of either of these affections in typhoid fever. 
 
 Concerning the spurious divisions that have been made, 
 sometimes by the humoralists, sometimes by the solidists, of 
 the last century, being purely hypothetical, they are very im- 
 perfect. Let us take, for example, the best authenticated 
 among the authors who accept this classification. Chomel 
 admits five forms of typhoid fever, — the inflammatory, the bil- 
 ious, the mucous, the nervous, and the ataxic, or the adynamic. 
 Yalleix made a very just criticism of this classification in his 
 Traite de Pathologie: " The first form is the inflammatory 
 typhoid fever. It exists especially at the o?iset, and is charac- 
 terized by the fullness and frequency of the pulse. Who can- 
 not see that a type of fever which shows itself only at the 
 beginning is something very odd ? The disease could therefore 
 have all the forms : at the onset, inflammatory ; later, bilious ; 
 still later, nervous ; and finally, adynamic. It is evident that 
 such distinctions are of no account. 
 
 "But, more than this, even when the patients have the 
 symptoms that I have indicated, are they not decidedly en- 
 feebled ? There is, therefore, adynamia ; but have they not 
 also vertigo, agitation, and troublesome dreams ? There must 
 be ataxia, therefore. Have they not also a coated mouth and 
 tongue, nausea, and sometimes vomiting? These are bilious 
 symptoms. 
 
 ' ' I could in this manner review all the conditions which have 
 been specified as characteristic of these different types, and I 
 would always find that the symptoms of typhoid fever are 
 
362 THE MEDICAL CLINIC. 
 
 united in them to a degree which is more or less pronounced, 
 and that if, at the first, some of them appear to be masked 
 by others, a slight examination will soon discover them.'* 
 (Yalleix, Guide du Medeein Practicien, t. I, page 33.) 
 
 I have left it for Yalleix, the friend of Chomel, to criticise 
 his classification of the forms of typhoid fever in as severe a 
 manner as it could be done ; for it is always best, when such 
 a thing is possible, to leave the dead to bury their dead! 
 
 This is very sharp, especially when we who follow get the benefit of the 
 debate between two such men as Chomel and Valleix. There is force in what 
 the former has written ; and the latter has contributed something to our knowl- 
 edge of typhoid fever while castigating his friend. It is very unfortunate that 
 medical controversy is not always so fruitful of good. — L. 
 
 Let us now recall, in a few words, what we have taught 
 in our treatise on general pathology, that the varieties of dis- 
 ease are constituted by a totality of symptoms and of lesions, 
 which form states and conditions that are absolutely distinct 
 from each other, from the commencement to the end of the 
 disease, and that these forms cannot be changed into each 
 other any more than the different morbid species can be so 
 changed. For example : the benign variola can never become 
 malignant, the discrete variola never becomes confluent; whence 
 we conclude that the classifications of typhoid fever, which have 
 been made in despite of these conditions, are not satisfactory. 
 
 The clinical advantages that result from a natural division 
 of the forms of typhoid fever pertain chiefly to its prognosis 
 and its therapeutics. 
 
 It is not difficult to understand the prognosis in the benign 
 form, and also that of the common malignant form ; or to know 
 that the chronic type, or the slow nervous form, will have a 
 longer duration than the other forms, and that, in the ataxic 
 variety, death may happen in a few days. 
 
 But the importance of a proper classification of these types 
 
TYPHOID FEVEK. 363 
 
 is not less evident in the special therapeutics of typhoid fever. 
 Indeed, it is to the confusion of these forms that we owe the 
 conflicting statistics and the consequent uncertainty with re- 
 gard to the different methods of treating this disease. We un- 
 derstand that, whatever remedies are given, the results will 
 always be favorable or unfavorable, according to the series 
 operated upon, and whether they contain a greater or less 
 number of the milder or more serious cases. It is the absence 
 of this distinction of forms which explains the temporary suc- 
 cess of the anti-phlogistic treatment as a substitute for that 
 which is tonic. It is also to this imperfect classification that 
 we must attribute the popularity of Brand's system of treat- 
 ment, which was said always to cure the typhoid fever, but 
 which was afterward rejected, because, besides the difficulty of 
 its application, it very often failed to effect a cure. 
 
 The homoeopathic physicians would be wrong to conclude 
 that they might dispense with searching for, and studying out, 
 the forms of this disease, because their method of treatment, 
 based upon the state of the patient under treatment, renders it 
 unnecessary to occupy their minds with the type of the disease 
 in order to find the best indicated remedy. 
 
 We have often referred, and especially in Lecture X, to the 
 necessity of the diagnosis of the morbid species for a correct 
 and satisfactory idea of the indications furnished by the totality 
 of the symptoms ; and we have given the details of an unfor- 
 tunate blunder in the choice of remedies in pneumonia, where 
 the error was entirely due to the absence of diagnosis. It is, 
 therefore, unnecessary further to insist upon the importance of 
 diagnosticating the form of a disease, which is only a final 
 analysis of it, or a more precise diagnosis of the particular 
 case in point. 
 
 These observations are very practical. The intelligent traveler in a civilized 
 country could not very well dispense with a study of its geographical peculiari- 
 
364 THE MEDICAL CLINIC. 
 
 ties, or the astronomer with the observations and the calculations that have 
 been made and recorded in his department; nor can the doctor get on very far 
 without access to the maps and charts and the clinical experience of his profes- 
 sional brethren. 
 
 But, in order that our experience may serve as a guide for ourselves and for 
 those who shall come after us, it should be reported and recorded with the 
 greatest care and discrimination. The apparent conflict in the experience of 
 physicians in the treatment of typhoid fever, and of many other diseases, would 
 soon cease if they were always careful to note the peculiar phase and type of the 
 affection, the form that it assumed under different circumstances, and all the 
 hygienic conditions that multiply or modify the chances of recovery, with or 
 without treatment. 
 
 For there are doubtless many cases of typhoid fever that would get well 
 without any medicine whatever; but it is equally certain that many other cases 
 of the more serious type of the disease would not recover if left to themselves. 
 It is not fair or just, therefore, that physicians should report their success in an 
 indiscriminate manner; for in that case their conclusions would mislead others, 
 and their aggregated experience would not satisfy anybody- 
 Yet this is exactly what has been done in the therapeutics of typhoid fever; 
 and there is no better evidence of the fact than we find in the long list of reme- 
 dies that have been advised in its treatment. It is a wretched compromise, and 
 not a compensation, to have a hundred remedies thrust upon our notice when 
 ten or twenty would answer the purpose, if we always had a clear idea of what 
 we were trying to do, and of what others had already accomplished. — L. 
 
 Treatment. — In closing this lecture I desire to call jour 
 attention to some peculiarities in the treatment of typhoid 
 fever. 
 
 Muriatic acid, 3d dil., and belladonna, 3d dil., given al- 
 ternately, the former during the day and the latter at night, 
 constitute, according to Teste, the best treatment for this fever. 
 Clinical experience has very often confirmed its value, and 
 whenever the typhoid fever occurs with the usual brain and 
 abdominal symptoms, it will be sufficient. But I must warn 
 you against falling into a routine treatment which may be 
 adopted in advance, and which is thought to be suited to all 
 cases alike. We must search carefully in order to learn where 
 phosphoric acid may take the place of muriatic acid, and in 
 what class of cases both these remedies may be substituted by 
 arsenicum. It is hardly necessary to add that, in those cases 
 in which the cerebral symptoms have passed away, the bella- 
 donna need not be given any longer. 
 
TYPHOID FEVER. 365 
 
 Mtcriatic acid is indicated by a greenish, frequent diarrhoea, 
 which is sometimes involuntary ; by gurgling and the develop- 
 ment of a great deal of gas ; by stomatitis, with swelling of the 
 gums and extreme dryness of the mouth, and also by great 
 adynamia. 
 
 In typhoid fever occurring in puerperal subjects we have found the muriatic 
 acid to be worthy of the greatest confidence. In addition to the symptoms 
 above noted, it has done us good service where there was a great deal of rum- 
 bling, with a feeling of emptiness in the abdomen; sticking pains in the iliac, 
 inguinal and ovarian regions; diarrhoea, with burning or bleeding at the anus; 
 chilliness and coldness of the extremities; a colliquative perspiration; an aph- 
 thous condition of the mouth and the tongue; watery stools, with muttering and 
 unconsciousness, even while awake; great prostration and threatened paralysis, 
 and a disposition to slide down in the bed. — L. 
 
 Phosphoric acid, the indications for which in typhoid fever 
 are not given by Hughes, is a remedy which is quite as impor- 
 tant as the muriatic acid. The symptoms of a case of poison- 
 ing by phosphorus are very similar to those of typhoid fever, 
 and the action of phosphoric acid is very analogous to that of 
 phosphorus. The involuntary stools, which are of a pale 
 rather than of a deep green color ; the involuntary urination, 
 the tympanitis, and the very marked debility, are the principal 
 symptoms which indicate the phosphoric acid. 
 
 The almost colorless stools, the palor of the face, or pale- 
 ness of one cheek while the other is red ; the hemorrhagic 
 tendency, with epistaxis, bleeding of the gums, hemorrhage 
 from the bowels, or petechias, would cause us to select phos- 
 phoric acid in preference to muriatic acid. 
 
 The alternation of bryonia and rhus tox. is a kind of traditional prescrip- 
 tion in typhoid fever, like that of phosphorus and bryonia in pneumonia, of 
 ipecac, and china in uterine hemorrhage, of nux vomica and sulphur in hemor- 
 rhoids, and of aconite and arnica in the early puerperal state. Whether it is 
 scientific, sensible, logical, or even commendable, that these two remedies, or 
 any others, shall be given in this way, makes no difference with the facts in the 
 case. For it so happens that, in years gone by, the resort to rhus and bryonia 
 in alternation in this fever made more reputation for homoeopathy throughout 
 the West and the South than the prescription of any single remedy, or mode of 
 treatment that has been adopted in this or any other disease, has ever done. 
 
366 THE MEDICAL CLINIC. 
 
 Whether we are so rich in resources that we can afford to throw this one 
 away is a question that should be carefully settled at the bedside. For our- 
 selves, in a practice of nearly thirty years, in which we have treated our share 
 of cases of genuine typhoid fever of all types, we have had the good fortune 
 never to lose one of them ; and in the most of these cases our chief reliance has 
 been upon the third attenuation of these two medicines, given alternately, some- 
 times as often as every hour, but usually at intervals of from two to four hours. 
 
 For this reason, and because so many of our brethren throughout this whole 
 -region of country and all over the world have done, and are doing, the same 
 thing to-day, we are very skeptical of the dicta of those who declare that such 
 an experience is impossible. We cannot say if the single remedy and the 
 higher potency would have answered equally well; but it is absolutely certain 
 that they could not have given us any better results. — L. 
 
 Arsenicum is the great remedy for typhoid fever of a 
 grave type at its full period of development. The arsenical 
 fever is characterized by excessive heat with a small, feeble 
 and very frequent pulse. In very bad cases the pulse is irreg- 
 ular, although the heart still beats, and finally ceases; the 
 face is pale, changed, unnatural, and sometimes livid ; there 
 is great debility, with trembling of the limbs, and a ten- 
 dency to fainting ; rapid emaciation, anguish ; the anxiety is 
 soon followed by the typhomania, id est, by a mixture of de- 
 lirium and stupor, in which the patient unconsciously talks 
 in a manner that is unintelligible ; the mouth is dry, the lips 
 are sooty ; the tongue is so dry that it is painful to move 
 it ; there is grinding of the teeth, and, in the worst cases, 
 a kind of paralytic dysphagia ; an irrepressible thirst, which, 
 despite the dryness of the mouth, is soon followed by com- 
 plete adypsia ; a greenish brown, very foetid, copious, and 
 often involuntary, diarrhoea, and a paralysis of the bladder. 
 The arsenicum may be given in from the sixth to the third 
 dilution, and repeated every three hours. 
 
 But the muriatic and phosphoric acids, belladonna, and 
 arsenicum, do not constitute our only therapeutic resource in 
 typhoid fever ; they are merely the principal remedies in 
 the period of its full development. 
 
TYPHOID FEVER. 367 
 
 At the onset, aconite and ipecac, are often indicated. Bry- 
 onia, phosphorus and ipecac, are also indicated when the pul- 
 monary complication is predominant. 
 
 In the mild form of cerebral typhoid, with stupor, indifference to what is 
 going on, or what is done with him, or a low delirium, with tenderness of the 
 epigastrium, heavily-loaded urine, pains in the walls of the chest, and cough on 
 deep inspiration or upon motion, bryonia is sometimes of the greatest benefit ; 
 but it may need to be given for several successive days before there is any per- 
 ceptible or decided result. 
 
 In a coincident peritonitis, belladonna, rhus tox. or terebinthina may be of 
 the greatest service. In three cases of this kind great relief was experienced 
 from painting the abdomen thoroughly with Latour's oleaginous collodion. 
 The lighter emollients may also be useful. — L. 
 
 Opium, hyoscyanms and stramonium are often called for 
 instead of helladonna in the cerebral complications. Ipecac, 
 in the 1st dil., in copious epistaxis, and phosphoric acid, 3d 
 dil., in intestinal hemorrhage, are excellent remedies. 
 
 Other important remedies in the hemorrhage from the bowels in this dis- 
 ease are nitric acid, hamamelis, china, terebinth., erecthites and ledum. Our de- 
 pendence has been chiefly upon nitric acid in the second dilution. Nux vomica 
 is the remedy for epistaxis occurring during the course of this fever in hemor- 
 rhoidal subjects. — L. 
 
 But I shall not undertake to expose the complete treat- 
 ment for typhoid fever at this time, for I prefer that you 
 should consult the works on practical medicine and the Ma- 
 teria Medica. 
 
 I should, however, say a word of a remedy which you 
 have seen me prescribe for two of our patients, which is the 
 chininum, sulphuricum. The sulphate of quinia, in the third 
 trituration, is indicated at the termination of typhoid fever, 
 when the fever takes a perfectly remittent type ; but it is 
 only at the end of the disease, and when the paroxysm is 
 not serious, that this remedy is appropriate. For the per- 
 nicious chills which may happen at the height of the disease, 
 and more rarely at its decline, the quinine should be pre- 
 
368 THE MEDICAL CLINIC. 
 
 scribed in larger doses. We have found this remedy in all 
 forms to be without effect against the remittent type of the 
 fever, which is sometimes observed at the onset of the dis- 
 ease. 
 
 The Condition of the Bowels. — Experienced practitioners of our school of 
 medicine do not need to be told that the old-fashioned canonical purge that 
 formerly has slain so many puerperal women is no longer necessary, but is really 
 harmful, in the treatment of typhoid fever. The best rule of practice in these 
 cases is to let the bowels alone, for if there are any discharges of which the sys- 
 tem should be rid, it is safe enough to say that they will find a means of escape 
 when the diarrhoeic stage comes on; and to worry and annoy the inflamed and 
 ulcerated patches in the small intestine for the mere sake of forcing a stool, 
 when the patient has eaten nothing and the bowel needs rest, is foolish and 
 hazardous. It is foolish, because it is unreasonable ; and risky, because it may 
 provoke such a lax condition of the bowels as cannot afterward be controlled. 
 
 There is no question, in our mind at least, that, under the new dispensation 
 in medicine, the annoying complications and sequelae of this and other eruptive 
 fevers are not half so frequent as they were under the old method; and it would 
 not be very difficult to show that a large share of the present immunity of our 
 patients from a contingent hemorrhage from the bowels, from peritonitis and 
 from chronic diarrhoea, and extreme debility as consecutive upon typhoid fever, 
 is due to the fact that we never find it necessary to purge them during the 
 whole course of the disease. — L. 
 
 You have, perhaps, been surprised that I have not ordered 
 a remedy which, at present, is very much in vogue among 
 homoeopathic physicians — I refer to the haptisia tinctoria. 
 The reason is because I am suspicious of new things, and 
 because the eulogies that have been written upon this rem- 
 edy seem to me to be exaggerated, and to rest upon a wretched 
 confusion of gastric fever with the typhoid fever. 
 
 The pathogenesis of haptisia has, however, certain symp- 
 toms which might induce you to try it in the first stage of 
 typhoid fever, viz : c ' the weak and tremulous feeling, the 
 quick (90), full and soft pulse ; the internal and external heat 
 with thirst ; the headache, and tendency to delirium ; the 
 tongue yellowish brown in the center, red at the edges ; the 
 constipation alternating with diarrhoea." (Hughes' Manual 
 of Pharmacodynamics, page 131.) 
 
TYPHOID FEVER. 369 
 
 But you are not to believe that, with this remedy, any more 
 than with others, you can abort a typhoid fever, or limit its 
 duration to the first stage thereof. Claims of this kind are 
 based on errors of diagnosis. 
 
 Although I have been abused for holding that one cannot 
 strangle a disease, I must still repeat this axiom in general 
 pathology. We may abridge a disease by shortening the dura- 
 tion of each of its stages, and by destroying certain of its 
 symptoms ; but we do not prevent its evolution. Take the 
 variola, for example. Do you know a remedy that will pre- 
 vent the febrile stage, that of the eruption, that of suppura- 
 tion, and finally, that of desquamation % Vaccine, which is the 
 most powerful remedy known to us, has produced the varioloid, 
 or a modified variola ; and it has been claimed that in variola, 
 modified by vaccine, the suppuration is lacking. This should 
 be a case in which a therapeutic agent has strangled a disease, 
 id est, suppressed one of its stages and cut it short. But I 
 observe that this language is not literal. The stage of suppu- 
 ration is not suppressed: it is only shortened and modified. In 
 fact, the pustules do suppurate in varioloid; but this stage is 
 very short, and, what is very important, it is not accompanied 
 by fever. 
 
 The effect of a previous vaccination in the treatment of 
 variola is the strongest illustration known in therapeutics of 
 the power of a remedy over the course of a disease ; but this 
 powerful agent only modifies and abridges the different stages 
 of a disease — it cannot suppress them. If you have read what 
 has recently been written on the treatment of typhoid fever by 
 cold baths, you will be convinced, moreover, that the most 
 substitutive treatment is powerless to prevent the evolution of 
 this disease. The physicians who have been most enthusiastic 
 over Brand's treatment have freely acknowledged that, even in 
 the most favorable cases, the cold bath has not prevented the 
 
 24 
 
370 THE MEDICAL CLINIC. 
 
 development and the duration of the disease. The febrile heat 
 is reduced, the delirium ceases, the appetite, the strength and 
 the sleep return from the beginning of the treatment, and even 
 in the period of its fullest development ; but the disease con- 
 tinues its evolution during three, four, or more weeks. 
 
 The sulphate of quinia — that hero among remedies, that 
 pretended specific which is claimed to be infallible — may abort 
 the febrile paroxysm, but it will not strangle the disease. It 
 is quite clear that in the mild and in the pernicious forms, 
 where the disease has a very short duration, to arrest the par- 
 oxysms is equivalent to cutting short the disease ; but the truth 
 is, that in these forms the development of the disease is rapid. 
 If you abridge a type which is naturally short, you will sup- 
 press a complication that might have been fatal, as in the per- 
 nicious fever ; but the modified symptoms which follow the use 
 of the quinine, and which often necessitate its continuance, 
 demonstrate that, even on this favorable ground, we do not put 
 an end to the disease. 
 
 But when we speak of the common form of the intermit- 
 tent fever, which is vulgarly called the autumnal fever, quartan 
 fever, etc., you will see that to cut short the paroxysm is not 
 to abort the disease. In fact, it frequently happens, in coun- 
 tries where fevers prevail, that there are cases which, in spite 
 of quinine, continue for a year, eighteen months, or longer ; 
 and if the patient does not change climate, or the doctor does 
 not change the remedy, the ague cachexia is developed. No, 
 we do not strangle diseases, and for the very simple reason 
 that we do not make the cures. It is the living organism which 
 cures itself; it is Nature, as Hippocrates has said, and Nature 
 cures in her own way, id est, by the developments which are 
 peculiar to herself. 
 
 According to this doctrine, what is the use of medicine ? 
 Medicine inclines the organism toward the cure, and puts it. 
 
TYPHOID FEVER. 371 
 
 in the way of a cure. As my friend, Dr. Cretin, has said, 
 medicine is the railroad-switch that turns the train from dan- 
 ger to safety. You will, perhaps, find this role very modest ; 
 but it is true, and that is enough for me. The father of 
 medicine has expressed the same idea in the noble language 
 which was proper to him : Natura medicatrix • medicus inter- 
 pres et minister. 
 
 Diet. — I should put you on your guard against the too 
 rigid diet of patients with typhoid fever v to which physicians 
 are inclined. When I was an interne of the hospitals of Paris, 
 from 1842 to 1848, those patients were put upon an extreine 
 diet during the whole course of the fever. We did not allow 
 them a single dish of broth during the three to six weeks 
 that the fever continued. To-day the maxim is, that we must 
 nourish our fever cases ; and the custom, in some cases, is to 
 give them cutlets and beefsteak in the very height of the 
 disease. 
 
 You should avoid these two extremes ; soups, milk, or very 
 clear porridge should form the diet in typhoid fever so long 
 as the fever continues, and you can vary the quantity and 
 quality of this food according to the digestive ability of each 
 patient, and also according to the predominance of this or of 
 that symptom. You may find that the intestinal difficulty 
 will require an absolute diet for some days. Some patients 
 can more easily digest milk, others broth, and others por- 
 ridge ; let the individual preference decide between them. 
 
 Dr. Tucker, of this city, recommends* a mode of preparing beef-tea by 
 combining it with ice cream, which may be grateful and acceptable in some 
 cases of this and of other diseases. He takes 120 grammes of cream, 30 
 grammes of sugar, 8 grammes of the extract of vanilla, and 8 grammes of beef- 
 juice. (He generally uses Johnson's beef-juice, but that squeezed from a good 
 beefsteak will answer.) These articles are frozen by the confectioner, or it can 
 be made at home. — L. 
 
 *The Chicago Medical Journal and Examiner for July, 1879, page 38. 
 
372 THE MEDICAL CLINIC. 
 
 When the disease is of long duration, a little wine is 
 necessary. When the debility is more and more pronounced, 
 Bordeaux or any other mild wine, with a little water, will 
 sustain the patient's strength until the fever has run its course. 
 We have just said that the bowel afTection should be your 
 guide in the choice of an aliment. Now the brain symptoms 
 play the same part in regulating the use of wine and of 
 alcohol. Remember that in typhoid fever there often exists 
 a true meningo-encephalitis, in which case the alcoholic prep- 
 arations are contra-indicated. 
 
 Drinks. — In this fever, more than in any other, and naturally enough, our 
 patients are very likely to want to drink very often, and to crave a change in 
 what they drink. We should try and minister to their comfort as much as pos- 
 sible in this way, for the old-fashioned, barbarous method of making the sick as 
 uncomfortable as possible, in this as well as in other respects, and of putting 
 them through a species of purgatory because they happen to be in our clutches, 
 is very cruel and unkind. 
 
 As a rule, even when there is considerable diarrhoea, acid drinks are not 
 only grateful, but also beneficial. A mild lemonade that is not too "sweet, an 
 orangeade made in the same way, the juice of fresh fruit, or currant or rasp- 
 berry jelly put into water, the water off stewed prunes, or apples, or raisins, or 
 peaches, or water that contains a little old cider, or wine, or a few drops of 
 vinegar, make quite a list from which to select. Of course they should be given 
 in moderation. 
 
 It is a good plan, as a rule, to have the drinks of a nourishing kind. The 
 acids supply one need of the organism under the circumstances, just as they do 
 in the eruptive fevers; but the patient's strength must be sustained, and it 
 cannot be done quite so well in any other way as by insinuating the food, little 
 by little, with the drinks that he would, could and should have. And, now that 
 the doctors have learned that good milk is not poisonous, we can allow our 
 typhoid-fever cases to take as much milk as they will in broken doses with their 
 drinks. For this purpose, plain, fresh country milk, diluted with good water, 
 may be taken or sipped very often. It is not only nourishing, but bland and 
 soothing to the inflamed mucous surfaces, and it is grateful by coating them 
 with a thin protective pellicle from the action of the air. Of course the acid 
 drinks and the milk should not be given at the same time or very near together. 
 The koumiss will answer very well when fresh milk is not available. 
 
 We append a brief communication, which embodies the experience of Prof. 
 Small in the treatment of typhoid fever, as related in his lectures on Theory and 
 Practice in the Hahnemann Medical College of this city. — L. 
 
TYPHOID FEVER. 373 
 
 "Since we commenced our professional labors in Chicago 
 and vicinity, twenty-three years ago, we have encountered 
 quite a number of cases of typhoid fever. 
 
 "According to our observation, the adults who are at- 
 tacked with this disease are of that class which is easily 
 impressed by malarious influences, — the greater proportion 
 of which are those of a nervo-bilious, or nervo-sanguineous 
 temperament. 
 
 "Children, without regard to temperament, being more 
 tender and susceptible, have apparently been equally the 
 subjects of the disease. 
 
 "During a practice of all these years, we have no recol- 
 lection of attending a solitary case in a person of a purely 
 sanguine temperament. Nevertheless, we have treated many 
 cases of the class first mentioned, with uniform success, when 
 it has not been complicated with other dyscrasise. 
 
 "After making our diagnosis and seeing that our patients 
 were placed in the best possible conditions for recovery, if 
 we have found them complaining of severe pain in the 
 head, with a dry, hot skin, and an accelerated, full pulse, 
 without appetite, and a yellowish-white coating upon the 
 tongue, we have invariably prescribed aconite, repeating the 
 doses every two or three hours, until the force and fre- 
 quency of the pulse became reduced and the skin became 
 more soft and inclined to moisture. 
 
 "If the pain in the head had only become dull and the 
 patient was inclined to coma, the coating on the tongue in- 
 clined to assume a darker hue, and, as is usually the case, 
 he did not wish to be moved, we gave bryonia, repeating 
 the doses every two or three hours, until we obtained some 
 kind of a reaction. 
 
 " If a more prostrating stage of the disease ensued, at- 
 tended with muscular soreness or stiffness in the lower ex- 
 tremities, we changed to rhus tax., which, after a few doses, 
 
374 THE MEDICAL CLINIC. 
 
 seldom failed to break up the disease. Sometimes directly, and 
 again after forty-eight or seventy-two hours, a normal secretion 
 would show itself on the margin of the tongue, and the 
 thick, black coating upon the dorsum of that organ would 
 begin to crack and come off in scales. The clammy and 
 almost foetid taste would be dissipated, the senses of taste 
 and smell return, and become normal, food and drink were 
 relished, and the excretions from the kidneys and bowels 
 soon presented healthy characteristics. 
 
 "In a majority of uncomplicated cases of average sever- 
 ity, .the above treatment was all that was required. We 
 usually rely upon the third decimal attenuation of the reme- 
 dies, and having been uniformly successful, without ques- 
 tioning the utility of the higher and the highest attenuations 
 in the hands of others, we prefer to stand upon the firm 
 ground which we have, for nearly forty years in all, found 
 to serve us so well. 
 
 "In connection with the use of aconite, bryonia and rhus 
 tox., which we regard as indispensable remedies in such 
 cases as we have described ; when slight or serious compli- 
 cations arise we have called into requisition belladonna, in 
 the first stage, when there was any indication of congestion 
 or chilliness, or when the pain in the head was so severe as 
 to be attended by a furious delirium. 
 
 "¥e have also resorted to phosphorus when, from phy- 
 sical examination, we found the evidence of an ulceration of 
 the mucus coat involving the glands of Pyer ; and arsen- 
 icum, alsp, in case of distention and a tympanitic condition 
 of the bowels, and when there is great prostration and offen- 
 sive discharges from the bowels. 
 
 "We have employed the baptisia tinctoria when the 
 odor of the breath was so offensive and sickening that even 
 the nurses regarded it cruel to be obliged to stay in the 
 
TYPHOID FEVER. 375 
 
 room, and this in spite of the use, meanwhile, of the best 
 disinfectants. 
 
 u In some instances we have employed gelsemium in the 
 early stage, when the pains in the head were neuralgic, 
 and shooting from temple to temple ; and in those cases 
 that were complicated with torpidity of the liver and con- 
 stipation of the bowels, we have prescribed mercurius vivus 
 first, for several doses, and then have given the nux vomica 
 or podophyllin, until we have seen a change in both. 
 
 "For those typhoid conditions that 'come on and disap- 
 pear, as if cerebro-spinal meningitis were threatening, we 
 have found no remedy that has served us so well as the 
 eupatorium jperfoliatum. 
 
 "Such cases as seem to come on gradually without any 
 pain whatever, except a sense of weariness and fatigue, with 
 a loss of appetite, not much acceleration of the pulse, but a 
 sunken expression of the countenance, a collection of sordes 
 on the teeth, the tongue covered with a thick, dark-brown 
 coating, and a suspended nutrition and a rapid loss of flesh, 
 with a thick, brick-dust sediment in the urine, and a tedious 
 constipation, respond favorably to the first dilution of bryonia, 
 twenty drops in half a goblet of water, and a teaspoonful to be 
 taken every hour. After the fever, in cases of this kind, as 
 well as in all other varieties, has subsided, and the appetite is 
 not quite restored, china, third dilution, will act usefully in 
 promoting recuperation and a rapid convalescence. As soon 
 as the appetite is fully restored, neither tonics nor stimulants 
 nor medicines can be of any further service. Solid food should 
 never be forced down the throat of a patient when the appe- 
 tite repels it and when the system is not in a condition to 
 dispose of it." 
 
376 THE MEDICAL CLINIC. 
 
 Meningo-Encephalitis in Typhoid Fever. 
 
 The love that the doctors have for metaphysics has always 
 inclined them to receive with favor the most fanciful explana- 
 tions of the nature of disease. At the present day it is suffi- 
 cient to refer this whole question to blood-poisoning • and 
 typhoid fever, being due to a poisonous influence, why 
 should we be any more surprised to observe a delirium in 
 this fever than in other diseases of a similar kind % Such 
 folly prevents the study of the symptoms and lesions of the 
 brain, the meningoencephalitis of typhoid fever, and causes 
 practitioners to overlook them, even when the disease may 
 have gone so far as to cover the convolutions of the brain 
 with a layer of pus. I can only treat this question in an 
 incidental way, but I will, however, give a brief outline of 
 the history of this affection. 
 
 Chomel, Louis, Barth, and some of their contemporaries, 
 unite in denying the existence of this form of meningitis in 
 typhoid fever. It was in vain that Piedagnel described it to 
 them, and enlarged upon the ramollissement, the adhesions of 
 the superficial layer of the central convolutions, and the kind 
 of ulcerations that form upon the surface of the brain in 
 consequence of those portions which are adherent to the gray 
 matter. Piedagnel was not a teacher ; he had no authority, 
 and when he discovered a fact the observers and statisticians 
 refused to examine it, and they have continued to declare that 
 the delirium of typhoid fever is of nervous origin, sympathetic, 
 and caused by changes in the blood. In other words, when it 
 becomes a question of studying the symptoms and of locating 
 the lesions, they wander back to proximate causes, precisely 
 as they did in the time of Galen. 
 
 Where Piedagnel had stranded, Dr. J. -P. Tessier could 
 not succeed. The former was not an authority, the second 
 
MENINGOENCEPHALITIS IN TYPHOID FEVER. 377 
 
 was under suspicion, so that his descriptions, with the proof 
 attached, at the clinic of the Hotel-Dieu, and his teaching 
 at the Practical School, failed on account of the obstinacy of 
 these same pathologists, who could not he induced to study 
 a lesion which their school had not the merit of discovering. 
 
 The monograph, which I published upon the same subject 
 in 1856, in the IS Art Medical, necessarily elicited no response 
 because of its place of origin. 
 
 But, when M. Quinquaud, of the Biological Society, and 
 M. Popoff, of the laboratory of Recklinghausen, discovered 
 these lesions, in 1874, the professional attention was immedi- 
 ately drawn to this subject. * * * * 
 
 What was the school represented by the I? Art Medical in 
 comparison with the Biological Society, and Tessier as com- 
 pared with Popoff, of the Recklinghausen laboratory ? And 
 wherefore, after we were so obstinate as to hold to our own 
 views in spite of the opposition of our enemies, although they 
 were very powerful, do we continue to-day to be the defenders 
 of positive and experimental therapeutics 1 * * * * 
 
 It is not possible that all the schools can discover, in 1874 
 and 1876, what was minutely described in 1845 and 1856. 
 This is our revenge, and it is sufficient. 
 
 The symptoms which characterize the meningo -encephalitis 
 of typhoid fever are: delirium, jerking of the tendons, and par- 
 tial paralysis. The delirium is not a simple, transient, noctur- 
 nal delirium, from which the patient is easily aroused when 
 one speaks to him, but it is continuous. It may be violent, with 
 crying, agitation and efforts to get out of the bed ; or it may, 
 on the contrary, be mild and mixed with sopor. Its distinctive 
 symptom is its continuity. The functions of the cerebral con- 
 volutions are decidedly deranged, and it is impossible to get 
 him out of his delirium. 
 
378 THE MEDICAL CLINIC. 
 
 The twitching of the tendons is caused by very slight con- 
 vulsions. The partial paralysis is incident to the advanced 
 development of the lesion. The muscles of the eye, of the 
 tongue, of the pharynx, and the sphincters, are most apt to be 
 paralyzed. 
 
 We shall reproduce in this connection the lesions that we 
 have very minutely described in 1? Art Medical: 
 
 "If we carefully lift the membranes of the brain, we find 
 that the pia-mater is red, thick, and more or less infiltrated 
 with a bloody liquid. This redness is caused by arborizations 
 at a right- angle, and by small ecchymoses, which, in certain 
 cases, are so close together that the membrane presents a uni- 
 formly red color. The lesion is especially marked upon the 
 free borders of the double fold which the pia-mater forms in 
 order to pass between the convolutions, and also in the tri- 
 angular space at the point where the two layers of the pia-mater 
 are doubled to unite with the visceral layer of the arachnoid. ' ' 
 
 But the lesions of the brain, which are observable after 
 the membranes are removed, are much easier to recognize and 
 are much more important. They may be observed when the 
 brain has been thoroughly washed. 
 
 " This lesion is made up of small, rounded, irregular ecchy- 
 moses, which vary in size, but which are always very small. 
 They are of a bright red color, and form a spot which cannot 
 be washed off. In certain places these ecchymoses are so near 
 together that they form a patch that is uniformly red. But 
 this abnormal discoloration does not constitute the entire 
 lesion, for there is also a diminution in the consistence of 
 the brain tissue. This very superficial softening, which is 
 easily recognized by its wrinkled appearance, and the unequal 
 surface (like that of a tomato) of the diseased convolutions, is 
 much more pronounced than the ecchymosed spot, and more 
 extensive also. 
 
 "Sometimes the softening is so marked that, in spite of 
 every precaution, the parts are broken down and confounded 
 
MENINGOENCEPHALITIS IN TYPHOID FEVER. 379 
 
 with the pia-mater, even when there are no real adhesions, but 
 simply by a defect of the proper cohesion." 
 
 When the patient succumbs to a stage of the disease which 
 is very much advanced, "the pia-mater sometimes presents a 
 real dropsy, and the firm adhesions unite with the pia-mater to 
 those points in the gray matter which are also diseased." (L 'Art 
 Medical, t. IV, page 2 et suiv.) 
 
 The microscopical researches which I have made since the 
 publication of this paper confirm the inflammatory nature of 
 the lesion in this febrile delirium. 
 
 In closing, I have a word of reply to a singular method 
 of reasoning by M. Louis. This excellent observer denies 
 the existence of the lesion which produces the delirium in 
 typhoid fever, because similar lesions have been found in 
 patients who have died from other febrile diseases with de- 
 lirium. But the conclusion that should justly be drawn from 
 this double fact is, that meningo-encephalitis is an affection 
 which is common to all those febrile diseases that are accom- 
 panied by a continuous delirium. This is what we have most 
 decidedly established in our Memoire by autopsies made in 
 cases of pneumonia and of acute phthisis. 
 
LECTURE XXVI. 
 
 Summary. — Of pneumonia, case. Rapid termination of the disease. Lack of 
 defervescence. Importance and difficulty of the diagnosis. Of individual- 
 izing and of curing by name or title. Arsenicum and tartar emetic. Case 
 of pneumonia with absence of the usual signs. No defervescence. Crit- 
 ical days. Necessity of examining all febrile patients by auscultation. 
 The expectant system, and the errors and fallacy of its statistics. The 
 boasted success of Dr. J. Hughes Bennet. Puerperal pneumonia, case. 
 
 Pneumonia Cured on the Ninth. Day. 
 
 Gentlemen : In a former lecture we have already spoken 
 of pneumonia and of its classical treatment by hryonia and 
 phosphorus. A jwopos of two cases which you have lately 
 seen in the men's ward, we shall resume this very practical 
 subject to-day. These two cases have been very serious in 
 their nature ; both of them were difficult of diagnosis, and 
 in both, bryonia having failed, we had recourse to arsenicum 
 and tartar emetic. This is the first of these cases : 
 
 Case LXYIII. — M. Charles B , aged forty-eight, was 
 
 admitted on the 31st of January, and discharged on the 20th 
 of February. (Men's ward, No. 3.) 
 
 The antecedents of this patient have been bad, and his gen- 
 eral condition on being admitted into the hospital was very 
 unfortunate. He tells us that for ten years past he has taken 
 cold in winter and summer, and that generally he coughed for 
 several months together. Ten days ago he was forced to take 
 to his bed. Although he is not sensibly emaciated, and has 
 never raised any blood, yet he looks like one with phthisis. 
 
 From the beginning of winter his health had been very 
 good, and he had not had the least sign of trouble, when, four 
 days ago, he was suddenly seized with severe chills. The next 
 day he had some cough and a violent dyspnoea, which has not 
 left him since that time. 
 
PNEUMONIA CURED ON THE NINTH DAY. 381 
 
 The observable symptoms do not accord in their gravity 
 with those revealed by auscultation ; he appears to be seri- 
 ously ill ; there is a profound adynamia, and the face is red 
 and swollen ; the breathing is difficult, and the fever intense. 
 On the evening of his admission the temp, was 103.1°, and the 
 pulse 124. 
 
 The cough is frequent, and the expectoration difficult ; the 
 sputa are not characteristic, but white, purulent, slightly aerated 
 and somewhat tenacious. There is a complete loss of appetite, 
 with a foul tongue. 
 
 Percussion shows a slight dullness over, the middle lobe of 
 the right lung ; and auscultation detects some loud and sibilant 
 rales on both sides of the chest, but more especially upon the 
 right one. 
 
 February 1, fifth day. Morning temp. 101.7°, pulse 96; 
 evening temp. 102.5°, pulse 96. Bryonia and ipecac. 12th dil. 
 
 February 2, sixth day. Morning temp. 101.3°, pulse 104; 
 evening temp. 102.9°, pulse 108. The patient had been very 
 restless during the night ; the dyspnoea was as bad as at the 
 beginning, and the debility still more pronounced. The ex- 
 pectoration is a little more copious, and the sputa more sticky. 
 
 This morning, auscultation reveals a tubular souffle at the 
 summit of the right lung, but the sonorous rales are still ob- 
 servable throughout the whole of this lung. Tartar emetic, 1 st 
 trit. He was also ordered two large spoonfuls of brandy. 
 
 February 3, seventh day. Morning temp. 102.5°, pulse 
 108; evening temp. 103.1°, pulse 108. 
 
 To-day the general condition of the patient is very bad ; 
 the temperature is very high, and he complains of a constant 
 oppression in the right lung. Besides the blowing sounds, 
 there are crepitant rales. Tartar emetic, 1st trit., during the 
 day, and arsenicum , 3d trit., at night. 
 
 February 4, eighth day. Morning temp. 101.6°, pulse 100 ; 
 evening temp. 101.8°, pulse 96. 
 
 The general condition of the patient is not improved, but 
 the temperature has fallen nearly one degree, and auscultation 
 reveals, instead of the souffle, a mixture of the mucous and 
 crepitant rales. The sputa are bloody and viscous. Arseni- 
 cum, 3d trit., alone. 
 
382' THE MEDICAL CLINIC. 
 
 February 5, ninth day. Morning temp. 99.9°, pulse 60; 
 evening temp. 98.9°, pulse 64. As the thermic curve shows 
 that the temperature has fallen to the physiological point, the 
 general condition of the patient is much better than it was 
 yesterday. 
 
 Now the sputa are quite characteristic ; they adhere to the 
 bottom of the vessel, and have the color of barley-sugar. There 
 are sub-crepitant rales in the right lung. Arsenicum, 3d trit. 
 
 February 6, tenth day. The temperature remained at 98.5° 
 both morning and evening. The dyspnoea of which he com- 
 plained has ceased. We still hear some moist rales in the 
 lung, but we also perceive a slight souffle of expiration at its 
 apex. Arsenicum, 3d trit. 
 
 February 7, eleventh day. The patient is going on well. 
 He was allowed to eat some porridge, and to drink a little 
 wine and water ; there is a very copious diarrhoea. The same 
 treatment. 
 
 February 8, twelfth day. The appetite is returning very 
 decidedly, and the expectoration is becoming less and less co- 
 pious. Continue the arsenicum., 3d trit., and give him an egg. 
 
 February 9, thirteenth day. The respiration in the dis- 
 eased lung is normal again; the mucous rales have entirely 
 disappeared. 
 
 February 11, fifteenth day. The patient still continues to 
 have a mucous expectoration ; the cough, however, is infre- 
 quent. Tartar emetic, 1st trit. 
 
 February 14, eighteenth day. He coughs and expectorates 
 less than before ; the digestion is very well performed. The 
 same remedy was continued for two more days, and the patient 
 left entirely cured. 
 
 Now, here is a case of pneumonia occurring in a man who 
 was worn out and ill, which terminated on the ninth day, and 
 the convalescence from which was complete after eight days. 
 Seventeen days have therefore sufficed for the disease and for 
 its convalescence. When these patients were subjected to 
 treatment by bleeding coup sur coup, by blisters, and by 
 large doses of tartar emetic, such rapid results were unknown. 
 
PNEUMONIA CURED ON THE NINTH DAY. 383 
 
 It is worthy of remark that, in this case, properly speak- 
 ing, there was no defervescence, since it required seventy-two 
 hours for the temperature to return to its normal state. In 
 fact, on the seventh day the temperature was 102.5° in the 
 morning, and 103.1° in the evening, id est, it varied only six- 
 tenths of a degree during the day. On the ninth day it 
 fell one degree, but it was not until the tenth day that it 
 reached the normal point of 98.5°. 
 
 It is also worthy of note that, in the case before us, the 
 ninth day (which in pneumonia is the mo&t pronounced of all 
 
 the critical days) marked the term of the morbid evolution. 
 
 «/ 
 
 The diagnosis was beset by a difficulty which is not often 
 encountered in such diseases as have their proper physical 
 signs ; for, although auscultation was practiced every morn- 
 ing and evening, yet it did not give us the characteristic signs 
 of pulmonary hepatization until the sixth day of the disease. 
 Until that time, we had only heard the rales proper to bron- 
 chitis, and therefore diagnosticated the case as one of grave 
 bronchitis. What was the cause of this anomaly % Undoubt- 
 edly it was the adynamic state of the patient, and the feeble- 
 ness of the respiratory movements. 
 
 Discrepancies in physical diagnosis are quite as possible in pulmonary dis- 
 ease as elsewhere, and under different conditions. The case corresponds with 
 the detection of uterine deviations. One physician examines a case and fails to 
 find any displacement. The next day another physician may be equally posi- 
 tive of the existence of prolapsus, or of some version or flexion of the organ. 
 Both were right and both were wrong if either insisted that a mistake had 
 been made in the diagnosis. With the change of conditions, diseased or ab- 
 normal states had developed that were not recognizable at first and under dif- 
 ferent circumstances. A little common sense would often keep physicians from 
 getting into a snarl in these matters, and more careful observation will make 
 us all more charitable. — L. 
 
 When our patient had reached the sixth day, the diagnosis 
 suddenly illuminated the whole pathological picture, and with 
 a positive proof of the lesion, the therapeutics ceased to be 
 doubtful and uncertain. The treatment was immediately 
 
384 THE MEDICAL CLINIC. 
 
 changed to the two remedies which are suited to a dangerous 
 form of pneumonia, viz: tartar emetic and arsenicum. When 
 the fever was intense (103.1°), the prostration very profound, 
 and the nightly agitation had afforded the principal indication 
 for it, the arsenicum was given alone, and it established the 
 convalescence. We also prescribed that a small quantity of 
 brandy should be taken, and we believe that the moderate 
 use of alcohol has not been without its influence in the happy 
 issue of this case. 
 
 It is especially in the pneumonia of old people, senile pneumonia, in some 
 forms of typhoid pneumonia, and in this disease, occurring in patients with a 
 broken-down constitution and unpromising antecedents, as in Case LVIII, that 
 alcohol in some form is of excellent service. We could cite a number of cases 
 from our own experience in which, judiciously given, it certainly was the means 
 of saving life. — L. 
 
 This example also shows you, gentlemen, that it is not 
 necessary to restrict or to limit the treatment which we apply 
 to all diseases of the same kind. We must study earnestly 
 the indications which are furnished by the symptoms of the 
 individual case; this is what I call individualizing, in the 
 true medical sense of the word. 
 
 You should, in fact, guard yourselves against two errors, 
 one of which consists in founding the indications upon certain 
 symptoms that are proper to the sick person, and in taking 
 no account of the diagnosis, the other in making, as it is some- 
 times styled, a cure by the name of the disease, or by the 
 use of a treatment which is arranged beforehand for all the 
 diseases of the same name or kind, without reference to the 
 particular indications in each case. After the first of these 
 methods one might prescribe ehamomilla, for example, in 
 tuberculous meningitis, croup, or the colic, if the child is quiet 
 only when it is carried, in the arms. In the latter case one 
 should not obstinately treat such a pneumonia, as we have 
 just detailed, by bryonia and phosphorus, else the patient will 
 be very apt to die. 
 
SPINAL SCLEROSIS WITH INTERCURRENT PNEUMONIA. 385 
 
 Spinal Sclerosis with. Intercurrent Pneumonia. 
 
 Here is a second case of pneumonia, which bears some 
 resemblance to the preceding one. 
 
 Case LXIX. — M. Georges P , aged thirty-six, admitted 
 
 on the 3d of February, 1876. (Men's ward, No. 6.) 
 
 This patient, who was attacked, some days after his entrance 
 into the hospital, with pneumonia, asked to be treated also for a 
 spinal affection from which he had suffered for about two years. 
 He was a janitor, and had lodged in a damp room ; but he had 
 never been very ill, and declared most positively that he had 
 not been of dissipated habits. 
 
 This disease had set in abruptly, with such a weakness of 
 the limbs that it was impossible for him to walk, except for a 
 very short time, without great fatigue. He had had bruised 
 pains in both legs ; but never had experienced the sharp, terri- 
 ble pains that are usual in locomotor ataxia. 
 
 From the beginning of his disease there was a continual 
 oppression, with occasional fits of violent suffocation. He had 
 also had vertigo for some time. Now we find him with the 
 following symptoms : The general condition is pretty good ; 
 there is, however, a slight emaciation of the lower extremities. 
 When his eyes are open he walks with comparative ease, and 
 the legs have not the irregular and jerking movements that 
 occur in locomotor ataxia ; but when his eyes are bandaged he 
 walks with the greatest difficulty, and threatens to fall at any 
 moment. 
 
 There is an habitual constipation, urination is difficult, and 
 he cannot empty the bladder entirely. 
 
 The cutaneous sensibility is preserved, and so, also, is the 
 muscular sensibility ; for some time, however, his vision has 
 been a little weak. He was given phosphorus, 12th dil. 
 
 This remedy was continued, but without improvement, 
 until the 10th of February. The night before he took a little 
 walk in the hospital court, and afterward complained of a vio- 
 lent headache and of great oppression. He also had fever, the 
 temperature being 101.3°, and the pulse 100. 
 
 February 10, second day. The patient complains severely, 
 25 
 
386 THE MEDICAL CLINIC. 
 
 but is not so oppressed as during the niglit, and does not cough. 
 Morning temp. 101.1°, pulse 120; evening temp. 101.3°, pulse 
 120. Aconite, 6th dil. 
 
 February 11, third day. Morning temp. 101.8°, pulse 108; 
 evening temp. 103.25°, pulse 112. He is not doing so well; he 
 does not cough, and there is no sign of an acute affection of 
 the lungs. The same remedy. 
 
 February 12, fourth day. Morning temp. 104°, pulse 120 ; 
 evening temp. 104°, pulse 112. The fever is intense ; the 
 patient had some bleeding from the nose during yesterday, and 
 this was followed by a pretty frequent cough. Auscultation of 
 the back part of the thorax gives a negative result. Aconite, 
 6th dil. 
 
 February 13, fifth day. Morning temp. 103.25°, pulse 112; 
 evening temp. 103.6°, pulse 120. He continues to cough, but 
 raises nothing ; the headache of which he complained at first 
 is better. 
 
 February 14, sixth day. Morning temp. 101. b°, pulse 112; 
 evening temp. 103.25°, pulse 112. At our morning visit there 
 was an adherent, yellowish, sticky sputa, which clung to the 
 bottom of the vessel, and which was a little streaked with 
 blood. Auscultation of the thorax, both anteriorly and poste- 
 riorly, revealed an intense souffle, which was located in front 
 and in the upper portion of the right lung ; there were no rales. 
 Bryonia, 3d dil. 
 
 February 15, seventh day. Morning temp. 102.5°, pulse 
 116; evening temp. 103.25°, pulse 120. This morning the gen- 
 eral condition of the patient was very bad ; the souffle extends 
 both in the front and behind ; there is complete prostration, 
 and the tracheal rale can be heard at a distance. Tartar emetic, 
 1st trit., for the day, and arsenicum, 3d trit., for the night. 
 
 February 16, eighth day. Morning temp. 101.6°, pulse 
 100; evening temp. 100.4°, pulse 100. There is a decided 
 improvement in the patient's condition ; the dyspnoea is less 
 marked, and the facial expression is better. During yesterday 
 he had a slight epistaxis ; to-day auscultation discloses blowing, 
 sub-crepitant and crepitant rales. The same prescription. 
 
 February IT, ninth day. The fever is completely broken ; 
 the evening temperature was 99.6° ; the respiratory souffle has 
 disappeared. Arsenicum, 3d trit. 
 
SPINAL SCLEROSIS WITH INTERCURRENT PNEUMONIA. 387 
 
 February 19. He still coughs a little, and complains of a 
 slight pain in the right side. There are some mucous rales in 
 the chest. Bryonia, 3d dil. 
 
 February 22. He coughs but very rarely ; the pain in the 
 side has left ; his strength returns very slowly. Phosphorus, 
 6th dil. 
 
 February 25. Last evening he had a slight oppression, 
 with a pretty sharp pain in the epigastric region. JSfux vomica, 
 3d trit. 
 
 February 28. Respiration in the right lung is normal, but 
 he still coughs a little ; the digestion is better, but not perfect. 
 The same remedy. 
 
 The patient had no more symptoms, but continued to im- 
 prove during the month of March. 
 
 In this case the diagnosis has been very difficult, on account 
 of the absence of the usual signs of pneumonia ; neither cough, 
 nor expectoration nor pain in the side were present. Perhaps 
 we were wrong not to have practiced auscultation more thor- 
 oughly. The seat of the hepatization, above and in front of 
 the chest, is so rare, that we have spoken of it ; it certainly 
 helped to prolong the error in diagnosis. The disclosures 
 of the thermometer were those proper to pneumonia. There 
 was a rapid rise of the temperature, without oscillation, to 
 
 104:°. 
 
 We should at least feel as kindly toward the failures of physical diagnosis 
 as we do toward the failure of our remedies, when we do not obtain the desired 
 result from their employment. If we depend upon them to the exclusion of 
 others, the signs revealed by auscultation and percussion are no more reliable 
 than the general symptoms. For one is the complement of the other, and both 
 are necessary. 
 
 The author's point is well taken, but he might have added that there are 
 two forms of pneumonia in which one would almost certainly be misled, if he 
 should rely to any considerable extent upon this mode of examination, more 
 especially in the early stage of the disease. These two kinds of pneumonia are 
 the pneumonia of infancy, or of early childhood, and that which occurs in the 
 puerperal state. 
 
 In infantile pneumonia, a careful physical examination of the child's chest, 
 more especially of the front part of the thorax, is often impossible ; for nothing 
 short of a profound anaesthesia would keep the youngster quiet and overcome 
 
388 THE MEDICAL CLINIC. 
 
 his opposition. Add to this the fact that, in the lobular form of pneumonia, 
 the lesion may be so limited to the interior of the organ, and so covered by the 
 healthy lung tissue, as practically to be beyond the reach of the ear and of the 
 pleximeter. In such a case we cannot, therefore, depend upon the physical signs 
 exclusively, any more than we could upon the subjective sensations of the pa- 
 tient, when the little one is not old enough or wise enough to tell us how or 
 what he feels. 
 
 We shall add a clinical talk on puerperal pneumonia at the close of this 
 lecture. — L. 
 
 In this case we have to remark also that there was no 
 proper defervescence. On the seventh day the temperature 
 was 103.25° ; on the eighth day, 100.4°, and on the ninth day, 
 99.6°. Here was, therefore, a regular, although rapid, decrease 
 of the temperature. 
 
 Besides the last peculiarity, there was the termination on 
 a critical day, the ninth day of the disease, and the rapidity 
 of the convalescence, which was complete after two days. 
 
 The prostration and the oppression complained of were the 
 symptoms that led to the choice of the tartar emetic and 
 arsenicum . We believe that it will not be useless to recom- 
 mend physicians to practice auscultation with care in all those 
 patients who have fever, even when they have no cough nor 
 pain in the side. You have just seen two cases which illustrate 
 the importance of this precept. 
 
 The Expectant Method and its Fallacies. * 
 
 You know, gentlemen, that pneumonia is one of the acute 
 diseases which has served for a clinical demonstration of the 
 efficacy of the homoeopathic treatment. This demonstration 
 has been established upon such numerous and well-authenti- 
 cated facts that our opponents have vainly tried to destroy the 
 force of the argument. The most radical objection, and that 
 which has found most favor, consists in claiming that pneu- 
 monia is a benign affection, with a natural tendency to re- 
 covery ; that the success of homoeopathic remedies is that of 
 the expectant system ; and that by this expectant method we 
 may cure almost every case of pneumonia. 
 
THE EXPECTANT METHOD AND ITS FALLACIES. 389 
 
 Our opponents have not reflected that if the spontaneous 
 cure of pneumonia was of every-day occurrence ; if the expect- 
 ant treatment lost only eight or ten per cent, the old-school 
 treatment would be murderous, for in the hospitals of Paris 
 the mortality from pneumonia is generally increased to thirty 
 or thirty-five per cent. But these marvelous results of the 
 expectant method in the treatment of pneumonia are founded, 
 upon an undoubted fallacy ; and we must in good faith have 
 done with the fantastic and lying statistics which the enemies 
 of progress in therapeutics so constantly * quote, in order to 
 undermine the success of homoeopathy in the treatment of 
 pneumonia. 
 
 The author of an anonymous article upon Alcohol in Thera- 
 peutics, which was published in the Bulletin general de thera- 
 jpeutique for October 16, 1875, cites some statistics which are 
 very inaccurate and untruthful. This table is printed in the 
 JLegons cliniques de Vhopital de la Oharite, by Dr. Jaccoud 
 (page 70). It is as follows: 
 
 I. PNEUMONIA TREATED BY VENESECTION. 
 
 From Edinburgh, 698 cases; mortality, 34.52 per cent. 
 
 From Dietl, 85 cases; mortality, 20.40 " 
 
 Total, 783 mean mortality, 27.06 " 
 
 II. PNEUMONIA TREATED BY TARTAR EMETIC. 
 
 From Rasori, 648 cases ; mortality, 22. 06 per cent. 
 
 From Dietl, 106 cases; mortality, 20.70 
 
 a 
 
 Total, 734 mean mortality, 21.98 " 
 
 III. PNEUMONIA UNDER A MIXED TREATMENT. 
 
 (From groups of cases by Laennec, Grisolle and Skoda.) 
 Maximum mortality, 16.00 per cent. 
 Minimum mortality, 12.05 " 
 Mean mortality, 14.25 " 
 
390 THE MEDICAL CLINIC. 
 
 IV. CASES OF PNEUMONIA WITHOUT TREATMENT. 
 
 Collected by Dietl, 189 cases; mortality, 7.4 per cent. 
 
 V. PNEUMONIA TREATED EXCLUSIVELY BY TONICS. 
 
 Collected by Bennett, 129 cases; mortality, 3.10 per cent. 
 
 We have already replied {L^ Art Medical, 1862), to the 
 argument drawn from the use of the expectant method in 
 the treatment of pneumonia ; and we have shown that, in 
 pneumonia treated by homoeopathy, instead of recovery by 
 defervescence, as with those which are left to expectation, 
 there is usually a gradual subsidence of the symptoms ; 
 that the pain in the side diminishes before disappearing ; 
 that the pulse falls each day a certain number of beats be- 
 fore reaching the normal state ; and that the febrile heat 
 itself does not fall abruptly from 104° to 98.5°. We then 
 said, and now we repeat it, that it is wrong to judge of the 
 merits of the expectant method by the results obtained by 
 Dietl during the first year (1849), for he had a fortunate 
 group of cases, of which he lost only 7.4 per cent. If we 
 mean to get at the truth of the matter we should study the 
 following series : Thus, in 1852, the mortality increased to 
 9.2 per cent, and in 1854, to 20.7 per cent. 
 
 We must also make note of the experiments of Bordes, 
 who, in 1855, cured 22.0 per cent; those of Schmidt, who 
 lost 23.0 per cent, and finally in the Archives of Yirchow 
 (XV, 3 B. und 4 Heft, p. 210), that Brander, of Copenhagen, 
 had a mortality of 31 per cent under the expectant treatment. 
 
 The total of these statistics gives us 18.88 per cent as the 
 result obtained by the expectant method in the treatment of 
 pneumonia, and a very sad result it is. 
 
 We must say, therefore, that it is very untrue to claim that 
 7.4 per cent expresses the mortality of pneumonia when left 
 to simple expectation, for the true figure is 18.88 per cent. 
 
THE EXPECTANT METHOD AND ITS FALLACIES. 391 
 
 These facts have alreadj 7 been quoted by the author (see page 100), but 
 their echo in this connection gives additional emphasis. — L. 
 
 If we acknowledge to our opponents that this triumph has 
 been too easy and too quickly accomplished by Dietl, we must 
 say that Bennett has obtained results that are still more sur- 
 prising. His treatment exclusively by restorative medicine 
 gives a mortality of 3.10 per cent in a total of one hundred 
 and twenty-nine cases. What shall we now say of the suc- 
 cess of homoeopathy in the treatment of pneumonia ? Can 
 we do better than to save 3.10 per cent* in those who have 
 pneumonia ? 
 
 For a long time I have wanted to say what I thought of 
 this English clinicien' and since he has recently died, it is 
 proper to make his funeral oration with a freedom that be- 
 longs only to history. I will make it in three words which 
 pertain strictly to the subject before us : 
 
 (1) Bennett did not know how to practice auscultation ; (2) 
 he arranged his own statistics, and (3) far from treating his 
 patients who had pneumonia exclusively by restorative means, 
 Bennett gave them a host of remedies. 
 
 For these three reasons, which are well established, the 
 claim of 3.1 per cent mortality in pneumonia is an out- 
 rageous fraud. How is it possible that experienced physi- 
 cians have not discovered this deception ? Who does not 
 know, indeed, that in the hospitals of Paris the mortality 
 from pneumonia almost every year exceeds 30 per cent? 
 How is it possible that a man could obtain the fabulous re- 
 sult of 3.1 per cent, especially if one takes the pains to 
 read his cases and to observe the singular treatment to 
 which he submits his patients ; but in France nobody has 
 taken the trouble to investigate this matter. 
 
392 THE MEDICAL CLINIC. 
 
 Now, for my own part, I am going to prove, first, that 
 Dr. Bennett practiced auscultation very badly, and for evi- 
 dence we may read some rare cases of pneumonia that are 
 given in his clinic. The expressions of rale, of souffle, of 
 dullness, which have a meaning with our French authors, 
 are, in Bennett's Clinic, used without precision, and it is very 
 difficult to understand the extent of the lesion in the case 
 of the patients who are the subjects of his clinic. 
 
 Dr. Hughes Bennett calls his treatment of pneumonia a 
 restorative medication. Now this plan of treatment is usually 
 composed of beef-tea as an aliment ; then of neutral salts, of 
 antimonials and diuretics, of ammoniacum, of tartar emetic, 
 and sometimes of dry-cupping. 
 
 This is a kind of expectant treatment, of which the druggists 
 would never make any complaint. 
 
 It was by means of this restorative treatment that Bennett 
 had only four deaths in 125 cases, and as these deaths were in 
 complicated cases, he suppressed them and reports 121 cures in 
 121 cases, the mortality being reduced to zero (p. 320). * * * 
 
 Besides those four deaths, which were due to complications, 
 the author also speaks, at page 315, of thirteen complicated 
 cases which he has not counted; then, at page 318, of 'some 
 other cases that were brought in in a dying state ; finally, Dr. 
 Bennett does not include in this list those cases in which the 
 treatment was begun or finished by his confreres. Thus, as 
 the result, 13.4 per cent out of seventeen complicated cases 
 terminated fatally, without counting those which were brought 
 in in a moribund state, and those also of which the treatment 
 had been begun or ended by his associates. 
 
 I believe, therefore, that we shall not be extravagant or 
 unjust in estimating 25 per cent of mortality instead of the zero 
 of this very boastful teacher. 
 
PUERPERAL PNEUMONIA. 393 
 
 This very plain talk of our author should be of real service to the cause of 
 clinical medicine. A mere idle boast that any particular system of treatment 
 is best suited to the cure of so grave a disease as pneumonia does not and can 
 not satisfy the earnest physician who desires to do his whole duty by his profes- 
 sion and his patients, and to place himself rightly upon the record. The 
 numerical method is full of fallacies; and when we come to figures (unless we 
 are very careful to qualify our reports), the quacks always have the advantage. 
 
 The real safeguard against deception is a careful statement and analysis of 
 the symptoms, more especially of the physical or objective symptoms, in any 
 case or class of cases. And Dr. Jousset is just, as well as keen and discrimi- 
 nating, when he proves that Bennett's statistics are worth but little because his 
 record of the physical signs of pneumonia is loosely and carelessly drawn. — L. 
 
 The success of the homoeopathic treatment of pneumonia 
 remains, therefore, as a proof of the value of this system ; 
 and the falsehoods as well as the illusions furnished by statis- 
 tics have only helped to increase the value of this argument by 
 demonstrating its reliability. 
 
 Puerperal Pneumonia. 
 
 The following case, and the clinical remarks upon it, were brought to the 
 attention of, and delivered to, my class in the Hahnemann Hospital, of this city, 
 April 9, 1877. They will serve still further to illustrate the teaching of our 
 author upon the subject of pneumonia, and more especially the difficulty of 
 diagnosticating it, in some cases, in its early stage. — L. 
 
 As members of the clinical classes which have accompanied 
 me to my ward in the hospital for the especial study of the 
 puerperal diseases, you will all remember Case ~No. 2,098. It 
 was one of puerperal pneumonia, and possessed many points 
 of practical interest. Despite our best efforts, the poor woman 
 died. An autopsy was held last evening ; but before showing 
 you the results of that examination, I will refresh your mem- 
 ories with a very brief history of the case. 
 
 Case 2,098. — Aggie M., aged twenty-three, came to the 
 hospital thoroughly wet from walking in a snow-storm. Ten 
 minutes after her admission she was delivered of a still-born 
 male child at the* seventh month. She had had two full-term 
 children before. Excepting the signs of a bad cold and a very 
 troublesome dry cough, which she said she had had for several 
 
394 THE MEDICAL CLINIC. 
 
 days, her condition was good. On the second day the lochia, 
 which had been very slight and offensive, disappeared, and did 
 not return until the morning of the fifth day, when it came for 
 a little, and then ceased altogether. She had no chill until the 
 afternoon of the fifth day, and no pain in the chest until the 
 eleventh day. The chill was repeated on the twentieth day. 
 The pain began over the right lung, and extended to the left. 
 It was worse when coughing, and from lying on the right side, 
 and finally spread over the abdomen, and was accompanied by 
 diarrhoea. During the night of the fifteenth day she com- 
 plained bitterly of pain in the left ankle, which was swollen, 
 but not discolored. For twenty-four hours that ankle was ex- 
 quisitely sensitive, and then the pain subsided. . On the morn- 
 ing of the fifth day she had a dizzy headache, with slight epis- 
 taxis. From the first there were circumscribed flushes, of a 
 carmine hue, on the cheeks, but the general complexion was 
 dusky. Until the eleventh day the most careful physical ex- 
 amination, frequently repeated, failed to elicit the signs of 
 pneumonia. She did not expectorate anything, but swallowed 
 the mucus, like a child. This evidently caused the vomiting, 
 which began at the end of a fortnight. On the seventeenth 
 day she had hoarseness, which continued, and the stools be- 
 came more frequent and offensive. A typhoid condition super- 
 vened. On the twenty-first day she raised some bloody mucus, 
 containing a small quantity of pus. The breathing grew more 
 difficult, the stools involuntary, and she died on the morning 
 of the twenty-fourth day. 
 
 The autopsy, made with the assistance of Messrs. Rockey, 
 Laning, Myers, Todd, Barker and Pillsbury, of the medical 
 class, revealed an abscess filling three-fourths of the upper lobe 
 of the right lung, and a smaller one, involving the internal and 
 external surfaces of the left ankle. The liver was healthy. 
 There was a clot in the right auricle of the heart, but, so far as 
 we could discover, there were no thrombi in the pulmonary 
 vessels. In patches the mucous surface of the small intestines 
 was ulcerated, and almost gangrenous. The uterus and its 
 appendages were undergoing the proper changes. There were 
 no traces of uterine phlebitis. 
 
PUERPERAL PNEUMONIA. 395 
 
 This record omits the treatment, of which you already 
 have the details, in order that I may call your undivided atten- 
 tion to other points in the clinical history of this disease. 
 
 Puerperal pneumonia is comparatively a rare affection. 
 It may be either primary or secondary. In the first of these 
 varieties it may have existed before delivery, as it undoubtedly 
 did, but in a latent form, in this instance. The secondary 
 pneumonia of childbed is very apt to terminate in abscess, and 
 if my experience is a reliable criterion, the same is true of 
 idiopathic puerperal pneumonia in those who miscarry with 
 still-born children after the sixth month. 
 
 Secondary puerperal pneumonia most frequently succeeds 
 or complicates the pelvic or abdominal diseases of the lying-in 
 state, viz : peritonitis, metritis, metro-phlebitis, and inflamma- 
 tion of the broad ligament. In case of metastatic abscess 
 occurring in the lungs, the lesion is the consequence of em- 
 bolic infarction, or of obliteration of some of the pulmonary 
 vessels. 
 
 Primary puerperal pneumonia may be due to the same 
 causes that will produce an attack of pneumonia in the non- 
 puerperal state. Its most powerful predisposing causes are : 
 the existence of bronchitis developed by pregnancy, and the 
 rapid evolution of tubercles which is sometimes hastened by 
 the same condition. It seldom begins with a chill, and it 
 may be latent. 
 
 The pneumonia of childbed is sometimes epidemic. In 
 its secondary form it may commence as early as the fifth, 
 or as late as the twentieth, day. In either case it is caused 
 by an extension or translation of the disease from other 
 viscera. The local causes which invite or suggest its devel- 
 opment are the occurrence of very small purulent deposits, 
 
396 THE MEDICAL CLINIC. 
 
 of metastatic abscesses, or of tubercles in the pulmonary 
 tissue, or the previous existence of pleurisy. 
 
 There is a variety of this secondary pneumonia which 
 was first described by Hervieux, in 1867, which he styled 
 the hypo-pleuritic, caused by contact of the lung with an 
 inflamed pleura. 
 
 The local symptoms of puerperal pneumonia are the same 
 as in ordinary pneumonia. The only exceptions to this rule 
 are in case the lesion is masked by pleurisy with extensive 
 effusion, or is limited to one or more of the lobules of the 
 lung. Our patient had lobular, instead of lobar pneumonia, 
 and hence the obscure nature of the attack, the absence of 
 the proper physical signs, and of expectoration, and the lin- 
 gering nature of the disease. She was ill from the date of 
 her delivery, with an unmistakable primary pneumonia, but 
 the local symptoms did not correspond until the eleventh day. 
 
 ISTow, whether this limited, lobular inflammation was due 
 to an infarction, or the blocking up of a small pulmonary 
 vessel by a floating shred, which was detached from the 
 thrombus, that we found, on the autopsy, in the right auricle 
 of the heart, I cannot say. It may have been, for this is 
 not a post-mortem clot. 
 
 Whatever its direct cause, the disease was circumscribed 
 and essentially latent. You remember our search for the 
 physical signs of pneumonia ; crepitus, sub-crepitus, bron- 
 chial respiration, absence of the vesicular murmur, and dull- 
 ness on percussion could not be recognized. We were equally 
 certain that it was not hypostatic. My friend, Prof. John C. 
 Morgan, visited her with me on the ninth day, and subjected 
 her to a very critical examination, but failed to detect any 
 physical trace of pneumonia. It was only when the lesion 
 had spread and come toward the surface of the lung, when 
 it had ceased to be lobular and had become lobar, that she 
 
PUERPERAL PNEUMONIA. 397 
 
 began to complain of pain on coughing and in lying on the 
 affected side, to expectorate like an adult with pneumonia, 
 and to offer the proper physical signs of that disease. And 
 this did not occur until the eleventh day. 
 
 If this had been a case of secondary pneumonia, the ab- 
 sence of these signs might easily be accounted for. If our 
 patient had first been ill with some pelvic or abdominal in- 
 flammation, and afterward with pneumonia, the evolution of 
 the chest symptoms would certainly have been delayed. But 
 it was not so. Neither the house physician's record, nor the 
 revelations of the scalpel, show that she had any primary dis 
 ease outside of the thorax. 
 
 The course and duration of the disease confirm our view 
 of the case. If puerperal pneumonia follows a serious at- 
 tack of peritonitis, phlebitis or of endometritis, it usually ter- 
 minates fatally within three days. The same is true of the 
 metastatic abscesses in the lung, when the patient has a 
 marked purulent diathesis. 
 
 More than this, the general symptoms of secondary puer- 
 peral pneumonia very readily assume the typhoid character. 
 If our patient had had that form of the complaint, the typhoid 
 symptoms would certainly have appeared a fortnight sooner 
 than they did. A knowledge of this fact will sometimes 
 give you a great advantage in the treatment of puerperal 
 pneumonia. 
 
 When the disease is complicated with tuberculosis it is 
 necessarily of a serious character. I would not despair of 
 a cure, however, unless the phthisis is far advanced, or the 
 pneumonia is secondary upon some puerperal affection, as 
 well as upon the tuberculosis. We must not forget that 
 there are cases in which, while pregnancy has apparently 
 arrested or suspended the development of tubercles, the pu- 
 
398 THE MEDICAL CLINIC. 
 
 erperal condition may have an opposite effect. With some 
 women this fatal acceleration of phthisis is very marked. 
 
 If this form of pneumonia is complicated with pleurisy, 
 and more especially with pleuritic effusion, the risks are in- 
 creased by the tendency of the contained serum to degene- 
 rate into pus, and to form an abscess. These cases recover 
 very slowly. 
 
 Metastatic abscess in the lung, like the case of mammary 
 abscess which I have shown you this morning, may be salu- 
 tary. They sometimes afford a means of escape and diver- 
 sion for poisonous matters, a species of safety-valve for the 
 organism, and are not of necessity fatal. In some cases 
 there is a tendency in these abscesses to revert to their 
 original site ; and in others to locate themselves in the 
 larger joints, and even in the pelvic articulations. Excep- 
 tionally, a secondary abscess in the ankle or elsewhere, in 
 the course of a primary pneumonia, may be a good sign ; 
 but usually, as with our patient, it is not so. 
 
 G-risolle's idea that the pneumonia of pregnancy is a 
 very serious affection is undoubtedly correct ; but there are 
 some cases of broncho-pneumonia of a catarrhal nature which 
 come over from the pregnant to the puerperal state, that are 
 curable. So that the prognosis is not always unfavorable. 
 It is said to be a bad sign when the odor of the breath dis- 
 tinctly resembles that of the lochial discharges. 
 
 When puerperal pneumonia is complicated with very grave 
 general conditions, or when it is hypostatic, we should be chary 
 of promising to cure it. Occasionally, no doubt, the pulmo- 
 nary lesion affords a diversion which, although it is beset with 
 danger, may be salutary and curable. Usually, however, as 
 in other puerperal diseases, the prognosis varies not only with 
 
PUERPERAL PNEUMONIA. 399 
 
 the septic or the pyaemic vitiation of the blood, and of the 
 secretions, but also with the more or less serious nature of 
 the intercurrent affections. 
 
 Exposure of the patient to cold and wet, and to injurious 
 atmospheric influences, when it has caused pneumonia during 
 the lying-in, sometimes appears to stamp it with an almost 
 necessarily fatal character. It was for this reason, among 
 others, that I felt extremely anxious in regard to our patient 
 at my first visit. You cannot have forgotten my remarks 
 upon this subject. 
 
 This drawing on the blackboard will give you the morning 
 and evening record of the pulse, and of the temperature in 
 the case under review. The blue line indicates the pulse, the 
 red one the temperature. The figures are already in your 
 case-books, but this chart is more graphic and suggestive. 
 
 Observe that, in this instance, the septic period was ex- 
 tended until the close of the thirteenth day. This is some- 
 what unusual, and is referable to two causes: (1) to the total 
 suppression of the lochia, and (2) to the fact that at first 
 the pneumonia was circumscribed, and of very limited extent. 
 For the space of eight days, with two brief exceptions, the 
 temperature did not fall below 102°, and then it only reached 
 101°. While this state of things indicated exemption from 
 immediate danger, in so far as the lungs were concerned, it 
 could not continue. The local lesion must declare itself, bv 
 a lowering of the temperature, and by a disclosure of the 
 physical signs which should and did unmask the pneumonia. 
 
 When this septic period had passed, and the pneumonia 
 had become lobar, the descent in the scale indicated the 
 drift toward suppuration. A falling temperature, in cases 
 like this, always foretells one of two things, id est,, either 
 
400 THE MEDICAL CLINIC. 
 
 suppuration or convalescence. If the decline is gradual, and 
 the general and local symptoms improve accordingly, the 
 prognosis is favorable. But, if the local symptoms become 
 more extended and manifest, and a typhoid condition sets 
 in, the very approach of the temperature to the normal stand- 
 ard implies the risk of abscesses, and is full of danger. It 
 is under such circumstances that one may be gratified and 
 encouraged, as we were on the eighteenth day, by a rise of 
 the temperature ; but, if it drops again suddenly, as it did 
 on that day, and more especially at evening, our hopes will 
 be blasted. 
 
 So that, in similar cases, it will not always be safe to con- 
 clude that, because the temperature has become more nearly 
 normal, therefore our treatment has been most fitly chosen, 
 or that our patient is getting well. Invaluable and indis- 
 pensable as is the clinical thermometer in the diagnosis, prog- 
 nosis and treatment of all kinds of puerperal affections, it 
 nevertheless may be insufficient to meet all the requirements 
 of the case. We must not rely upon it exclusively. 
 
 In the study of puerperal pathology there is nothing more 
 tricky than the pulse. But, in this case, the record of the 
 pulse had a certain significance, which this blue curve-line will 
 keep in your minds. Observe that from the thirteenth day 
 the relative position of these two lines is changed. Until 
 that time (excepting for about twenty-four hours, beginning 
 on the evening of the second day), the heat-line was invariably 
 the highest. But from the evening of the thirteenth day for- 
 ward, this order was exactly reversed. The inference to be 
 drawn from this clinical fact (which is absolute and not fanci- 
 ful), is that an exclusive reliance upon either of those two 
 methods of examination would certainlv have misled us. To 
 have judged by the pulse alone in the first half of the period, 
 you would have said that the patient was doing well ; and 
 
PUERPERAL PNEUMONIA. 401 
 
 to have depended upon the thermometer exclusively in the 
 last half of it, you would have decided that there was no 
 danger. 
 
 There are cases like this in which the contrast and com- 
 parison of these two curves is worth a hundred times more 
 than either of them alone. This is one reason why I have 
 had them arranged for you on the blackboard. They should 
 always be studied together and compared with each other, 
 for their conjoined use will enable us the more accurately to 
 perceive the real constitutional condition oi* the patient, and 
 therefore to make -a better prognosis and a better prescrip- 
 tion. 
 
 Here is the morbid specimen which illustrates our case. 
 Three-fourths of the upper lobe of the right lung is involved 
 in this abscess. You can see its outline, and when I turn 
 it inside out the whole suppurating surface is exposed. 
 
 The pus is thick, and of a greenish-yellow color, and we 
 find, by cutting, that it had pushed its way into the right 
 bronchus. If this discharge had overflowed into the larger 
 tubes, the patient must have died from suffocation. For, in 
 her weak state, it would have been impossible for her to have 
 expectorated so large a quantity at one time. 
 
 Whether this lesion began with the embolic infarction of 
 
 one or more of the small pulmonary vessels, we cannot say. 
 
 According to Virchow, if the abscess had been metastatic, it 
 
 must have originated in that manner. It is very probable 
 
 that the abscess at the ankle was due to the plugging up of 
 
 some of the little vessels in that vicinity. But in this case 
 
 the pneumonia must have followed the usual course in its 
 
 local development, always remembering its lobular character. 
 
 There was, probably, engorgement, then effusion, fibrinous 
 
 coagulation, extension of the disease, and a gradual coming 
 
 on of the suppurative process. 
 26 
 
402 THE MEDICAL CLINIC. 
 
 When the stage of red hepatization is reached, in puerperal 
 pneumonia especially, there is a fearful tendency toward puru- 
 lent infiltration. Hence the simplest and most circumscribed 
 attack of primary pneumonia in a lying-in woman may develop 
 into an abscess, as this has done, and quite independently of 
 pulmonary infarction. In secondary puerperal pneumonia this 
 termination is the rule and not the exception. 
 
 I take pleasure in showing you the uterus and its append- 
 ages. You will be struck with the thickness and firmness of 
 the uterine walls. As we cut through them there is no evi- 
 dence of phlebitis, and the lining membrane of the cavity 
 appears healthy. The ovaries and other appendages are nor- 
 mal. You can examine the heart-clot and this section of the 
 ulcerated intestine at your leisure. 
 
 These convergent facts are worthy of your notice and study, 
 not only because they will be likely to repeat themselves in 
 your own professional experience, but also because, at present, 
 there is almost nothing in our literature on the subject of puer- 
 peral pneumonia. 
 
LECTUEE XXVII. 
 
 Summary. — Rheumatism, continued (see Lectures III, IV, V and IX). Case 
 of rheumatism with endocarditis. Aortic insufficiency. Two sounds in 
 the crural artery. How to distinguish the systolic from the diastolic mur- 
 mur. Theory and practice. Science and art. Theory of the two arterial 
 murmurs in insufficiency. Mono -articular rheumatism. Good effects of 
 china. Articular rheumatism. Contraction of the mitral orifice. Hemop- 
 tysis, case. Millefolium. Certain rare complications of articular rheu- 
 matism. Hematuria, case. Hamamelis and Spigelia. Spinal rheumatism, 
 case. Acute parenchymatous myelitis of the anterior gray columns of the 
 cord. Plumbum. Locomotor ataxia, cases. 
 
 Rheumatism. 
 
 Gentlemen: Unlike nosography, clinical teaching is not 
 compelled to follow a fixed order from which there is no de- 
 parture ; and, although we have already spoken to you of 
 rheumatism, and of its cardiac complications, we think it well 
 to return to this subject, and to call your attention to the 
 patient who occupies No. 4 in the men's ward. The occupant 
 of ~No. 5 will furnish the occasion to speak to you of mono- 
 articular rheumatism. And several other rheumatic patients 
 will illustrate the clinical history of some rare complications of 
 this disease, especially of rheumatic paraplegia and hematuria. 
 
 Case LXX. — Acute articular rheumatism, endocarditis, 
 aortic insufficiency, double murmur in the crural artery. 
 
 Joseph R , aged twenty-eight, domestic, admitted to 
 
 ~No. 4, men's ward, on the 22d of December; discharged on 
 the 23d of January. 
 
 Except the small-pox, with which he was attacked six years 
 ago, this man, whose constitution is vigorous, enjoyed* good 
 health until the month of May, 1875. He says that during the 
 
404 THE MEDICAL CLINIC. 
 
 war he suffered very much, and that for eight months he was 
 exposed to the inclemency of the weather. 
 
 In the month of May last he began to have acute pains 
 in both knees. These pains were brought on by motion, 
 and disappeared with rest and at night. There was no 
 change in his general health, and he continued his occupa- 
 tion of footman until December. 
 
 On the 18th of December he had chills, and at the same 
 time the pains, which he had for seven months in a slight and 
 not very severe form, became so intense that he was forced 
 to take to his bed. The leg and the left foot, however, were 
 first seized. The next day the joints of the right leg became 
 in turn the seat of a painful swelling. In the onset there 
 was no sign of cardiac complication. 
 
 He entered the hospital on the 22d, with the following 
 symptoms : 
 
 The fever, which he had at the onset, has subsided ; in the 
 morning the temperature was normal, but in the evening it 
 reached 100.9°; the upj>er extremities have escaped, but the 
 joints of the left leg are still somewhat swollen and painful ; 
 respiration is slightly oppressed, and the qualities of the pulse 
 are such as to draw our attention to the heart. The pulse 
 is strong, vibrating and receding. 
 
 By listening to the heart-sounds we find at its base a bruit 
 de souffle, which can be heard from the vessels of the neck 
 to the femoral artery. Over this latter vessel we distin- 
 guish the double sound which corresponds to the systole 
 and the diastole of the heart. The first of these is the 
 stronger ; the second, which can only be heard by means 
 of the stethoscope, is the weaker one. Aconite, 3d dil., was 
 prescribed. 
 
 December 25. The patient suffers much less with the left 
 knee and with the joints of the left foot ; in the morning the 
 
RHEUMATISM. 405 
 
 apyrexia was complete, but in the evening the temp, was 
 101.12°, and the pulse 88. The same prescription. 
 
 December 28. So far as the articulations are concerned, he 
 is doing well ; but during the day, and more especially during 
 the night, he has had some palpitation of the heart. Colchi- 
 cum, 3d dil. 
 
 December 31. The souffle has diminished a little in its in- 
 tensity ; there is always a slight evening exacerbation of the 
 fever ; the appetite is better. The same remedy. 
 
 January 3. The swelling in the joints has disappeared, 
 and they are no longer painful. Aconite, % 3d dil. 
 
 January 8. The evening temperature is always 100.4° ; 
 the palpitation is less frequent, and the patient is more quiet 
 during the night. The same remedy. 
 
 January 11 . The fever is entirely broken, but he com- 
 plains of pretty severe pains in the joints of the left leg. 
 Chininum suljjh., 3d trit., twenty centigrammes. 
 
 January 13. The pains in the joints are less severe, but 
 the palpitation has returned and is worse than ever. Never- 
 theless, the same remedy was continued. 
 
 January 15. He passed a pretty good day yesterday ; to- 
 day auscultation shows that the souffle at the base of the heart 
 has returned, but that it is decidedlv softened in its tone. The 
 same remedy. 
 
 January 19. The pains have slightly increased since yes- 
 terday. Chininum sulph., 1st trit. 
 
 January 20. He complains very much of his heart. During 
 the night he had a great deal of palpitation, and for two 
 days the pulse has had an intermittent beat. Spigelia, 3d dih 
 
 January 22. No improvement in the rhythmic movements 
 of the heart. Spigelia in the mother tincture, three drops. 
 
 January 24. Yesterday there was a slight aggravation of 
 the symptoms. Spigelia, 30th dil. 
 
 January 26. He is more calm, and the intermittent beat- 
 ing of the heart is less frequent. Cactus, 12th dil. 
 
 This patient left us to try another kind of treatment. After 
 a few months he went home to the country with confirmed 
 heart disease. Then he applied for readmission to the hospi- 
 
406 THE MEDICAL CLINIC. 
 
 tal, but the condition of his health did not permit him to make 
 the journey. 
 
 Here is, therefore, a rheumatic patient who, from the begin- 
 ning of his illness, has had a tendency toward chronic disease. 
 For seven months preceding it he had had occasional pains in 
 the joints, but without fever. Then followed an attack which 
 was not very severe, and which yielded to remedies, but which 
 returned three or four times within a month with diminishing 
 intensity. 
 
 The endocarditis, which began with his admission to the 
 hospital, was not accompanied by a violent febrile reaction; 
 but the lesion increased whenever the trouble with the joints 
 disappeared. This endocarditis persisted, in spite of homoeo- 
 pathic and allopathic treatment, until a cardiac cachexia was 
 developed. 
 
 The intensity of the heart affection, and the absence, or at 
 least the mildness of the febrile reaction, incline us to believe 
 that it was not of very recent date. And yet the physician 
 who had charge of him previously insisted that, in the outset, 
 his heart was not at all implicated. 
 
 Therapeutically considered, this case is one of very little 
 interest, for the patient left before the principal remedies for 
 the cardiac lesion could be used. Following the indications of 
 Petroz in rheumatic endocarditis, we gave colchicum. But it 
 was insufficient; and so also were aconite and spigelian and he 
 determined to leave just as we had begun with the cactus. 
 
 The interest of the case centers in the diagnosis of aortic 
 insufficiency, and in the clinical value of the signs that pertain 
 to this lesion. We shall insist for a moment upon this par- 
 ticular point. 
 
 A diastolic bruit de souffle having its greatest intensity at 
 the base of the heart, and extending along the peripheric 
 
KHEUMATISM. 407 
 
 arteries, in which vessels we may recognize the double murmur, 
 and a pulse that recedes and rebounds, are unmistakable symp- 
 toms of an insufficiency of the sigmoid valves of the aorta. 
 
 Theoretically speaking, nothing is easier than the diagno- 
 sis of this aortic lesion ; but if you cannot distinguish clearly 
 between a diastolic and a systolic murmur ; if you do not 
 know how to seek and to find the double murmur in distant 
 arterial trunks, — in the femoral artery, for example ; if you do 
 not detect the evidence afforded by Corrigan's pulse (which 
 rebounds and recedes), you will blunder in the practice, for 
 medicine is both a science and an art* — a science, when it 
 treats of those principles upon which it rests, and also when 
 it describes morbid phenomena; and an art, when its knowl- 
 edge is made use of for the benefit of the sick. Here the 
 most extensive and the most positive learning is not suffi- 
 cient ; for the application of the senses is necessary, and 
 upon their education and their delicacy will the success of 
 the physician depend ; and the special work and use of the 
 clinic is to educate the senses and to teach you to perceive 
 clearly the most delicate symptoms. 
 
 In this case you will recognize, when your ear has become 
 familiar with the heart-sounds and with the interval between 
 thern, that the bruit de souffle coincides with the cardiac 
 diastole. The systole causes a dull noise, which is followed 
 by a very brief silence, after which comes the diastole with 
 its clear and brief click, which is followed by an interval of 
 silence of a much longer duration than that which succeeds 
 the systolic murmur. Therefore, a dull murmur, a very 
 brief silence, a dry sound and an interval which is relatively 
 long, make a cardiac revolution. 
 
 If your ear was accustomed to seize upon these shades of 
 expression, it would be easy for you to observe in this case 
 
 * See my work on General Pathology. 
 
408 THE MEDICAL CLINIC. 
 
 the bruit de souffle following the brief interval and preced- 
 ing the other, and that, consequently, it takes the place of 
 the dry diastolic murmur, which murmur exists no longer, 
 from which you would conclude that the pathological mur- 
 mur is really, diastolic belonging to the second beat ; and, as 
 it is located at the base of the heart, it is to be 'taken as a 
 certain sign of aortic insufficiency. 
 
 In using the microscope it often happens that those who know the least of 
 what is really in the field of the instrument see the most, and say the most of 
 what they think they have seen. In the practice of auscultation the ear needs 
 to be trained to exclude what it does not hear, as well as to catch and to keep 
 what it does hear; and unless we are able to interpret these sounds, the mere 
 hearing of them will convey no more information than if we listen to one who 
 reads to us in a language that we do not know. Our author certainly does not 
 confuse his ideas with words, but, on the contrary, is very plain and practical. 
 With such an aid, a little study will make this whole subject clear and avail- 
 able. — L. 
 
 There is another and a more common method of deter- 
 mining whether the bruit de souffle is systolic or diastolic. 
 It consists in taking the pulse at the same time that we prac- 
 tice auscultation. Since the cardiac systole corresponds sen- 
 sibly with the arterial diastole, and the cardiac diastole with 
 the arterial systole, this method answers very well. By it, 
 a bruit de souffle, which is heard the moment that the pulse 
 strikes the finger, will be a systolic murmur, while, on the 
 contrary, the diastolic murmur occurs during the interval be- 
 tween the pulse-beats ; but if the heart beats rapidly, the 
 application of this method will be difficult, and will necessi- 
 tate a delicacy of touch and of hearing of which every doc- 
 tor is not possessed. 
 
 Here, then, are two means of knowing if a bruit de souffle 
 is diastolic or systolic. You can use them conjointly ; but 
 when there is a diastolic murmur in the aorta with insuffi- 
 ciency of the semi-lunar valves, you will confirm the diagnosis 
 by detecting the two sounds in the remote arteries. 
 
RHEUMATISM. 409 
 
 The femoral artery, by its volume, by its superficial posi- 
 tion in Scarpa's triangle, and by the ease of its exploration 
 with the stethoscope (for in this case the stethoscope is in- 
 dispensable), is the one in which yon should seek the double 
 bruit de souffle which confirms the existence of insufficiency of 
 the aorta. By applying the stethoscope very carefully to the 
 femoral artery, you will readily hear a dull murmur which cor- 
 responds to the arterial diastole, and consequently to the sys- 
 tole of the heart. But if, without removing the instrument, 
 you press it firmly against that vessel, you will hear a second 
 sound, which is more feeble and more clear, and which cor- 
 responds with the arterial systole and the cardiac diastole. 
 
 The first of these sounds is due to the volume and force of 
 the column of blood, and to the compression of the vessel by 
 the stethoscope ; but the second murmur, or that which cor- 
 responds to the arterial systole, is due to the falling back of 
 the column of blood that results from the aortic insufficiency. 
 This reverse flow affects the whole arterial system, gives the 
 rebounding character to the pulse, and to the sphygmographic 
 trace its dicrotic peculiarity. This sign, if carefully observed, 
 is, therefore, a positive sign of aortic insufficiency. 
 
 Since this second murmur is coincident with that of the car- 
 diac diastole, the attempt has been made to explain its occur- 
 rence, by supposing it to be an echo of the latter. -But the 
 retreat of the column of blood, which certainly takes place, 
 gives the only admissible explanation of this second murmur. 
 
 This very practical discussion of the physical signs of the case under 
 review is exceedingly suggestive and satisfactory. Those readers of this 
 work who are interested in the matter of physical diagnosis — and every 
 general practitioner should be — will do well to procure a copy of Dr. H. C. 
 Clapp's Tabular Hand-book of Auscultation and Percussion, Boston, 1879. 
 It is exceedingly concise and practical, and really deserves a wide circula- 
 tion. — L. 
 
 I hope that with these two signs you will be able to dis- 
 tinguish with certainty an insufficiency from a narrowing of 
 
410 THE MEDICAL CLINIC. 
 
 the aorta ; for, in the latter lesion, the bruit de souffle is 
 systolic ; there are no abnormal murmurs in distant arteries, 
 and the pulse is small and often unequal. Besides, the 
 sphygmograph will settle the question. You will recall the 
 tracing which belongs to aortic insufficiency, and which is so 
 characteristic that it cannot be confounded with any other. 
 (See Trace No. 2, page 20.) 
 
 Here is a case of mono-articular rheumatism which was 
 speedily relieved and cured by china : 
 
 Case LXXI. — Acute mono-articular rheumatism. China. 
 
 Cured. M. Joseph jST , aged twenty-six, was admitted to the 
 
 men's ward, ~No. 5, on the ^6th of December, and discharged 
 on the 16th of January. He applied for relief from an acute 
 affection of the right knee-joint. 
 
 His symptoms were as follows : The right leg is in a state 
 of deminexion, and cannot be straightened without difficulty; 
 the knee is swollen, and the skin red and somewhat tense ; the 
 joint is not sensitive to pressure, excepting over the posterior 
 ligament. With both hands applied in front of the joint the 
 sense of fluctuation is easily recognized. The etiology of this 
 case of mono-articular arthritis is somewhat obscure. 
 
 The patient has never had rheumatism, and tells us that it 
 is only four days since he began to suffer with the right knee. 
 He has not been dissipating of late, and, moreover, declares 
 that he has never had the gonorrhoea. 
 
 With this exception his general condition is good. There 
 is no fever, but the pains in that joint are very severe. The 
 prescription was rest and apis mellifica, 3d trit., twenty centi- 
 grammes. 
 
 December 28. The swelling of the knee has not diminished; 
 the pains are even a little worse than at the onset. China, 3d 
 trit., twenty centigrammes. 
 
 January 2. The condition of the knee is greatly improved ; 
 it is not so swollen, and the effusion within the joint is decid- 
 edly less than before. The same remedy. 
 
 January 0. He continues to improve. The movement of 
 
RHEUMATISM. 411 
 
 the joint is almost painless. China, 2d trit., twenty centi- 
 grammes. 
 
 January 12. The right knee is reduced to the size of its 
 fellow, but to-day he has some pains in the left knee which 
 resemble those of the first attack. Sulph., 6th dil. 
 
 January 15. The pains in the left knee did not return. The 
 patient complains only of the old stiffness in the right knee. 
 China, 3d trit., twenty centigrammes. 
 
 This patient was discharged cured. The effect of the china 
 was very remarkable. The improvement began with the first 
 days of its administration, and continued constantly until, in a 
 fortnight, the joint had returned to its natural size. You are 
 already aware of my preference for china and for chininum 
 sulph. in gouty and rheumatic arthritis. My experience has 
 often confirmed the value of these remedies, and I insist that 
 nothing is more certain than the effect of china in rheumatic 
 arthritis, although the excellent Manual of Dr. Richard Hughes 
 is almost silent upon this subject. 
 
 Case LXXII. — Acute articular rheumatism; mitral con- 
 striction ; hemoptysis. M. Eugene C , admitted on the 12th 
 
 of December, discharged on the 17th of December. (Men's 
 ward, No. 2.) 
 
 This patient, aged twenty-eight, followed a very severe 
 occupation, that of a machinist. Two months ago, after work- 
 ing harder than usual, he had some spitting of blood. Never- 
 theless, he continued to labor as usual until two days ago, when 
 he quit work entirely. 
 
 He had not enjoyed perfect health prior to this illness. At 
 the age of eighteen he had a first attack of articular rheuma- 
 tism, which was general, and which continued for three months. 
 Four years later he was again seized with rheumatism, and the 
 illness was of much longer duration. In fact, he says that he 
 kept his bed for eight months, and that his convalescence 
 dragged along for three months. 
 
 His health was, however, pretty well established finally. 
 The heart was not implicated until three or four years later, 
 
412 THE MEDICAL CLINIC. 
 
 and the cardiac symptoms were very mild at first. Palpitation 
 from time to time, breathlessness while walking, and a slight 
 oedema about the malleoli at evening, are the symptoms of 
 which he has now complained for some years. But during the 
 last two months his disease has taken a much more acute form. 
 
 When this man entered our wards he was still expectorating 
 blood in considerable quantity. That blood was of a bright red 
 color, and mixed with air and a little mucus. He took mille- 
 folium, 3d dil., and was put upon the milk diet. 
 
 December 14. He raised a little more blood yesterday, but 
 feels a great deal better to-day. Physical examination of the 
 lungs revealed nothing abnormal. We found by auscultation 
 of the heart that, at its apex, there was a bruit de souifle, which 
 was not intense, that preceded the first sound of the heart — 
 the pre-systolic murmur. At the base of the organ the sounds 
 were normal. 
 
 The pulse had no very decided peculiarities ; it was slow 
 and strong, with a feeling of resistance to the finger. The 
 same treatment. 
 
 December 16. The patient gains strength ; no more cough 
 nor bloody sputa ; respiration is free, and the palpitation occurs 
 very rarely. He wants to go to work again. Discharged. 
 
 A month later he had had a slight relapse ; but the san- 
 guineous expectoration was arrested in two days by the same 
 remedy that he had previously taken. 
 
 Two successive attacks of rheumatism, and a cardiac affec- 
 tion following the last of these attacks, several years later ; a 
 contraction of the mitral orifice, with a pre-systolic murmur at 
 the apex of the heart ; then a pulmonary congestion and 
 hemorrhage, which was the almost fatal consequence of the 
 obstruction of the blood in the left auricle, were the obvious 
 morbid symptoms of this case. For the relief of the cardiac 
 hemoptysis, millefolium has been quite as useful as we have 
 often found it to be in the hemoptysis that is incident to pul- 
 monary tuberculosis. 
 
RHEUMATISM. 413 
 
 I will now call your attention to a more complicated case, 
 and one in which the symptoms are mnch more difficult of 
 interpretation. 
 
 Case LXXIII. — Acute articular rheumatism; rheumatic 
 
 endocarditis; hematuria. Maria B , aged twenty-six, a 
 
 cook, was admitted to ward 3, ]STo. 3, on the 12th of Decem- 
 ber, and discharged on the 6th of February. 
 
 After having enjoyed good health until her twenty-first year 
 (1871), this patient experienced her first attack of articular 
 rheumatism. Its course was protracted, for it kept her in bed 
 six weeks. This attack left no perceptible sequelae, for, having 
 quite recovered, she resumed her usual occupation. For about 
 three years there was no trouble, either with the joints or with 
 the heart. 
 
 In 1873 she began to have palpitation and difficulty of 
 breathing whenever she walked, and especially when she was 
 forced to move rapidly. Sometimes, at evening, there was a 
 little oedema about the ankles. 
 
 Nevertheless, she continued at her work until the end of 
 November last, at which time she was seized with pains in the 
 joints, and chiefly in those of the inferior extremities. These 
 joints become slightly swollen. When she entered the hospital 
 she had only a few signs of this recent attack. 
 
 The fever also is broken, but the pulse is quite frequent, 
 and is characteristically strong and vibrating. The joints are 
 but slightly painful, but she complains the most of the excess- 
 ive violence of the palpitation, which persists for hours, forc- 
 ing her to sit up in her bed, and which is followed by great 
 agitation, that continues long after the palpitation has subsided. 
 The fits of palpitation recur several times during the day. 
 
 The symptoms disclosed by auscultation of the heart are a 
 soft bruit de souffle, with the first sound at the apex of the 
 heart ; and also the same kind of a murmur with the second 
 sound, at the base of the heart. Aconite, 3d dil. 
 
 December 14. Slight improvement. As she has not had 
 her menses for two months, Pulsatilla, 3d dil., was prescribed. 
 
 December 18. She has been taken with pains in both 
 knees again, but is less agitated than before. Bryonia, 3d dil. 
 
414 THE MEDICAL CLINIC. 
 
 December 24. The pains have disappeared, but for two 
 days she has complained of frequent palpitation. Cactus, 
 3d dil. 
 
 December 27. No improvement, and the palpitation is 
 accompanied by precordial anxiety. Spigelia, 6th dil. 
 
 December 30. She is a little better to-day. Aconite, 3d dil. 
 
 January 4. Spigelia, 3d dil., was resumed. The menses 
 have appeared. 
 
 January 7. She continues to be agitated, and complains of 
 a very severe pain at the apex of the heart. Spigelia, in the 
 mother tincture, three drops during the day. 
 
 January 11. She passes blood with the urine. Hama- 
 ?nelis, 3d dil. 
 
 January 13. The hemorrhage continues, but in smaller 
 quantity. It is worthy of note that the blood is found in the 
 urine only in the evening ; that which is passed during the 
 night and in the morning is quite limpid. Hamamelis, 1st dil. 
 
 January 15. No more blood in the urine ; she still suffers 
 greatly with her heart. Aconite, 1st dil. 
 
 January 17. Same. Spigelia, as before. 
 
 January 21. She is more calm;' the fits of palpitation 
 come very rarely. The same treatment. 
 
 January 22. The blood has reappeared in the urine. 
 Hamamelis, 1st dil. 
 
 January 24. The hematuria has ceased. Spigelia again. 
 
 January 29. Under the last remedy the patient continues 
 to improve. 
 
 February 2. . Although she had her menses at the begin- 
 ning of last month, they have not reappeared. Pulsatilla, 3d 
 dil. 
 
 February 4. The menses came yesterday, and to-day she 
 feels pretty well. 
 
 February 6. She is so much improved that she wants to 
 go to work again. The spigelia was continued for some days. 
 
 In this case, as with the former one, it was some years 
 after the first attack of rheumatism that the patient began 
 to complain 6f cardiac symptoms. In Case LXXII four 
 years, and in Case LXXIII three years, elapsed between 
 
RHEUMATISM. 415 
 
 the onset of rheumatism and the appearance of endocar- 
 ditis. Moreover, in these two cases, we remark that the 
 endocarditis was without fever from the beginning, and that 
 its course was decidedly chronic. The palpitation, the dysp- 
 noea, the precordial pain, and the oedema of the ankles, were 
 the only signs of the trouble with the heart. These facts 
 are far from being rare ; and, as you will often meet with them 
 in practice, I have called your attention to them in order 
 that you may not be surprised by this latent form of rheu- 
 matic endocarditis. For, when a patient has survived an 
 attack of acute articular rheumatism, and escaped without 
 any implication of the heart, you should not be quite cer- 
 tain that the cardiac affection will not develop itself some 
 years later, even though there is no new affection of the 
 joints. 
 
 Our j>atient presented one symptom which is very rare 
 in acute articular rheumatism — I mean the hematuria. 
 
 It might be asked if the hemorrhage in this case was 
 connected with a local rheumatism of the kidneys ; with the 
 trouble of the circulation on account of the cardiac disease; 
 or with the chlorosis of which this girl shows the most posi- 
 tive symptoms. Thus, the palpitation that she had was out 
 of proportion with the valvular lesions ; on the contrary, it 
 had all the qualities of chlorotic palpitation ; the delay and 
 suppression of the menses leave no doubt of the existence 
 of a chlorosis which, in this particular case, complicated the 
 articular rheumatism and its incidental affections. 
 
 We think that this patient's hematuria was due to the 
 condition of the blood, aglobulie, or a diminution in the 
 ratio of the red corpuscles, which characterizes both the 
 chlorosis and the articular rheumatism ; and that it was in- 
 duced by the delay and the scantiness of the menses ; that, 
 in a word, it should be regarded as a case of supplementary 
 
416 THE MEDICAL CLINIC. 
 
 hemorrhage, or, as some prefer to style it, a case of vicari- 
 ous hemorrhage. 
 
 Whatever it may be, the fact remains, as with all facts 
 which are exceptional, the pathological significance of this 
 hemorrhage is doubtful. 
 
 We should speak of the rapid action of the hamamelis. 
 This remedy, which you have already observed to be so 
 efficacious in bleeding hemorrhoids (see page 196), arrested 
 and cured the hematuria in this case, — the first time in four 
 days, and the second in two days. The first dilution acted 
 more promptly in this instance than the third. 
 
 Spigelia is the remedy which has afforded our patient the 
 most complete and the most durable relief for her frightful 
 palpitation. It was indicated by the severe pain at the apex 
 of the heart, and by the extreme anxiety of the patient. We 
 evidently had the best effect from the mother tincture. It 
 is worthy of remark, and of recollection, also, that, while 
 aconite seemed to be indicated by the rheumatic nature of 
 the affection, it failed completely. 
 
 The next case is interesting, both because of its rarity and 
 because of the clearly defined nature of its symptoms. 
 
 Case LXXIY. — Articular rheumatism • the acute paren- 
 chymatous tephro-myelitis of Dr. Charcot [acute fascicular 
 myelitis of the anterior cornua). Miss N , aged twenty- 
 six, admitted on the 19th of February, and discharged on the 
 19th of March. (Ward 3, JSTo. 1.) 
 
 This patient's health was pretty good until 18 73. During 
 her infancy, however, she had had a scrofulous affection. In 
 December of that year, being seized with acute articular rheu- 
 matism which affected the various joints, she kept her bed for 
 two months. After this first attack her health was pretty well 
 restored, and she was able to resume her duties. 
 
 At the beginning of January, 1875, she was taken with a 
 
RHEUMATISM. 417 
 
 second attack of rheumatism, accompanied by fever and violent 
 pains in almost all the articulations. For this she received the 
 ordinary treatment for rheumatism. 
 
 Her present symptoms are as follows : Several of the joints 
 are still somewhat painful, but they are neither red nor swol- 
 len ; there is complete paralysis, which has already involved 
 the muscles of the neck and those of deglutition ; the patient, 
 who is helpless when she is lying upon the back, cannot move 
 the extremities in the slightest degree ; when the assistants 
 seat her upon the bed her head falls upon her breast, and she 
 cannot lift it up again ; it is exceedingly difficult for her to 
 swallow, and she must be fed with the greatest care ; the sensi- 
 bility is intact, and when the parts are moved they are even 
 painful ; she is naturally and equally sensitive to the applica- 
 tion of cold and heat ; the electric contractility is almost abol- 
 ished, and while Faradization is very painful, it is necessary to 
 apply a very strong current in order to produce contractions of 
 the muscles of the fore-arms and of the legs. 
 
 This general paralysis appears insensibly to have followed 
 the immobility which was caused by the rheumatism of the 
 joints. 
 
 The respiration is very much oppressed, but this oppression 
 is due to a cardiac affection. There is, indeed, a bruit de souffle 
 with the first sound of the heart, heard at its apex, which is 
 the sign of a mitral insufficiency of rheumatic origin. 
 
 The patient has some appetite, but no fever ; obstinate con- 
 stipation, but no signs of paralysis of the bladder. 
 
 Plumbum, 30th dil. , four globules in 200 grammes of water, 
 three teaspoonfuls daily. The diet to consist of porridge. 
 
 February 24. Positive improvement ; she swallows better, 
 holds up her head, and lifts the right arm a little. The same 
 treatment. 
 
 February 27. The improvement continues ; the voluntary 
 movements have returned, but in a limited degree, to the upper 
 and lower extremities. Plumbum, 30th dil. 
 
 February 28. . The power to move increases, and the patient 
 can swallow solid food without difficulty. Plumbum, 30th dil. 
 
 March 10. Under the influence of plumbum all the natural 
 movements are entirely restored. The patient complains of 
 27 
 
418 THE MEDICAL CLINIC. 
 
 the eyes, which are red and inflamed. Apis mellifica cured this 
 rheumatic ophthalmia, and some days later she was discharged, 
 being completely cured of her paralysis, but still having the 
 mitral insufficiency. 
 
 Spinal rheumatism is an affection which is rare, and which 
 is still imperfectly understood. For anatomical reasons, the 
 physician generally locates this disease in the meninges, where 
 the arachnoid offers an analogy of structure with the synovial 
 membranes and the endocardium, and which seems to favor 
 the localization of rheumatism upon this membrane. The case 
 just cited does not confirm this prevalent idea, for the totality 
 of the symptoms proves that it is a case of myelitis of the 
 anterior gray matter of the cord, or of acute parenchymatous 
 anterior tephro-myelitis of Charcot. 
 
 In assuming the paraplegic form, the paralysis developed 
 itself very rapidly. In a few days it reached its maximum 
 of extent and of intensity. It involved the muscles of de- 
 glutition, which is a certain sign that the lesion had passed 
 the limits of the marrow and had attacked the bulb. Over- 
 come with inertia, the muscles had almost entirely lost their 
 reflex and electrical excitability. However, the sensibility 
 was intact, and the patient complained bitterly of the elec- 
 trical investigations that we thought best to practice upon her 
 Finally, there was neither a paralysis of the bladder nor ot 
 the rectum. 
 
 In this case the posterior gray fasciculi were intact, for 
 the general sensibility was perfectly preserved ; the lateral 
 fasciculi had also escaped, for there was neither contraction 
 nor convulsion, and, under the influence of volition the blad- 
 der and the rectum performed their functions regularly. Con- 
 sequently, the only lesion was one of the anterior or central 
 gray substance of the cord, for the affection consisted in the ' 
 
RHEUMATISM. 419 
 
 almost complete loss of the voluntary and electrical contrac- 
 tility. This part of the cord was undoubtedly involved 
 throughout its whole extent, for all the muscles except those 
 of respiration were paralyzed. There is no doubt that if 
 this disorder had persisted, muscular atrophy would have 
 developed very rapidly, for the gray cells of the anterior 
 columns exert an undoubted action on the nutrition of the 
 muscles. 
 
 In closing this lecture, gentlemen, I must insist upon the 
 heroic action of plumbum in this form of paraplegia. On 
 the fifth day of the administration of the remedy we already 
 observed a decided improvement ; the patient swallowed bet- 
 ter, held up her head, and lifted the right arm a little. 
 Three days later the voluntary movements, although still 
 feeble and limited, returned to all the extremities ; the next 
 day she began to swallow solid food, and in two days more, 
 id est, in less than twenty days, the paralysis had entirely 
 disappeared. 
 
 You will also observe that the remedy was given in glob- 
 ules of the thirtieth dilution. 
 
 Plumbum is perfectly homoeopathic to muscular paraly- 
 sis with a loss of electrical contractility, and with consecu- 
 tive atrophy. This fact is placed beyond a doubt by the 
 complete history which we have in our day of lead paraly- 
 sis ; but the plumbum is as applicable to the lesion as it is 
 to the paralysis itself. In fact, Vulpian caused an acute 
 myelitis by poisoning a dog with lead ; and Hallopeau has 
 observed the same fact in a man who had been poisoned 
 by it. 
 
 Plumbum is, therefore, homoeopathic to acute and chronic 
 inflammation of the gray matter of the anterior columns of 
 the cord. Consequently, it is indicated in the treatment of 
 acute or chronic anterior tephro-myelitis * in other words, in 
 
420 THE MEDICAL CLINIC. 
 
 the confirmed paralysis of infants, in acute spinal paralysis 
 and in progressive muscular atrophy, the lesion of which con- 
 sists in an acute or chronic inflammation of the substance of 
 the anterior cornua. Dr. Richard Hughes very properly 
 recommends plumbum in the treatment of progressive mus- 
 cular atrophy, which, as we have just said, is only a chronic 
 myelitis affecting the anterior horns of the gray matter. 
 
 Progressive Locomotor Ataxia. 
 
 As germane to the last case given by Dr. Jousset, we think best to insert a 
 few interesting- reports upon this peculiar and very troublesome disease. The 
 first of these is from our friend, Dr. N. A. Pennoyer, of Kenosha, Wis., and is 
 designed to illustrate the virtues of the argentum nitricum in this form of spinal 
 affection. — L. 
 
 Case I. — The first case was that of a lady sixty years of 
 age, who had been under the care of physicians in the east, 
 where she resided, and where she was treated for rheumatism, 
 neuralgia, etc. She suffered greatly from chilliness during the 
 previous winter, and required her room so very warm that it 
 was unbearable for her friends to remain in it. She suffered 
 from dimness of vision, attacks of vertigo that were worse in 
 the dark or when closing the eyes, neuralgic pains in hands 
 and feet, followed by numbness and awkwardness in gait when 
 walking. The sensation in the feet was of a prickling like 
 needles, followed by a velvety feel of what she touched. She 
 had difficulty in going up and down stairs and in moving one 
 foot first. The pulse was frequent. She had a sighing respira- 
 tion, and was considerably depressed in spirits. Argentum nit., 
 2d decimal dil., in spring water, was given four times daily. 
 
 The improvement was very satisfactory. Her eyes regained 
 their customary strength, the anaesthesia of the extremities 
 disappeared, so that she could walk as usual, going up and 
 down stairs with each foot in turn advancing. 
 
 In seven weeks she returned home, and I was informed that 
 no relapse occurred, she being able to attend to her usual 
 household duties. 
 
RHEUMATISM. 421 
 
 A year and a-half or two years following, a sister, had a 
 long illness with paralysis, which proved fatal, my patient 
 being with her continually, and doing much toward administer- 
 ing to her comfort. A few months ago I learned that she also 
 had died, but with general dropsy, nearly three years since she 
 was under my care. 
 
 Case II. — The next case was that of a bachelor, forty-two 
 years old, a saloon-keeper by occupation, who had led rather a 
 dissolute life. He had vertigo when the eyes were closed, and 
 in a dark room he could not stand ; the staggering, but jerking 
 step of this disease ; sleeplessness at night, and much neuralgia 
 in the extremities, which was worse at night. The pulse was 
 frequent and irregular ; sighing respiration ; an enormous and 
 ungovernable appetite ; the bowels were constipated ; he had 
 some cough and considerable emaciation. 
 
 The case was an unpromising one, it having been develop- 
 ing for years ; but we prescribed the argentum nit. , as for the 
 former case. The improvement was soon noticeable. The 
 vertigo was lessened ; the constipation was materially relieved ; 
 he walked easier, and could go up and down stairs so much 
 better that it was especially noted by the other house-patients. 
 
 He remained only four or five weeks under treatment, ask- 
 ing to go home on business, and did not return. I have since 
 heard that he was drifting into a worse condition, but the 
 effects of the argentum nit. were unmistakable while under its 
 influence. The case had advanced too far to reasonably expect 
 anything more than a stay in the progress of the disease. 
 
 Case III. — I had one other patient who had an asthmatic 
 affection that was causing him considerable difficulty, and in 
 which the symptoms of locomotor ataxia were present. The 
 asthma came on at night, as soon as he went into the house, 
 and it was worse in the room, so that it obliged him to seek 
 the open air. He also had a slight cough, and thought that a 
 cold was the cause of the difficulty. He used tobacco excess- 
 ively. 
 
 On close inquiry, I found that he had vertigo, which was 
 worse when closing the eyes, and he had difficulty in keeping 
 to the sidewalk when he was out at night, The bowels were 
 
422 THE MEDICAL CLINIC. 
 
 irregular, there being alternate costiveness and diarrhoea. He 
 had neuralgic pains in the extremities, and a sensation of numb- 
 ness in them. 
 
 This patient had been under my care several times before 
 for neuralgia. The symptoms indicated argentum nit., and it 
 was given him in the second dilution. In one week he was 
 entirely relieved of the asthma, the vertigo, and of all the 
 symptoms just enumerated. ' I do not regard this as a case of 
 locomotor ataxia ; but might it not have led to that disease if 
 it had been improperly treated ? 
 
 The symptoms of argentum nitricum point to it as a remedy 
 for loss of sensation rather than for a loss of motion. I have 
 had several cases of numbness of the lower extremities, with 
 coldness, that have been relieved by its use. One patient 
 with cerebro-spinal hyperemia had numbness of the limbs ; 
 they felt when rubbed "as if boards encompassed them, and 
 these were being rubbed." 
 
 A mental symptom which I have not noticed in any of the 
 books, and which I have many times relieved with this rem- 
 edy, is u a feeling as if a cloud hung over him, with great 
 depression." This is usually attended by a sighing respira- 
 tion. I never see a patient with sighing respiration that I do 
 not think of argentum nit. It is not the yawn that indicates 
 hyoscyamus, but an occasional sigh, which may even be un- 
 noticed by the patient. This symptom is aggravated in a 
 close room, and may require going to the window or to the 
 open air for relief. 
 
 One case of this sighing that was caused by a suppressed 
 eruption (the itch) I cured with sulphur, 200th dil. I should 
 give the sulphur for the relief of this symptom if it had been 
 caused in this way ; but if it came from other causes, the 
 argentum nit. answers a better purpose. The stomach symp- 
 toms of argentum nit. are valuable : Frequent or constant 
 empty eructations, great flatulency, and a weak digestion. 
 The empty eructations seem, in many cases at least, to come 
 
PSEUDOHYPERTROPHIC PARALYSIS. 423 
 
 from spasm of the diaphragm, the stomach literally pumping 
 up the wind. The bowels are constipated and torpid, or there 
 is diarrhoea alternating with constipation. We have many 
 times verified all of these symptoms, and find they may attend 
 locomotor ataxia. 
 
 I have used the argentum nit. in multiple sclerosis, but 
 without any special indications for it, and my patient derived 
 no benefit. I do not think it useful in antero-spinal paralysis ; 
 whereas plumbum, both by its pathogenetic symptoms and 
 from pathological indications, is eminently ^so. 
 
 The next selection is a case furnished by A. C. Clifton, M.R.C.S.E., to the 
 British Journal of Homoeopathy, Vol. XXXIV, page 127. In many respects 
 this is one of the most remarkable cures on record. — L. 
 
 A Case of Duchenne's Pseudo-Hypertrophic Paralysis. — 
 
 M. J , aged eighteen, has been ill more than a year. She 
 
 states that about a year ago she noticed purple spots, about the 
 size of a shilling, on her legs, and felt very weak. She bathed 
 her legs with cold water for several days, which did them good, 
 but at the next catamenial period she was unwell merely for a 
 few hours, and had only a slight and pale discharge. She con- 
 tinued to feel weak, lost her appetite, suffered with headache 
 and palpitation of the heart, and was unable to retain her situ- 
 ation as general servant. Whilst in this condition she went as 
 in-patient to the Northampton Homoeopathic Dispensary in the 
 following condition : 
 
 It is with great difficulty that she can walk a few yards ; 
 when she does so it is with her shoulders thrown backward, the 
 abdomen prominently forward, the legs separated, walking in a 
 waddling side-to-side manner, and it is with difficulty that she 
 can even stand, as her legs feel as if they will give way, except 
 when widely separated. She cannot rise from a chair without 
 assistance ; complains of numbness, and pins-and-needles sen- 
 sations in the lower extremities ; in the upper extremities no 
 pain or numbness is felt, but some amount of stiffness. She 
 can grasp an object with her hand for a few minutes, but can- 
 not retain the grasp longer than that time. Her face is pale 
 
424 THE MEDICAL CLINIC. 
 
 and anaemic in appearance; appetite is poor; suffers some pain 
 in the left side ; bowels act every third or fourth day ; the 
 catamenia are irregular, only occurring every six, seven or 
 eight weeks, very little, and pale in color ; the urine is normal ; 
 there is no vertigo, headache or defective vision ; there is some 
 tenderness of the lower dorsal vertebrae. When standing, there 
 is a deep anterior curve of the lumbar vertebrae, which, how- 
 ever, is much diminished when in the prone position. The 
 glutei muscles are firm and hard, and somewhat enlarged ; so, 
 also, are the oblique abdominal muscles ; the muscles of the 
 upper arm are enlarged, hard, and firm ; the right arm, across 
 middle of the biceps, when the arm is extended, measures, in 
 circumference, nine and three-quarter inches, and the left arm, 
 in the same place, measures nine and a-half inches ; the fore- 
 arms are apparently normal. The muscles of the thighs and 
 legs are much larger and harder than normal ; the circumfer- 
 ence of the middle of the right thigh is nineteen and three- 
 quarter inches, and of the left, nineteen and a-half inches ; 
 right calf measures fourteen and a-half inches, the left fourteen 
 and one-fourth inches. 
 
 This being her condition when admitted, the question of 
 diagnosis was important. I was at the time treating a similar 
 case in a little girl about six years of age, by treating merely 
 symtomatically, not having seen the disease before. Dr. D. 
 Dyce Brown, then of Aberdeen, was staying with me for a 
 day on his way to London ; he saw both cases, and diagnosed 
 them as the u pseudo-hypertrophic paralysis" described by 
 Duchenne, a case of which he had recently had under his care, 
 and an account of which he had published. Dr. Brown, how- 
 ever, gave me but little encouragement in the way of treat- 
 ment, saying that there never had been a case known to be 
 cured except when treated before the pseudo-hypertrophy had 
 commenced and when only in the first stage of weakness, and 
 that the only hope was in electricity. This I could not let the 
 patient have, living, as she did, some miles from here, and as 
 I had no institution for in-patients. I resolved, however, to 
 give the patient a chance of recovery by drugs. She was 
 advised to return home, receiving a placebo until time could be 
 given for studying her case and getting any more leading symp- 
 toms of it previous to her present condition. 
 
PSEUDOHYPERTROPHIC PARALYSIS. 425 
 
 On examination I found that, as a child, she had been sub- 
 ject to frequent violent attacks of epistaxis, frequent diarrhoea, 
 or rather lienteria, sometimes profuse flow of urine for several 
 days together, and that her growth from twelve to fifteen was 
 very rapid, causing weakness and fainting. These were the 
 only additional symptoms which could be obtained. Notes 
 were made of several medicines, which appeared more or less 
 indicated, such as natr. mur., pulsatilla, phos. acid, ferrum and 
 zincum, but phosphorus was decided on as most likely to do 
 good. Three weeks after her first visit, phosphorus, 3d dil., 
 two drops three times a day, was prescribed, and sufficient medi- 
 cine was given to last her a month. At the end of this time 
 she was rather better, felt stronger, appetite was improved, face 
 was of better color, there was less stiffness in her arms, and 
 less weakness in her legs. The medicine was, therefore, re- 
 peated. 
 
 I need not relate her report from time to time, as it was 
 always improved in some respect or other, and, therefore, the 
 same medicine was continued for a period of fourteen months, 
 with the exception of one month, when she had ferrum phos- 
 phoricum,, 1st trit., two grains three times a day, and that be- 
 cause the catamenia, though increasing in quantity, were still 
 very pale. It was an error, however, to give it, as she did 
 not improve by its administration. 
 
 At the end of the fourteenth month from commencing phos- 
 phorus she walked a distance of two miles to Northampton and 
 two miles home, though when she first came she could only 
 walk a few yards. She is now able to do household work, her 
 appetite is good, the catamenia are regular and of good color, 
 and her complexion, though rather pale, is otherwise healthy. 
 The muscles of her arms and legs are much smaller and much 
 less hard ; but on walking, her shoulders are thrown somewhat 
 backward, owing to the anterior curve in the lumbar region. 
 For this she wears a spinal support, which I should not have 
 recommended could I have taken her into an institution and 
 given her appropriate treatment by friction, movements, etc. 
 She, however, considers herself well. The course which her 
 improvement took was the reverse of that of the development 
 of her disease : the arms were the first to be relieved, then the 
 
426 
 
 THE MEDICAL CLINIC. 
 
 numbness and pins-and-needles sensations in her legs, then the 
 weakness of her legs, next the walking powers, followed by 
 diminution of the enlargement and hardness of her muscles, 
 and finally her general health and strength. 
 
 As this subject is not within the range of our special study and experience, 
 we have referred the foregoing cases to our colleague, Prof. Fellows, who is an 
 expert in the treatment of diseases of the nervous system, and who has been kind 
 enough to send us the following communication : 
 
 Chicago, 111., Sept. 4, 1879. 
 
 Dear Doctor: The proofs of the cases of Jousset, Pennoyer and Clifton, 
 which you were kind enough to show me, are very instructive. The use of 
 argentum nitricum in diseases of the central nervous system, where sclerosis 
 is the pathological change, is becoming more and more approved. Dr. Pen- 
 noyer's cases illustrate the action of this drug very well. 
 
 The history of a case of cerebral sclerosis in a young man was given me 
 orally by the late Dr. G. D. Beebe, where the argentum nitricum cured the case. 
 The diagnosis was confirmed by Dr. Wm, A. Hammond, of New York. 
 
 Some years ago I pointed out, in some remarks made before one of our 
 medical societies, that this drug was homoeopathic to such diseases of the nerv- 
 ous system as terminated in sclerosis; while plumbum would be useful where 
 there was a primary destruction of the nerve-cells, either by softening or atro- 
 phy. Dr. Jousset's case fully confirms this action of plumbum. Any sclerosis 
 about the roots of the nerves in this class of diseases is undoubtedly secondary, 
 and a consequence of the primary atrophy of the cells in the anterior cornua. 
 
 Allopathic writers say, "the well-known fact that phosphorus produces 
 fatty degeneration, should contra-indicate its use " in pseudo-hypertrophic pa- 
 ralysis. Dr. Clifton has shown that it may be the curative remedy when used in 
 safe doses. 
 
 A notable symptom in locomotor ataxia may be mentioned, because the 
 teaching of Westphal and Erb must be somewhat modified. They say that the 
 tendon reflex is always abolished in this disease whenever the lumbar cord 
 becomes involved. While this is true in general, exceptions are to be made to 
 the rule. Prof. Berger. of Breslau, found in eighty-two cases that it was absent 
 in two of them. The absence of the patellar reflex has also been observed in 
 diphtheritic ataxia. Should this symptom, however, come on in any given case 
 after atrophy of the optic nerve, after a very early symptom of the disease had 
 made its appearance, it would be very suggestive of tissue change. It should, 
 therefore, be sought for early and repeatedly, and, should the reflex disappear, 
 it would probably mark an extension of the disease. 
 
 Very respectfully, etc. 
 
 H. B. Fellows. 
 
LECTURE XXVIII. 
 
 Summary. — Scrofulous keratitis, case. Apis mellifica and apium virus. Acute 
 articular rheumatism terminating in white swelling, case; sal croisici. 
 
 Scrofulous Keratitis. 
 
 Gentlemen : We have already spoken (see page 261) of 
 the unreliability of the lower triturations of the apis mellifica 
 that have been made from the entire bee, and also of the 
 superior efficacy of the preparation which contains only the 
 poison of the insect, the apium virus. Here is a case that 
 confirms our opinion, while at the same time it demonstrates 
 with what rapidity a well-chosen remedy may overcome this 
 most rebellious disease. 
 
 We are inclined to think that the failure of apis mellifica to relieve in many 
 cases is due to the inefficient manner of its preparation. Some years ago we 
 had much trouble with failures to cure. After experimenting with such prepa- 
 rations as we had, we drove into the country and captured a number of healthy 
 bees, and with our own hands made at once a fresh trituration of them. This 
 trituration was afterward repeatedly used with the most gratifying results in 
 every case. — V. 
 
 We also have made some observations of a similar kind. Thus, in our 
 Lectures on Diseases of Women, page 459, we have said: 
 
 " Concerning the use of the apis mel., which is an invaluable remedy at this 
 stage of the complaint (pelvic cellulitis), I am of the opinion that many physi- 
 cians have failed with it because the preparation which they have given has not 
 been trustworthy. In 1868, my friend, Dr. J. D. Craig, of Mies, Michigan, 
 sent me a trituration of the remedy which he had prepared and prescribed with 
 excellent effect. His method was to extract the sting of the honey-bee, and its 
 poison-bag, also, with a pair of tweezers, and then to triturate these with the 
 saccharum lactis, in the proportion of two grains of the sugar to one sting. This 
 he called the first trituration, from which others could be made in the usual 
 manner. I have prescribed this preparation in the second stage of cellulitis, 
 and in dropsical disease, with good effect, and can, therefore, recommend it to 
 you."— L. 
 
428 
 
 THE MEDICAL CLINIC. 
 
 Case LXX Y. — Scrofulous Kerato - Conjunctivitis. — Miss 
 
 Mary T , aged eighteen, governess, was admitted on the 
 
 4th of January, and discharged on the 16th of January. 
 (Ward 3, No. 3.) 
 
 This young girl does not appear to be scrofulous, although 
 several members of her family have had strumous affections, 
 and she herself, at the age of three and a-half years, had sore 
 eyes for the first time, which continued for a whole year. Her 
 physician said that she had an attack of scrofulous keratitis. 
 
 From that time until about the 15th of last December her 
 health has been very good. Then she was seized with pains 
 in the eye, accompanied by a bright redness of the conjunctiva. 
 She continued to work; but, suffering more and more, and 
 finding no relief from homoeopathic treatment outside of the 
 hospital, she determined to enter this institution on the 4th 
 of January. 
 
 At the time of admission her symptoms were as follows : 
 The left eye is almost entirely well. There is nothing upon the 
 cornea, and only a very slight injection of the vessels of the 
 conjunctiva. On the right side there is an active inflammation 
 with tension and pain in the orbital region. The conjunctiva 
 presents a vascular plexus that is extremely developed ; and 
 there are several pustules upon the cornea, but fortunately 
 none of them are centrally located. The patient suffers very 
 much with this eye. There is a continual lachrymation and 
 photophobia. Ipecac, 1st decimal trit. 
 
 January 6. There is a slight improvement, which is lim- 
 ited to the conjunctiva ; the keratitis with the tearfulness and 
 photophobia persist. Apium virus, 3d trit. 
 
 January 9. To-day there is a very marked improvement ; 
 the suffusion and the vascular injection are decidedly lessened. 
 The same treatment. 
 
 January 12. The photophobia has entirely disappeared ; 
 the pustules on the cornea have shrunken, and the patient who, 
 when she was admitted, saw absolutely nothing with that eye, 
 begins to discern objects at a certain distance. The same treat- 
 ment. 
 
 January 15. She thinks herself cured, and wants permis- 
 sion to leave the hospital ; the inflammation has entirely ceased ; 
 
SCROFULOUS KERATITIS. 429 
 
 the vision of the right eye is satisfactory, but there are still two 
 or three little patches on the cornea. The same treatment. 
 
 We saw this patient again at the hospital dispensary, and 
 for a month the cure seemed to be perfect ; but at the begin- 
 ning of March she suffered a relapse, and the physician on 
 duty at the time gave her hepar sulph., 3d trit., and also 
 apis mellifica, 3d trit. The woman, however, followed us to 
 the dispensary in the rue de Ver?ieuil, and the opium virus 
 quickly cured her keratitis. Some months later I examined 
 her, and the cure seemed permanent. 
 
 This case affords an excellent illustration of the necessity 
 of affiliating our remedies properly, and also o,f the importance 
 of using them in the most reliable form for the cure of the 
 sick. Here is a serious case of scrofulous keratitis, with ulcer- 
 ation of the cornea, which was treated twice, but without suc- 
 cess, by homoeopathic remedies ; the first time, at the onset of 
 the disease, by one of our pupils, and the second time by one 
 of our colleagues. In the former instance I attribute the failure 
 to the omission of ipecac, as a remedy for combating the con- 
 junctivitis ; in the latter, to the premature employment of 
 hepar sulp/i., and in both cases to the unreliability of the apis 
 met. in the form in which it was given. For in twenty-four or, 
 at the most, in forty-eight hours after the apium virus had 
 been prescribed the improvement began, and it afterward con- 
 tinued without interruption until the cure was complete. 
 
 Hepar sulphur is not indicated, we think, unless pus has formed, or there 
 is immediate danger of it. When such is the case it is one of the most valu- 
 able remedies that we have. — V. 
 
 Therefore, gentlemen, I would have you remember this 
 precept: In the treatment of scrofulous keratitis, when the 
 keratitis is accompanied by an intense conjunctivitis, always 
 begin with ipecac. Then, when the improvement which follows 
 
430 
 
 THE MEDICAL CLINIC. 
 
 the use of this remedy has ceased, follow it with the apimn 
 virus, and continue its employment so long as it is necessary ; 
 for you know that in chronic diseases it is only by persevering 
 with the proper remedy that we can arrive at a cure. 
 
 The specific use of ipecacuanha in scrofulous conjunctivitis has never before 
 been so authoritatively laid down. We allude to it more fully under Lecture 
 XIX, page 250.— V. 
 
 When the keratitis has existed for years, and has caused 
 films and infiltrations and interstitial abscesses of the cornea ; 
 iritis ; and all the lesions which characterize scrofulous affec- 
 tions of the eye, in their chronic stage, even the opium, virus 
 may fail. You have seen an example of this kind in Case 
 LVIII. In such rebellious cases you will find the needed re- 
 source in hepar sulph., aurum muriaticum, opium, arsenicum 
 alb., eujphrasia, belladonna, and other remedies that are indi- 
 cated in inflammation of the eyes. 
 
 Always, when iritis complicates or threatens, and when it does not, if the 
 corneal inflammation or ciliary pain is great, a local solution of neutral atropia 
 sulphate is strongly indicated. This solution may be of from two to four grains 
 to the ounce of distilled water, and instilled at intervals of hours or days, as the 
 urgency of the case demands; for in iritic complications, so liable in this group 
 of eye troubles, the physician who depends on internal treatment alone does not 
 secure the greatest benefit to his patient, and will have a large percentage of 
 cases left uncured, and many seemingly cured but temporarily quieted with 
 lesions of great damage. — V. 
 
 The warm water which specialists so frequently use in 
 scrofulous keratitis may also be applied as adjuvants in the 
 worst cases. In our own experience, excepting in interstitial 
 abscesses between the layers of the cornea, we have rarely 
 been obliged to have recourse to them. 
 
 Properly and intelligently used, we think warm water compresses of the 
 greatest value. — V, 
 
ACUTE ARTICULAR RHEUMATISM. 431 
 
 Acute Articular Rheumatism. 
 
 Case LXXYI. — M. Xavier M , aged twenty-seven, a 
 
 baker, was admitted on the 1st of December, and discharged 
 on the 28th of February. (Men's ward, ]STo. 2.) 
 
 This patient, who is apparently of a vigorous constitu- 
 tion, had some scrofulous disorders during his infancy. On 
 two separate occasions he had trouble with the eyes, which 
 continued for several months, but from the twelfth year he 
 seems to have had no further manifestation of the strumous 
 habit. 
 
 The disease for which he enters the hospital had its origin 
 in a general attack of articular rheumatism, which began six 
 weeks ago. At present most of the joints are free, and are 
 not painful when they are moved. The wrist and the ankle 
 joints of the left side, as well as the corresponding radio- 
 carpal and the tibio-tarsal articulations, are considerably 
 swollen and painful on pressure. The muscles of the left 
 arm are slightly atrophied, and so, also, are those of the 
 shoulder ; indeed, the infra-spinatus muscle has almost en- 
 tirely disappeared. 
 
 The patient's general condition is tolerably good, the tem- 
 perature is normal, and the digestive functions are in good 
 order. China, 3d dil. 
 
 December 4. There is no observable improvement. Vipera 
 torv., 3d trit. 
 
 December 18. The swelling about the foot seems to dimin- 
 ish ; the power of motion in the affected part is returning ; the 
 swelling of the wrist continues, however, and when one tries 
 to flex the fingers, it causes severe pain. The same remedy. 
 
 December 22. He complains of severe pains in the wrist, 
 but it is neither red, nor is the heat of the part increased. 
 China, 3d trit., twenty centigrammes. 
 
 January 2. The swelling of the ankle joints continues to 
 diminish very sensibly ; concerning the wrist, there is no 
 
432 THE MEDICAL CLINIC. 
 
 change either in its size or its mobility without pain. Sal 
 croisici, 3d trit., twenty centigrammes. At the same time an 
 application of dry heat was made to the latter joint. 
 
 January 8. The wrist appears to have diminished a little 
 in its size, but on its dorsal surface we find a little soft pro- 
 jection which imparts the sense of fluctuation. Dry heat and 
 sal croisici, 3d trit. 
 
 January 30. This treatment has brought about a decided 
 improvement ; the little fluctuating tumor on the back of the 
 wrist has disappeared ; the proper movements of the ankle 
 joint have returned, and the patient can walk a little without 
 suffering very severely. 
 
 The extremities of the wrist bones, which were badly swollen, 
 are decidedly better ; and on motion the radio-carpal joint is not 
 very painful. The same treatment was continued. 
 
 February 15. The patient grows better and better. The 
 swelling lessens daily, and pressure upon the wrist joint is 
 scarcely felt. 
 
 The same treatment was continued until February 28, when 
 he quit the hospital that he might convalesce in the country. 
 The left tibio-tarsal articulation had nearly the same mobility 
 and volume as its fellow ; and although the left wrist was still 
 a little stiff in its motion, and there was also a slight swelling 
 that remained, still the patient could use it pretty well. 
 
 This case shows how very decidedly different diseases may 
 influence each other. This man was scrofulous, his rheuma- 
 tism was scrofulous, and the rheumatic arthritis was the com- 
 mon symptom that resulted in the development of the white 
 swelling. 
 
 The common symptom {^accident commun) in pathology 
 is an affection which is proper to two diseases. Thus, bron- 
 chitis is common to rubeola and to phthisis, and it is this 
 disorder which serves as a bridge between them. A catarrhal 
 ophthalmia, in a scrofulous subject, develops a scrofulous kerat- 
 itis, and the inflammation of the conjunctiva is the common 
 affection. In persons of a scrofulous diathesis, arthritis may 
 
ACUTE ARTICULAR RHEUMATISM. 433 
 
 be the common affection which shall carry the case to the pro- 
 duction of a white swelling, whether the arthritis itself is rheu- 
 matic, traumatic or gonorrhceal. The physician should never 
 lose sight of this law in general pathology. A surgeon in one 
 of the Paris hospitals has just re-discovered this law which had 
 been propounded thirty years ago by Dr. J. -P. Tessier, in his 
 lectures at VEcole pratique and at the Hotel Dieu. 
 
 You have remarked that the principal remedy prescribed 
 for this patient was the sal croisici, in the third trituration. 
 The name designates the salt derived from* the sea-water of 
 Croisic. This water contains the bromide of sodium chiefly. 
 Bathing in this sea-water is certainly the most decided remedy 
 for scrofula ; and since every one cannot go to the sea-side for 
 this treatment, I have had a trituration made of this salt, and 
 have given it internally. 
 
 During the last year I have frequently prescribed this 
 preparation for scrofula, and also in the treatment of uterine 
 affections which were characterized by copious and too pro- 
 longed menstruation. My observations are still too limited 
 and imperfect to permit me to give the precise indications 
 for its internal use. But they are, however, so satisfactory 
 as to prompt me to recommend my confreres to try the 
 efficacy of the sal croisici in all those cases for which they 
 usually advise sea-bathing. 
 
 Uterine affections are so often engrafted upon the scrofulous constitu- 
 tion that any remedy which promises to be of service in both these classes 
 of disorders, or, in other words, to relieve the symptoms which they have in 
 common, is worthy of trial. The great value of the preparations of calcarea 
 carb., calcarea phos., calcarea sulph., ammonium mur., kali carb., and other 
 remedies of a similar kind, lies in the fact that their curative sphere in- 
 cludes a relation to these compound disorders. There is no doubt, in our 
 own mind, at least, that the good effects of mineral waters and of sea- 
 bathing in chronic uterine complaints, comes from the taking of these and 
 various other salts that have been prepared and attenuated in the great 
 laboratory of Nature. It is not unlikely that the sal croisici recommended 
 by Dr. Jousset will yet prove of exceeding value in this class of cases. We 
 shall see. — L. 
 28 
 
LECTUEE XXIX. 
 
 Summary. — Hydrarthrosis, case. Jodium. Diagnosis of hydrarthrosis. Hy- 
 drarthrosis acutus, case. Aphim virus. Periodical hydrarthrosis, two 
 cases. Sea-bathing. Asthma with epileptiform vertigo, case. Arsenicum. 
 Hemoptysis in asthma, case. Arsenicum and nux vomica. 
 
 Hydrarthrosis. 
 
 Gentlemen: I shall speak to you at this time of a disease 
 which is extremely rebellious, especially when it has passed its 
 first stage. That disease is hydrarthrosis. Here is a case of 
 chronic hydrarthrosis taken from our wards: 
 
 Case LXXYII. — Miss G , twenty-five years of age, 
 
 was admitted on the 5th of December, and discharged on the 
 28th of January. (Ward 1, N"o. 3.) 
 
 During the preceding winter this patient had been treated 
 tor two months for a chronic hydrarthrosis of the right knee, 
 which she had had for at least ten years. She says that almost 
 every winter her knee was so swollen that she was obliged to 
 keep quiet for some time. 
 
 On her admission the following record was made of her 
 case: The knee is deformed, enlarged, and somewhat sensi- 
 tive ; by palpation an eifusion within the joint is easily recog- 
 nized; it is excessively painful for her to walk, and she can 
 scarcely stand upon the right leg. The general health is tol- 
 erably good. The prescription was: absolute rest, and j odium, 
 6th dil., two drops during the day. 
 
 December 11. The swelling of the knee is perceptibly di- 
 minished, and the joint is not painful to pressure. Jodium, 
 3d dil., in the same manner. 
 
 December 21. The effusion is almost entirely re-absorbed. t 
 
HYDRARTHROSIS. . 435 
 
 The joint can be flexed without much difficulty. Jodium, 12th 
 dil. 
 
 December 28. We cannot detect the fluid in the joint. The 
 patient has been allowed to rise, and can walk without difficulty. 
 She can, however, flex the knee only imperfectly. Jodhim, 2d 
 dil. 
 
 January 13. The same remedy has been continued. She is 
 doing well ; but when she begins to move the knee or to walk, 
 the joint is a little stiff. The ligaments remain congested. Apis 
 mellifica, 3d trit., and dry heat to be applied about the joint. 
 
 January 17. A new application of the heat over the articu- 
 lation. Apis mel., 3d trit. 
 
 January 20. The local condition of the joint is changed ; 
 the tissues that surround it are more supple, and motion is 
 much more easy. Dry heat, and the same remedy. 
 
 January 28. The patient left, in a very satisfactory condi- 
 tion. 
 
 It is very important not to confound hydrarthrosis with 
 white sivelling. The first of these two affections is almost 
 painless, and can only become painful by the extreme and 
 rapid distention of the joint. Moreover, the effusion is more 
 copious and more liquid than it is in the white swelling. To 
 feel the fluctuation, we must extend the limb so as to relax 
 the ligament of the patella, surround the patella above and 
 below with both hands firmly applied, and grasp the joint- 
 tightly ; then, with the index finger of the right hand, press 
 perpendicularly and quickly upon the patella. This bone will 
 sink in the water, which is below it, and strike upon the con- 
 dyles of the femur. When there is considerable effusion, the 
 patient carries the limb in a demiflexed position, because in 
 this position the capsular ligament is not so fully distended. 
 
 Jodimn was the chief remedy in this case, and it had the 
 effect to stimulate the absorption of the effused liquid. Apis 
 mellifica and the dry heat were necessary on account of the 
 congestion of the ligaments and the tendons. 
 
436 . THE MEDICAL CLINIC. 
 
 But, in acute hydrarthrosis, the apium virus is the princi- 
 pal remedy, as you will see in our next case. 
 
 Case LXXYIII. — Of Acute Hydrarthrosis. — Mrs. C , 
 
 aged thirty-two, is a somewhat delicate woman. Her courses 
 having been habitually too free, she has a consequent anaemia ; 
 but, otherwise, her general health is usually good. Early in 
 December she was taken with a painful impediment in the 
 left knee, with a very rapid swelling of the joint. I saw her 
 on the third day from the beginning of her trouble, and noted 
 the following symptoms : Enormous tumefaction of the knee, 
 which is round like a globe ; very evident fluctuation ; con- 
 stant deminexion of the limb ; pain from the distention ; 
 neither heat nor redness of the part ; loss of appetite and 
 of sleep, but no increased frequency of the pulse. She was 
 ordered to remain in bed or upon an extended chair, and to 
 take of the aphim vines, 3d dil., three drops in 200 grammes 
 of water, one teaspoonful every three hours. 
 
 Fifth day. There is undoubted improvement ; the knee is 
 still large, but the tension is decidedly less, and the sleep and 
 appetite have returned. The same treatment. 
 
 Seventh day. She is still improving ; the joint is not so 
 swollen, and the leg can be extended without pain. The same 
 treatment. 
 
 Ninth day. The natural outline of the joint is readily made 
 out, but there is still some fluctuation ; the patient keeps the sit- 
 ting posture one-half of the day. The same treatment. 
 
 Twelfth day. The effusion has disappeared ; the patient 
 begins to walk a little, but the joint is still stiff. The same 
 treatment. 
 
 Some days later she began to go out of doors, and then 
 gradually resumed her old habits. 
 
 In this case the medicine acted promptly, and the im- 
 provement was so constant that it was not necessary to 
 make any change in the treatment. 
 
HYDRARTHROSIS. 437 
 
 A propos of this subject, I will report two cases of a. 
 variety of hydrarthrosis which is very rare, — I mean the 
 periodical hydrarthrosis, which, in this instance, occurred in 
 a scrofulous subject. 
 
 Case LXXIX. — Mrs. G , aged forty-six years, still 
 
 menstruates regularly, but is slightly anaemic. The cervical 
 glands are swollen, although they were once very much re- 
 lieved by the waters of Saline. Last year she had hydrar- 
 throsis of the right knee, which has been quite cured. Dur- 
 ing the summer of 1873 she spent a month at Croisic, for 
 the sake of the waters, which helped the glandular swellings 
 very much, but brought no sensible relief to a slight and peri- 
 odical hydrarthrosis which dated from the previous winter. 
 
 January, 1874. The dropsy of the joint continues for 
 from four to six days ; then, after six or eight days, in 
 which it seems to have passed away, it returns again. The 
 duration of the disease is not always the same, but its re- 
 appearance occurs, in the same location, with great regu- 
 larity every twelve days. There is no pain, but a simple 
 stiffness ; the knee is tumefied, of a globular form, and 
 fluctuation is evident. 
 
 Pulsatilla, 3d dil. , had no effect ; sulphur, 30th dil. , 
 produced only a slight improvement ; but sea-bathing and 
 the baths in the Croisic water, taken during the month of 
 July, effected a cure which lasted until the next spring. 
 Chininum sulph. , ' 3d trit. , and china, 3d trit. , afterward kept 
 this affection at bay for some months, but did not cure it, 
 for the dropsy came again with its old periodicity. The 
 patient was obliged to remove to Pau, and I do not know 
 what has become of her. 
 
 Here is a case of periodical hydrarthrosis in a woman 
 with monorrhagia and consequent anaemia: 
 
 Case LXXX. — Mrs. de Saint-G , aged forty, the 
 
 mother of several children, has been subject for some years 
 to very copious menstruation, and also to an abundant leu- 
 corrhoea. She is verv anaemic, feeble and short of breath. 
 
438 THE MEDICAL CLINIC. 
 
 For fifteen months she has been afflicted with a periodical 
 hydrarthrosis seated in the left knee. This affection returns 
 about once in twelve days, and continues four or five days. 
 The knee is swollen, stiff, non-painful and fluctuating. Two 
 years ago she had the same trouble in the right knee, which, 
 after four months' duration, was cured by the waters of Saint 
 Honore. The interval of health between the two attacks was 
 six months. Last year she passed a season at the waters of 
 Canterets, but these powerful thermal springs had no effect in 
 breaking up the periodicity of the hydrarthrosis. 
 
 Chininum sulph., 3d trit., was prescribed in February, 
 1876, but it produced only a slight and insignificant change 
 in the symptoms. In the month of March I gave her of the 
 sal croisici, 3d trit., sixty grains divided into twenty-four pow- 
 ders, one to be taken in two parcels daily. In April the menses 
 were not so abundant. The same remedy was continued, with 
 the addition of hydrotherapia. Under their combined influence 
 the flow diminished, and became almost normal, but the par- 
 oxysms of the hydrarthrosis were scarcely changed at all; but 
 a season of sea-bathing at Croisic disposed of the articular 
 affection completely, and restored the catamenia to their nor- 
 mal condition. The patient regained her strength and her 
 appetite, and seemed to be entirely cured. 
 
 I have cited these last two cases more as a pathological 
 curiosity than as an argument in favor of homoeopathic medi- 
 cation, since the sea-baths at Croisic have played the chief 
 role in the improvement of the first case and in the cure of 
 the second. 
 
 Asthma with. Hemoptysis. 
 
 I have often had occasion to speak to you of asthma, and 
 of its treatment. Of late we have had two patients in our 
 wards who furnish us a reason for returning to this sub- 
 ject. The first of these is remarkable for the paroxysms of 
 epileptiform vertigo which accompany the fits of coughing, 
 and also for the occurrence of hemoptysis at the onset of the 
 
ASTHMA WITH HEMOPTYSIS. 439 
 
 disease. The second one, who was attacked with bronchitis 
 during the course of his asthma, had likewise experienced 
 slight returns of hemoptysis during the first years of his 
 illness. 
 
 Case LXXXI. — Albert Gr , thirty-three years of age, 
 
 was admitted on the 21st of December, and discharged on the 
 30th of December. 
 
 This man, endowed with a good strong constitution, came 
 hither because of paroxysms of dyspnoea, which began a long 
 time since, but which of late have assumed such an acute form 
 that he has been forced to quit his very painful occupation as a 
 butcher's boy. He is not a hemorrhoidal subject, and has had 
 no herpetic affection. But he has had some symptoms of the 
 gout. 
 
 His emphysema began ten years ago, when he had an attack 
 of hemoptysis, which continued for ten days, and which was 
 the first symptom of his ill-health. 
 
 He takes cold every winter, and then coughs for three or 
 four weeks. At these times his dyspnoea is decidedly aggra- 
 vated, and he is forced to abstain entirely from work. Then 
 he also has severe fits of asthma, which come especially at 
 night, but sometimes also during the day, after eating. His 
 respiration is slightly oppressed during the summer season, 
 but at that time he does not suffer very much, and can continue 
 his employment. 
 
 We must not forget to state that our patient has a deposit 
 of red sand in his urine ; but nevertheless he has never had 
 pains in the joints, nor nephritic colic. The appetite is good, 
 but the digestion is slow, and accompanied by a determination 
 of blood to the head, with a tendency to sleep ; in a word, he 
 is dyspeptic. 
 
 To-day his condition is as follows: The cough is quite fre- 
 quent, loud and resounding, but rarely followed by expectora- 
 
440 THE MEDICAL CLINIC 
 
 tion. The sputa are slight, mucous, and a little ropy. The 
 soft parts being very thick over the thorax, percussion reveals 
 nothing. On auscultation we detect sibilant and snoring ronchi, 
 and prolonged expiration. Arsenicum, 3d trit., twenty centi- 
 grammes during the day. 
 
 December 24. The patient feels no better; the expectora- 
 tion is still scanty and very difficult. Arsenicum, 2d trit. 
 
 December 25. He complains of vertigo, which comes with 
 the fits of coughing. This vertigo is so violent that, for a little 
 while, he loses consciousness. Cuprum, 12th dil. 
 
 December 26. He was more quiet yesterday. The dysp- 
 noea has subsided very much, but the vertigo persists. Ar- 
 senicum, 3d trit. 
 
 December 27. In so far as the chest is concerned, our 
 patient is improving ; but he suffers to-day from a stitch in the 
 left side. The expectoration is easier and a little more free ; 
 the paroxisms of vertigo have disappeared. Nux vomica, 3d 
 trit. 
 
 December 29. The cough and the stitch in the side have 
 almost ceased. The patient feels so well that he begs for his 
 discharge. He was given arsenicum, 3d trit., to take after he 
 had left the hospital. 
 
 This case presents two peculiarities to which I desire to 
 call your attention ; the first is the occurrence of an hemop- 
 tysis at the onset of the disease, and the second, the returning 
 fits of vertigo simultaneously with the paroxysms of coughing, 
 
 It is very rarely that hemoptysis occurs during the course 
 of asthma, and this complication always awakens in the mind 
 of the doctor, as well as in that of the patient, a fear of 
 phthisis pulmonalis. It is necessary, therefore, that you 
 should be forewarned of the possibility of hemoptysis, even 
 in a violent form, in the case of those who have the asthma, 
 but without any tubercular or cardiac complication. 
 
 The elder Gabalda, in a memoir upon asthma, published in 
 the Journal de la Societe Gallicane, has spoken in the following 
 
ASTHMA WITH HEMOPTYSIS. 441 
 
 terms of the existence of hemoptysis occurring in the course 
 of ordinary asthma : 
 
 "The hemoptysis of asthmatic patients has some peculiari- 
 ties which are not always the same. Sometimes the matter 
 that is expectorated is mixed with a greater or less quantity 
 of blood, so long as the exacerbation of the other symptoms 
 of the disease continues ; at other times a large quantity of 
 pure blood is expectorated in a few moments, as happens in 
 phthisis." (Page 559.) 
 
 It was a copious hemorrhage from the* lungs that our pa- 
 tient had ten years ago, and yet you see that not only has he 
 failed to have phthisis, but he is still of a vigorous constitution. 
 The capital fact which you should remember, and which is 
 very important in a prognostic point of view, is, that asth- 
 matics may have even an abundant hemoptysis without being 
 threatened with tuberculosis. 
 
 • 
 As a clinical rule in these cases, the greater the degree of a decided asthma, 
 or of periodical suffocation in connection with attacks of hemoptysis, the less 
 the probability of a tuberculous complication. If a patient who is subject to 
 distinct and repeated fits of asthma is seized with hemoptysis, the probabilities 
 are. that he is not suffering from and will not have phthisis. — L. 
 
 The second point concerns the vertigo, with Joss of con- 
 sciousness during the coughing fit in the case of asthmatics. 
 We have already had occasion to refer to this peculiar com- 
 plication in the case of a woman whose clinical history you 
 will remember (see page 137). That woman had a general 
 tonic convulsion, with a cyanotic hue of the face and entire 
 loss of consciousness. Arsenicum will cure this condition. 
 The man of whom we have been speaking had neither a con- 
 vulsion nor cyanosis, but vertigo with insensibility. 
 
 Within the present year the occurrence of epileptiform 
 vertigo during the fits of coughing to which asthmatics are 
 subject has attracted the attention of clinical teachers. M. 
 Charcot is disposed to admit a vertigo, the origin of which 
 
442 THE MEDICAL CLINIC. 
 
 he refers to the larynx (like that of Meniere, which began 
 in the labyrinth of the ear), as an explanation of the sudden 
 fall of these patients, as if struck by lightning, at the close 
 of a fit of coughing. He has observed this form of vertigo 
 in gouty and asthmatic persons. 
 
 V 
 
 A propos of M. Charcot's report to the Biological Society, 
 M. Gelle presented, in the name of M. Collin, of Yangirard,. 
 the following case of 
 
 Apoplectic Spasm of the Larynx. — M. Collin was seated at 
 the table opposite M. G , one of his friends, aged sixty- 
 eight, who was slightly emphysematous, but actually very well. 
 
 While the dessert was being served, M. G laughed at a 
 
 joke and was suddenly seized with a fit, which at first was 
 very light, but then grew worse, and had no remission. His 
 face became red and congested, the eyes were injected, and 
 it seemed as if he was being strangled by a cough. Then 
 he leaned his head forward and stopped coughing, and re- 
 mained for some seconds in that position, immovable, with 
 his nose in his napkin. From the moment in which he be- 
 came conscious he was giddy, and knew very little of what 
 had passed. There was also a slight stupor. Although the 
 fit lasted only a few minutes, it seemed like hours to his 
 friends. M. G had several paroxysms of this kind dur- 
 ing the last three years of his life. 
 
 He died, at the age of seventy-one, of tracheo-pneumonia. 
 For fifty years he had suffered from chronic hypertrophic 
 pharyngitis, with slight deafness. 
 
 Here is a clinical fact that may throw some light on the 
 subject of laryngeal vertigo : 
 
 Fibroma of the Larynx as a cause of Epilepsy. — The au- 
 thor knows of the case of a man, fifty-four years of age, who 
 had a tumor seated upon the vocal cord of the left side, which 
 
ASTHMA WITH HEMOPTYSIS. 443 
 
 had caused a hoarseness that had continued for several years. 
 The year after the hoarseness began to increase it became 
 complicated with dyspnoea ; and, moreover, the patient was 
 seized with epileptiform paroxysms, which usually came dur- 
 ing the night. One of these fits was followed by a slight 
 paralysis of the extremities on the left side of the body, and 
 also of the muscles supplied by the facial nerve on the same 
 side. The paralysis disappeared little by little. The means 
 used to prevent the epileptiform attacks having failed of effect, 
 they became more frequent and severe, and it was supposed 
 that the presence of the tumor in the larynx had something 
 to do with their occurrence. It is worthy of note that fifteen 
 years before the patient had had a few epileptiform fits, of 
 which he was cured by the incision of a cutaneous cicatrix 
 located on the back of his hand. With the aid of a bistoury, 
 Sommerbrodt removed the tumor, which proved to be a fibroma. 
 *'*■** The hoarseness of the voice and the dyspnoea disap- 
 peared at once, and, five months after the operation, the epilep- 
 tiform fits had not returned a single time. (.Berliner JTlin., 
 Wochens, No. 39, 1876.) 
 
 We do not wish, at this time, to attempt any physiological 
 explanation of this new form of vertigo ; but let us not forget 
 that, in the two cases which you have seen in our clinic, arsen- 
 icuin has promptly caused it to disappear. 
 
 Here is another case of asthma, in which we also find there 
 have been slight attacks of hemoptysis, not only at the onset, 
 but likewise during the course of the disease : 
 
 Case LXXXII. — M. Charles L , aged forty, was ad- 
 mitted on the 1st of February, and discharged on the 18th 
 of February. (Men's ward, No. 4.) 
 
 This patient, who has asthma, with pulmonary emphysema, 
 has never had any herpetic or hemorrhoidal troubles. 
 
 His health was very good until the age of thirty, when it 
 
444 THE MEDICAL CLINIC. 
 
 became somewhat broken by paroxysms of asthma, for the re- 
 lief of which he sought our advice, now ten years ago. From 
 that time he has taken cold every winter, and then has coughed 
 for two or three months. 
 
 His general condition, despite the expectoration of a slight 
 quantity of blood, which almost always accompanies his yearly 
 attacks of bronchitis, is satisfactory. The dyspnoea, which is 
 the principal difficulty, disappears almost entirely in the sum- 
 mer, but returns in a very severe form in the winter. 
 
 He is now in the acute stage, and has coughed for a week. 
 This cough is dry and extremely painful. The expectoration, 
 which is slight, is of whitish, aerated sputa, which does not 
 adhere to the bottom of the vessel. 
 
 His breathing has been very much oppressed for some days, 
 and during the night he is seized with violent fits of asthma, 
 which prevent him from sleeping. 
 
 A physical examination of the thorax reveals the ordinary 
 signs of pulmonary emphysema. His chest, which is very 
 much protruded in front, gives, on percussion, both before and 
 behind, an exaggerated resonance. 
 
 By auscultation we perceive on the two sides of the thorax 
 a great many sibilant and sonorous rales ; at the base and pos- 
 teriorly, there are mucous rales on inspiration. The expiration 
 is very much prolonged. Ipecac, 12th dil., and hryonia, 12th 
 dil., to be taken alternately. 
 
 February 3. The patient still coughs ; the dyspnoea is very 
 bad, and^worse at evening. Cuprum, 12th dil. 
 
 February 4. ~No improvement. Arsenicum, 3d trit. 
 
 February 8. He is a little better to-day ; the expectoration 
 is easier, and the suffocation less painful. Arsenicum, 3d trit. 
 
 February 11. For two days he has not been quite so well ; 
 the cough is a little more frequent. Arsenicum, 3d trit., in 
 the morning, and mix vomica, 3d dil., at evening. 
 
 February 15. There is a considerable improvement in his 
 condition ; he coughs no more, excepting at very long inter- 
 vals, but he complains of a pain in the left side ; the dysp- 
 noea is scarcely observable. Bryonia, 3d dil. 
 
 February 18. There is no more pain in the side, and the 
 respiration is easy. He wants to go to work again. 
 
LECTUKE XXX. 
 
 Summary. — Vaginismus, case. Causes and treatment. The French surgeons 
 and Dr. J. Marion Sims. Note; case. Hemorrhagic variola. Influence of 
 vaccination upon the suppurative stage, and the therapeutic fallacies which 
 spring from it, case. The hemorrhagic rash and the scarlatinal rash. 
 Phosphorus. Hemorrhagic variola without increased frequency of the 
 pulse; death; case. The malignancy of disease. 
 
 Vaginismus. 
 
 Gentlemen: Here is an illustration of a disease from 
 which no one has ever died, but which has very often caused 
 the poor women who suffer from it to wish that they could 
 die. Accompanied by a painful spasm of the sphincter vag- 
 inae, as a fissure of the anus is accompanied by a like spasm 
 of the sphincter ani, vaginismus may or may not be com- 
 plicated with excoriations and fissures of the vulva ; but in 
 this affection, as in the disease of the anus (which has been 
 so well described by Boyer), the lesion of the mucous mem- 
 brane plays only a secondary part, for the painful spasm 
 of the sphincter is the principal, and, sometimes, the only, 
 difficulty. 
 
 We are indebted to a French surgeon for the first work 
 on vaginismus. In his inaugural thesis, published in 1834, 
 Huguier detailed a case of vaginismus, and in this connec- 
 tion gave its pathological history and treatment. He very 
 properly compared it to a fissure of the anus, and proposed 
 to treat it by incision of the sphincter. It is, therefore, proof 
 of the ignorance of the American surgeon, Sims, who, when 
 he met with his first case of vaginismus, in 1857, avowed 
 that "the books threw no light'' on the subject of its 
 
446 THE MEDICAL CLINIC. 
 
 treatment. He bethought himself of a surgical operation, 
 but adds : ' ' However, I declined to do anything, on the ground 
 that an untried process was not justifiable on one in her posi- 
 tion in society (the patient being in high life), the hospital 
 being the legitimate field for experimental observation." {Clin- 
 ical Notes on Uterine Surgery, 1866, page 323.) 
 
 If Dr. Sims had known the French surgeons he would not 
 have ignored the operation made by Huguier in 1831 ; that 
 practiced by Pinel-Grandechamp, and reported in Dupuytrerts 
 Clinic (2d edition, 1839) ; or the operation of Michon in 1851. 
 He might also learn from our surgeons that the rank of the 
 patient constitutes neither an indication nor a contra-indication 
 for an operation, and that those unfortunates who are obliged 
 to go to an hospital, far from being mere subjects for experi- 
 mentation, are so much the more respectable because they 
 have nothing to care for but their misery and their disease. 
 
 Vaginismus is most frequently developed at the first sexual 
 act, which, under the circumstances, is rendered impossible. 
 At other times it follows excessive coitus (as in the case cited 
 by Huguier, and the XlXth of Yisca's memoir); or it may 
 happen after child-birth, and even where there is a rupture of 
 the perineum ; and sometimes it is due to eczema, to pruritus 
 of the vulva, or to a Menorrhagia. Certain cases seem to 
 depend upon the different uterine affections, and upon the 
 leucorrhcea that accompanies them ; upon fissures and ulcera- 
 tion at the entrance of the vagina, of the labia minora, but 
 especially of the caruncles or of the hymen. Polypi within the 
 meatus urinarius are often the point of departure for a painful 
 spasm of the vaginal sphincter. In the case of hysterical sub- 
 jects the affection is sometimes periodical, accidental, and of 
 temporary duration, when it is not associated with some other 
 lesion. 
 
VAGINISMUS. 447 
 
 In some cases in which this painful affection is linked with hysteria, result- 
 ing in periodical headaches, incipient and temporary insanity, spasms, convul- 
 sions, and even hemi- anesthesia, the trouble really originates in the ovary. And 
 in milder cases, where the disorder has existed for a long time in the unmar- 
 ried, and in those women who, by reason of circumstances beyond anybody's 
 control, are forced to live apart from their husbands for weeks or months at a 
 time, the same is true. It is a little strange that most writers in gynaecology 
 have overlooked this important clinical fact. 
 
 So, also, there are cases of vaginismus which are the indirect result of spinal 
 irritation, of concussion of the spine, of nervous shock, of uterine flexures, and 
 of uterine engorgement. — L. 
 
 It is an important question whether an habitual and per- 
 manent vaginismus, like an anal fissure, is always connected 
 with a hemorrhoidal difficulty. We cannot decide that it is so. 
 
 A forced continence which is more or less absolute is the 
 usual result of this disease. The history of the young woman 
 who is now in our wards is but a repetition of that which is 
 common in such cases, id est, her separation from her husband 
 and her determination to return home and live with her mother. 
 
 In his Principles and Practice of Gynaecology, page 601, Emmet says: 
 *' There is a certain condition which is almost always accompanied by a moder- 
 ate cellulitis in one of the broad ligaments, rendering the female devoid of all 
 sexual desire. For a time, woman-like, she will submit to marital approaches 
 through a sense of duty, but after a while, by degrees, their suggestion even 
 excites a feeling of disgust. If she continues to submit to what she supposes she 
 is obliged to do, this hypersesthesia and spasm become finally developed as an 
 earnest of the disgust, in the same manner as the gullet closes spontaneously 
 against, and rejects, a nauseous draught. If the necessary treatment can be 
 administered by degrees, this condition will disappear without an operation, 
 and the woman will return to her duties as a wife with very different feelings. 1 ' 
 
 Other causes of this painful affection are linear ulcers about the meatus 
 urinarius and the neck of the bladder, granular vaginitis, herpes of the vulva, 
 vulvar folliculitis, vaginal neuromata, spasmodic dysmenorrhea, pelvic cellu- 
 litis, and the contact of an acrid leucorrhceal discharge. — L. 
 
 This particular case will serve to acquaint you with the 
 usual symptoms of vaginismus, and, at the same time, will 
 show you the close analogy between it and painful spasms of 
 the other sphincters. It will also demonstrate that dilation is 
 not an infallible means of curing this disease, since the de- 
 
448 THE MEDICAL CLINIC. 
 
 livery, although it was premature, has had no effect in modify- 
 ing the painful spasm of the vulva. 
 
 Case LXXXIII. — Marie M., aged seventeen, was admitted 
 on the 13th of January, and discharged on the 25th of February. 
 <;Ward 2, No. 2.) 
 
 This woman, of a good constitution, was married in her 
 sixteenth year. She says that her sexual relations were always 
 exceedingly painful ; however, she became pregnant, and after- 
 ward suffered an abortion in the fourth month. She soon 
 recovered from this mishap ; but the vaginismus, instead of 
 being mitigated by her delivery, was so much worse that she 
 renounced her married life altogether. At the same time she 
 began to suffer from hemorrhoids, and with vesical irritation. 
 Three weeks from the invasion of these new symptoms she 
 came to the hospital, and the following is her record : 
 
 There is a hemorrhoidal discharge, with tenesmus, and for 
 some hours after a stool she has the excessive pains which are 
 characteristic of fissure of the anus ; there is also an extremely 
 painful tenesmus of the bladder, painful urination and hema- 
 turia ; the spasm of the vagina is so severe that it is extremely 
 difficult to practice the" touch "; the attempt to pass the finger 
 makes her scream, and the pain caused by it persists for several 
 hours. There is neither a fissure, an excoriation, nor a Menor- 
 rhagia. 
 
 The patient believes that this painful condition has been 
 greatly aggravated by her accouchement. Independently of 
 the spasms which are caused by urination, defecation or the 
 "touch," there is a constant pain that is very much increased 
 by walking. 
 
 Phosphorus, 6th dil., aloes, 3d trit., nux vomica, 3d dil., 
 and capsicum, 3d dil., have entirely cured the hematuria and 
 the hemorrhoidal discharge ; and sedum acre, 3d dil., has al- 
 layed the painful spasms of the sphincter ani ; but these reme- 
 dies have been of no avail for the relief of the vaginismus. 
 
 Plumbum, 6th dil., internally, aided by the application of 
 bits of charpie dipped in lead- water, brought no improvement. 
 We also tried the effect of bathing the parts with a solution of 
 the hydrate of chloral, but the extreme pain caused by the in- 
 
VAGINISMUS. 449 
 
 troduction of the charpie caused us to desist from its use, and 
 we 'have advised the patient to consult a surgeon. 
 
 In this case the extreme youth of the woman at the time of 
 her marriage and a decidedly hemorrhoidal tendency, may be 
 considered as having caused the vaginismus. The dilatation of 
 the- vulvar orifice by a premature delivery, far from having the 
 favorable result that one would reasonably expect, really made 
 matters worse and aggravated the difficulty. But this is not a 
 novel result. Depaul has reported a case of vaginismus which 
 was caused by a wound resulting from the passage of the foetal 
 head during labor ; and Bernutz has seen a woman in whom 
 vaginismus was caused by an abortion. In his clinic, Guneau 
 de Mussy cites the case of a lady in whom vaginismus had per- 
 sisted, and was reallv increased after four deliveries at term. 
 
 In common with ourselves, Scanzoni has observed instances 
 in which the vulvar spasm existed conjointly with spasms of 
 the sphincters of the rectum and of the urethra. And in these 
 cases he has remarked that walking will often increase the suf- 
 fering, as it did with our patient. 
 
 As in the treatment for fissure of the anus, relief is best ob- 
 tained by surgical means. In the Old School, belladonna and 
 the bromide of potassium have not had the success which the 
 nature of the disease and the properties of the remedies would 
 seem to warrant. In our own school, we are still without any 
 clinical records upon the medical treatment of this affection. 
 The indications which are given by Jahr for ferrum, kreo- 
 sotum. and berberis for pain during coitus correspond only to a 
 sensation of smarting, and not to a contraction of the vagina. 
 
 In his treatise on the Diseases of Women, this author (Jahr) 
 
 enumerates several remedies which he declares have been very 
 
 effectual in the treatment of this disease. But if you try -to 
 
 verify the symptoms of belladonna, mix vomica, ignatia, pla- 
 29 
 
450 THE MEDICAL CLINIC. 
 
 tina, etc., in the Materia Medica, you will find that the patho- 
 genesy of these remedies does not contain a single symptom 
 that belongs to vaginismus. Besides, the description which 
 Jahr gives of this affection proves that he did not understand 
 it, and destroys all confidence in his declarations. 
 
 As the author puts it, this criticism is just; for Jahr evidently wrote from 
 the pathogenetic side of this question only. It is very doubtful if he ever saw a 
 case of vaginismus. The medical treatment of this affection affords another in- 
 stance in which clinical experience has outrun the provings. We certainly have 
 several times cured the milder forms of this disease, when it was secondary 
 upon ovaritis, with belladonna, platina, gelseminum, caulophyllin, and kindred 
 remedies. 
 
 In these cases the vaginismus was symptomatic, and disappeared when the 
 lesion upon which it depended for its existence was cured. — L. 
 
 According to Dr. Richard Hughes, plumbum should pro- 
 duce vaginismus ; but you have seen that it did no good in the 
 case under review. Possibly its use was not continued for a 
 sufficient length of time, or the dose may not have been strong 
 enough. This question is, therefore, an unsettled one. 
 
 Gradual dilatation ; rapid dilatation, as for anal fissure ; the 
 incision of the sphincter ; the incision of the border of the hy- 
 men, and of the vaginal mucous membrane ; either, separately 
 or combined, have produced a large number of radical cures. 
 The painful points must be removed, and the dilatation result- 
 ing from the operation, maintained by a kind of tampon that 
 is anointed with belladonna. 
 
 Several different operations have been proposed and practiced for the cure 
 of vaginismus. Dr. Burns first recommended a division of the pudic nerve. 
 Dr. Sims' plan is to make deep incisions to the right and left of the mesian line 
 of the vagina, passing across the sphincter vaginae for about half an inch, but 
 not through it. He then inserts a conical glass or rubber dilator, which is to be 
 worn while the parts heal. Dr. Tilt recommends the forcible dilatation of the 
 constrictor muscles of the vagina by introducing the two thumbs with their 
 backs toward each other into the vaginal orifice, and forcibly stretching the 
 orifice by their separation for some minutes. Scanzoni treated one hundred 
 cases mainly by dilatation, and cured them all without having recourse to the 
 knife. 
 
HEMORRHAGIC VARIOLA. 451 
 
 The following case is copied from our work on the "Dis- 
 eases of Women," page 467: 
 
 Case. — March, 1862. — Mrs. consulted me for the re- 
 lief of an irritable and sensitive condition of the vagina, which, 
 during her three years of married life, had caused her untold 
 suffering, and interfered most positively with sexual congress. 
 She was a most intelligent person, frank and candid in her 
 manner, and extremely anxious that something should be done 
 for her relief, more especially lest her husband should become 
 disaffected, and her family and friends continue to ridicule her 
 for not having become a mother. 
 
 On physical examination there was nothing abnormal about 
 the external generative organs except the hyperesthesia of the 
 vulva and of the vaginal outlet. The slightest and most deli- 
 cate touch with the finger caused the vaginal spasm immedi- 
 ately, and she was thrown into the same state of suffering 
 which she said she had always experienced in the conjugal act. 
 I placed her under the influence of sulphuric ether by inhala- 
 tion, and these symptoms disappeared. The dilatation with 
 bougies, anointed with belladonna, was begun, and repeated 
 every two days for a fortnight, then every day for another 
 week, and the barrier to intercourse was removed. She soon 
 conceived, and now has a son, a beautiful boy, nine years old. 
 I gave her no medicine. — L. 
 
 Hemorrhagic Variola. 
 
 Some days ago you saw, in a private room of the hospital, 
 a young girl who had all the symptoms of hemorrhagic variola. 
 You observed that we were very anxious concerning the issue 
 of the case, and you also witnessed the slow but certain influ- 
 ence of vaccination over its progress. Indeed, at the sixth 
 day, the morbid process was decidedly modified, and the pa- 
 tient has recovered, after having been dangerously ill during 
 the first two periods of the disease, and finally passed through 
 the stage of suppuration, which is usually the most perilous, 
 in a comparatively easy manner. You should always rem em- 
 
452 THE MEDICAL CLINIC. 
 
 ber this fact, gentlemen, in order that yon may not blunder 
 in the prognosis of variola, and also that you may not become 
 the victims of a therapeutical illusion. 
 
 Yariola is more or less modified by vaccination. Between 
 the case in which it prevents the small-pox altogether and 
 that in which the patient dies in spite of it there are many 
 degrees of influence which are not always appreciated. Very 
 often the effect of an old vaccination is shown in the sup- 
 purative stage of vari'ola, which is so modified that, as in the 
 varioloid disease, there is no suppuration. You will often 
 see cases, like the one before us, where the variola sets in 
 and continues during the eruptive stage with the most alarming 
 symptoms, but in which the danger disappears, as if by magic, 
 on the seventh or the eighth day, and the patients pass directly 
 into a state of convalescence. 
 
 You will understand that this very remarkable effect is a 
 fertile source of therapeutical error. The doctor is always 
 inclined to attribute these happy results, — which really depend 
 upon a former vaccination, — to the remedy or remedies that 
 he has given. It is this kind of a fallacy which has made no 
 little rejDutation for the saracennia and other boasted specifics 
 for small-pox. 
 
 In order that a remedy may be absolutely beneficial in 
 variola occurring in those who have been vaccinated, it is not 
 necessary that the suppurative stage should be suddenly ar- 
 rested, but that, while it follows its proper course, it should be 
 decidedly mitigated and modified thereby. And it is also 
 necessary that this result should be equally pronounced in the 
 case of those who have never been vaccinated. 
 
 If vaccination did no more than to mitigate and modify the small-pox, or 
 to abort its suppurative stage, it would still remain an incalculable blessing to 
 the race. 
 
 The cases that follow are of exceeding interest, their only defect consisting 
 in the fact that we are not informed if either of the patients were of the hemor- • 
 
HEMORRHAGIC VARIOLA. 453 
 
 4 
 
 rhagic diathesis; for cases of eruptive fevers engrafted upon this constitution 
 are, in our experience, always of a serious character, and, what is more, should 
 be treated with especial reference to that diathesis. — L. 
 
 Case LXXXIY. — Hemorrhagic variola / phosphorus / cure. 
 
 Augustine P , twenty years of age, a washerwoman, was 
 
 admitted to a private apartment in the woman's ward on the 
 19th of December, 1876. She had never had an eruptive fever. 
 She had been vaccinated when very young, but could not 
 give the date thereof. She had not been exposed to the small- 
 pox. 
 
 December 16. In the evening, having been in perfect 
 health, she was seized with severe pains in the loins ; chills, 
 headache, nausea, bilious vomiting, inability to sleep, loss of 
 appetite, and a violent epistaxis. 
 
 The same symptoms continued for several days. 
 
 Fourth day. She entered the hospital on the 19th of De- 
 cember. At the morning visit there was upon the front of 
 the neck and upon the upper and anterior part of the thorax a 
 very decided hemorrhagic rash. The same eruption was also 
 observed upon the abdomen. This rash appeared upon the 
 neck on the 17th, or the second day of the disease, and upon 
 the abdomen on the 18th, or the third day of the disease. 
 There was some redness of the face, but no visible eruption. 
 The nose-bleed, the vomiting and the constipation continue, 
 and there is also some sore-throat. The axillary temperature 
 reached 104°. In the course of the day the eruption appeared, 
 the pustules being small and slightly confluent ; between them 
 the skin is reddish-looking. They also appear upon the hands, 
 are less numerous on the arms and the breast, and there are 
 very few of them upon the abdomen. 
 
 The morning prescription was phosphorus, 6th dil., which 
 appears to have arrested the epistaxis ; the evening temperature 
 was 101.9°. 
 
 Fifth day, or the second day of the eruption, she had a bad 
 night, with delirium, vomiting, and constipation. There is no 
 nose-bleed, but the menses have appeared five days too soon. 
 Morning temp. 101.72°. The eruption continues. The same 
 treatment. 
 
 Sixth day. Another bad night with delirium. This morn- 
 
454 THE MEDICAL CLINIC. 
 
 ing she is a little more calm, with less heat and vomiting ; no 
 epistaxis ; the sore throat is more pronounced, with deferves- 
 cence ; the temperature being 99.68°. At the evening visit the 
 face is slightly swollen, but the hands are not so ; the eyes are 
 red and tearful ; the temperature is 100.76°. The same remedy. 
 
 Seventh day. Mild but continual and wandering delirium, 
 with nausea ; the temperature is normal. Tartar emetic, 6th 
 dil., during the day, and belladonna, 6th dil., for the night. 
 
 Eighth day. The wandering continues, but there is no 
 vomiting ; the face is decidedly swollen, but the hands are 
 very little so ; the pustules are surrounded by an ecchymotic 
 aureola ; the temperature is normal. 
 
 Ninth day. More delirium, very little nausea ; but some 
 of the points are suppurating, while others are drying up with- 
 out having suppurated. 
 
 Tenth day. The patient is convalescent. 
 
 What has the phosphorus accomplished in this case ? We 
 shall not commit the blunder of which we have just spoken ; 
 but we may remark that it would not have answered so good 
 a purpose in the rash of scarlatina, where the prognosis is 
 not usually so grave, as it did in this hemorrhagic rash, which 
 was characterized by many little spots of ecchymosis that run 
 into larger patches, some of which are red and others black, 
 with intermediate tints. 
 
 You will not forget that this rash included a large part of 
 the cutaneous surface ; that it was accompanied by repeated 
 attacks of nose-bleed ; then by premature menstruation or a 
 real uterine epistaxis ; and that, finally, the disease was not 
 arrested on the sixth day, but the delirium and other serious 
 symptoms continued until the ninth day, while some of the 
 vesicles suppurated. From this we conclude that, in a sim- 
 ilar case we might depend with confidence upon the use of 
 phosphorus. 
 
 A most remarkable cure of hemorrhage by phosphorus was reported in a 
 medical clinic, given in April, 1878, in the Hahnemann Hospital of this city, by 
 
HEMORRHAGIC VARIOLA. 455 
 
 Prof. Hawkes. The case was one of hematuria. We extract the more im- 
 portant facts from the lecture as it was published in the United States Medical 
 Investigator, Vol. VII, page 370. — L. 
 
 The history of the case is as follows: The patient is a young 
 man of about twenty-six years of age, tall, well-built, and of 
 nervo-sanguine temperament. About the 8th of February last 
 he fell while descending the steps of his residence, striking hfs 
 left side on one of the steps. The blow left but little mark, 
 and was followed, for a short time, by a feeling of faintness. 
 This soon passed off, however, and he went about his aifairs 
 as usual. Three days afterward he observed an unusual ap- 
 pearance of the urine, which led him to consult a prominent 
 allopathic physician, who, on examining the urine, advised him 
 to go home, and promised to call and see him. Some pain 
 was experienced in the region of the right kidney at this time. 
 The patient did as directed, and the physician called, as he had 
 promised, the same day. There seemed to be some doubt in 
 the physician's mind as to the source of the large quantities of 
 blood which were found in the urine, he at one time thinking it 
 came from the kidney, and at another from the bladder. The 
 patient was obliged to keep his bed after the first day. The 
 quantity of blood discharged from the bladder steadily increased 
 in spite of the most "heroic" means employed by the attend- 
 ing physician, and a second prominent practitioner was called 
 in consultation with the first, and the already aggravating doses 
 of irritating drugs were doubled with the advice. 
 
 Turpentine, in combination with various other substances, 
 was given in nauseating doses, until the stomach heaved at 
 even the thought or sight of it, and had become so irritable 
 and sensitive that it could retain nothing whatever. The kid- 
 neys, bladder and whole urinary tract were being inflamed by 
 the drugs in addition to the already existing serious lesion. 
 While the turpentine, in reasonable doses, might have been 
 beneficial and curative, as it often is in such cases, and in ac- 
 cordance with the law of cure, here it was largely adding to 
 the trouble. All sorts of absurd and torturing expedients 
 were blindly resorted to by the physicians in charge, in their 
 great extremity ; such as cramming ice up the rectum while 
 they diagnosed the difficulty to be in the kidneys, and injecting 
 
456 THE MEDICAL CLINIC. 
 
 a solution of nitrate of silver and other irritating astringents 
 into the bladder, when they thought the lesion was in that 
 organ ! 
 
 I found the patient, on the 26th of February, in a truly 
 deplorable condition. He was passing half a chamber-vessel 
 full of bright red arterial blood three times a day ; his lips 
 were the color of his cheeks, and his cheeks were the color of 
 the sheets upon which he lay. His stomach was so sensitive 
 and irritable as to be unable to retain even the simplest nour- 
 ishment. After repeated trials it had been able to retain a 
 spoonful of alkathrepta. His pulse was feeble and thready, 
 the heart beating 120 to 130 times per minute. He was nerv- 
 ous and sleepless. What passed from the bladder seemed like 
 pure blood, and, as I said before, half filled an ordinary cham- 
 ber-vessel three times in a day. A microscopic examination 
 showed nothing but red blood corpuscles. 
 
 There was some pain in the region of the right kidney, and 
 frequent spasmodic pains from that locality, along the course 
 of the corresponding ureter to the bladder. These pains, to- 
 gether with the elongated clots in the vessel, settled the ques- 
 tion of the locality of the lesion, to my mind. I fully realized 
 the gravity of the case before me, and diagnosed a severe, pro- 
 tracted and aggravated case of hematuria, with the kidney as 
 the seat of the lesion and the source of the vast quantities of 
 blood discharged. 
 
 The next problem which presented itself to my mind, and 
 to me and to the patient the most important and vital question 
 of all, was, what shall be the remedy which will most speedily, 
 radically and effectually stop this terrible, and if not soon 
 checked, necessarily fatal, waste of the vital fluid. 
 
 On glancing mentally back over the provings and symptoms 
 of phosphorus, I found that it produces hemorrhages from the 
 kidneys. I found that arsenicum, carbonate of ammonia and 
 phosphorus are mentioned by even the old-school authorities 
 (Ziemssen) as producing hemorrhage from the kidneys. This 
 being the case, and phosphorus being so completely indicated 
 constitutionally, and independent of this particular occasion, 
 there was no other proper or scientific course for me to pursue 
 but to give this patient phosphorus. This I consequently did. 
 
HEMORRHAGIC VARIOLA. 457 
 
 Phosphorus, 6th trit. and 30th dil., in water, a dose every hour 
 for a few hours, and later every two hours, was prescribed, 
 with a discontinuation of all external, useless and annoying 
 applications. This was about 11 a.m. 
 
 In the evening I fancied there was even then a little im- 
 provement in the patient's appearance and in the pulse. I 
 anticipated a sleepless night, and advised his friends and him- 
 self that such would probably be the case, as he had been un- 
 der the influence of morphia the previous night. I explained 
 to them why I expected it, and why it was better to have him 
 wakeful and restless than to stupefy him with morphia, and 
 thus retard his final recovery, and eventually increase his rest- 
 lessness. 
 
 February 27, 10 a.m. Found the patient had passed a 
 sleepless night, but was no worse. In fact, he was able to re- 
 tain quite a little alkathrepta on his stomach. In the evening 
 I found him certainly better. Pulse steadier and below 120, 
 and the stomach much less irritable. The contents of the ves- 
 sel showed little if any change, with the probabilities favorable. 
 Continued the phosphorus. 
 
 February 28, 10 a.m. Patient had passed another sleepless 
 night. Had been at times delirious, gazing and speaking 
 wildly at and to the nurse, raising himself up on his elbow and 
 calling them to take a great weight off his chest and shoulders, 
 saying some one was sitting on his shoulders and chest. The 
 pulse, however, had still further steadied and decreased in fre- 
 quency. He asked for food. The contents of the vessel were 
 more brown, and less like pure blood. He was stronger ; there 
 was present, however, a troublesome hiccough, or half belch 
 and half hiccough, which was so severe as to shake his whole 
 body, and was painful to hear. This was, in a measure, relieved 
 by taking a teaspoonful of warm fluid — milk and water or al- 
 kathrepta — whenever the trouble would appear. In the even- 
 ing he seemed decidedly better. Continued the remedy. 
 
 March 1. Had slept fifteen minutes to half an hour at a 
 time, though in a nervous, starting manner ; pulse 1 08 and 
 stronger ; quite an appetite, and stomach less irritable ; the 
 vomiting has ceased altogether. Urine is visible in the vessel 
 after standing awhile, showing a less proportion of blood. 
 
458 THE MEDICAL CLINIC. 
 
 Better in every way ; hiccough still annoying. In the evening 
 he seemed better, but begged for something to make him sleep. 
 Left three powders of coffea, 30th trit., to be given one every 
 hour from 10 o'clock. Phosphorus, 30th dil., continued. 
 
 March 2, 10 a.m. Patient had had but little sleep, although 
 some more than he had had the previous night. Found in the 
 vessel quite a number of fibrous-looking particles of various 
 sizes, together with clots of dark blood. We were all very 
 much alarmed, although the patient was better in all other 
 respects. We much feared that the fibrous-looking particles 
 were portions of the substance of the kidney. However, ex- 
 amination under the microscope showed no well defined tube- 
 casts, and a careful examination convinced me that the alarm- 
 ing substances were shreds from either the lining membrane of 
 the pelvis of the kidney, ureters or bladder, and such they 
 proved to be. The quantity of urine had hopefully increased, 
 and the quantity of blood proportionately decreased in the 
 vessel. Food was relished and comfortably retained on the 
 stomach, and the belching or hiccough was much less severe. 
 Continued the phosphorus, and ordered an injection into the 
 bladder of two teaspoonfuls of hamamelis in one pint of water 
 after each urination, or three times a day. Gave three powders 
 of belladonna, 30th dil., in the evening, to relieve a certain 
 wakefulness, characterized by starting wide awake immediately 
 after falling asleep. 
 
 The improvement was steady and satisfactory from this 
 time on. The hemorrhage became steadily less and less, until 
 it had altogether ceased, and only mucus appeared in the field 
 of the microscope, with" an occasional mucous tube-cast, and 
 now and then a group of pus cells, and quite a number of crys- 
 tals of the triple phosphates, which latter, and the mucus in 
 greater or less quantity, remained for several days. 
 
 In less than three weeks from the time I first saw him he 
 was up and dressed, and in less than four weeks he walked out. 
 There seems at the present time no sign whatever of the trou- 
 ble, or of serious consequences. The patient attends to his 
 business as usual, walks long distances daily, experiences no 
 pain, and has almost fully regained his former strength. 
 
 The symptoms upon which the remedy was selected, and 
 
HEMORRHAGIC VARIOLA. 459 
 
 which are characteristic of phosphorus, were: the hemorrhagic 
 diathesis, the disposition to bleed much from small wounds, 
 the spongy, easily bleeding gums. Phosphorus has also, in a 
 marked degree, relieved that annoying belching of wind which 
 distressed this patient so much. 
 
 Possibly, if we had given phosphorus in the following 
 case, which I borrow from my private records, we should 
 not have had to regret the death of the patient ; but I con- 
 fess that the absence of fever, or at least of the frequency 
 of the pulse, during the first days of the disease, deceived 
 me completely. 
 
 Case LXXXV. — Hemorrhagic variola • painful and in- 
 cessant vomiting, without increased frequency of the pulse y 
 repeated hemorrhages / death on the sixth day, from collapse 
 
 with asphyxia. Madame de S , aged forty-five, vaccinated 
 
 in her infancy, but not revaccinated, is a stout, fresh-looking 
 woman. For some months she has lived in the country where 
 the small-pox was prevalent, and she visited and nursed those 
 who were ill with it. 
 
 Second day. I found this patient greatly excited ; she had 
 bilious vomiting every hour, frightful pains in the loins, an 
 intense headache, a cool skin, and a pulse at 72 ; the vom- 
 iting had resisted Seltzer-water and ice. Ipecac, nux vomica, 
 opium and belladonna were prescribed successively during that 
 day and the following days, but almost without effect. 
 
 Third day. She has not slept ; the excitement is great ; 
 she sits down, lies down and moves about continually ; vomits 
 almost constantly, but still thinks herself hungry ; she has 
 taken some broth, which increased the vomiting ; the face is 
 highly colored ; the eyes are injected with hemorrhagic patches 
 which are beneath the conjunctiva upon the globe of the eye, 
 and the other symptoms are unchanged ; the pulse is always 72. 
 
 Fourth day. In the morning she vomits less, but every 
 quarter of an hour she is seized with violent and painful retch- 
 ing ; she complains of a severe pain in the heart ; has had no 
 sleep during the night ; the agitation increases ; the face is red 
 
460 THE MEDICAL CLINIC. 
 
 and puffy ; there is a true hemorrhagic chemosis of the eye, 
 and papules of a dark red color are seen on the neck ; the 
 pulse is still 72. 
 
 In the evening the eruption had spread, the papules touched 
 each other, and appeared upon the arms and the palms of the 
 hands ; some patches of purpura are mixed with the eruption 
 on the neck. Aconite in the mother tincture and vaccinium, 
 3d trit, 
 
 Fifth day. She had a horrible night. Excitement and 
 anguish, fear of death ; many of the pimples are vesicular ; 
 hemorrhage from the bowels and with the urine ; the pulse 
 varies from 72 to 80 ; the skin is not warm to the touch (the 
 patient refused to have the thermometer placed in the axilla) ; 
 the face is more and more bloated ; the vomiting has ceased, 
 and she has taken some broth and some jelly. Arsenicum, 3d 
 trit., every hour. 
 
 Sixth day. The agitation and anguish are constantly in- 
 creasing ; she changes her place several times in a minute ; 
 the hemorrhages continue; there is a good deal of the purpura, 
 and she expectorates a bloody mucus. The morning pulse had 
 increased to 96 ; she is quite rational, but believes that her 
 death is very near. At about three o'clock a mucous rale began 
 to be observed in the chest; the pulse increased to 120; the an- 
 guish and agitation increased until she had a frightful sense of 
 suffocation. She died at 10 p.m., having retained her conscious- 
 ness and her unrest until 9.45; then she fell into an asphyxi- 
 ated collapse, and sank away in half an hour. 
 
 Every earnest physician who reads this work will be thankful to the author 
 for his frankness and candor in publishing this case. It is good and wholesome 
 for the truthful mind to meet with such an honest confession of inability to cope 
 with everything in the shape of disease. Such a statement will do us infinitely 
 more credit than a thousand reports from those doctors who protest that they 
 have never, under any circumstances, lost a patient. — L. 
 
 We sincerely regret not having taken the temperature of 
 our patient. The pulse continued normal until the fifth, day, 
 and in spite of the terrible condition, which terminated fatally 
 on the sixth day. What was the temperature of this frightful 
 case of variola? The patient's whims prevented me from 
 
THE MALIGNANCY OF DISEASE. 461 
 
 taking it, and the skin did not show any elevation of temper- 
 ature when the hand was applied to it. 
 
 I have found the same condition of the pulse with several 
 patients whose clinical history is given by Dufresne, a propos 
 of an epidemic of hemorrhagic variola at Geneva, but in these 
 reports, also, the temperature is not given. 
 
 In the cases of hemorrhagic variola, observed by Huchard 
 (On Death from Variola, in the Archives de Medecine, 1871), 
 the pulse was 'frequent, and the temperature above 102.2°. 
 But we remark that in Case YII, on the evening of the sixth 
 day, the pulse being at 72, the temperature had reached 
 104.72°. The pulse may therefore be normal, and yet the 
 temperature ascend to, and perhaps exceed, 104°. This is 
 because of the lack of coordination, or of relation between 
 the usual symptoms and the malignancy of the attack. 
 
 In order to obtain the most trustworthy data from the pulse and from the 
 patient's temperature, we must study them together, and not separately. No 
 better illustration of this fact could be found than in the cases quoted. So wide 
 a discrepancy between the pulse and the temperature, more especially if the 
 latter remains very high, is almost always a bad sign. Exceptionally, however, 
 in the puerperal state, this disparity is met with in very nervous and hysterical 
 women, where, from some unknown cause, the hyper-thermic condition con- 
 tinues, or recurs, for some days without being necessarily dangerous. — L. 
 
 The Malignancy of Disease. 
 
 In what, therefore, does this malignancy consist ? 
 
 Pathologists have agreed to drop this word from their 
 nosography, because the existence of this state does not rest 
 upon a precise definition, and because the word malignancy 
 belongs to medical tradition as a sort of metaphor that serves 
 to indicate what is very grave but very indefinite. The dog 
 that bites without barking is, evidently, not a faultless character, 
 and in the science of observation we should only be satisfied 
 with rigid definitions ; but since, in spite of us, this malig- 
 nancy is too real and too frequent in the course of disease, 
 
462 THE MEDICAL CLINIC. 
 
 in our clinical teaching we must retain the word and make 
 use of it almost daily. Let us see if, by the observation of 
 facts, it will not be possible to give it a more precise and posi- 
 tive meaning. 
 
 The type of the malignancy is illustrated in the pernicious 
 fevers. But what are the symptoms that are proper and com- 
 mon to the pernicious fevers ( Or, in other words, what is the 
 peculiar something that makes them pernicious ? 
 
 The first peculiarity is, the danger of a very early death ; 
 for, whoever is attacked with a pernicious fever, no matter 
 what its form, may die in a few hours. 
 
 The second peculiarity is, that this death is not caused by 
 the mechanical process that belongs to other diseases, as in 
 cerebral hemorrhage, croupal diphtheria, or an endocarditis, 
 which kill by arresting the functions of one of those organs 
 that are essential to life — the brain, the lungs, the heart — 
 and the cessation of which functions is explained by the 
 organic lesions that characterize each of these disorders. In 
 these pernicious affections the heart ceases to beat, and the 
 lungs to carry on the proper oxydation of the blood with- 
 out any appreciable lesion that might account for the result. 
 
 A third peculiarity of this malignancy pertains likewise to 
 the mode of death in such cases. This peculiarity consists in 
 the fact that it is quite as difficult to foretell the time of death 
 as it is to explain it ; and that the fatal result is very often un- 
 expected. 
 
 The ancients held that in consequence of this malignancy 
 there might be a complete derangement of the vital functions, 
 (Galen classed the respiration and the circulation as vital func- 
 tions,) and that this condition, which is always so serious, and 
 which often causes death in a few hours, may furnish another 
 
THE MALIGNANCY OF DISEASE. 463 
 
 quality of this malignancy, id est, the discrepancy among the 
 symptoms. For example, a normal pulse and a temperature 
 that exceeds 104°, as in hemorrhagic variola; and a complete 
 absence of the pulse, although the physical strength remains, as 
 in the Asiatic cholera, in which disease the patients may get up 
 and go around for some hours after they have become pulse- 
 less. This blow which is aimed at the vital functions, explains 
 the anguish, the agitation, the precordial oppression, the cold- 
 ness of the extremities, the lividity, and the tendency to syn- 
 cope, which permit the experienced practitioner to recognize 
 the malignancy of the attack and to prognosticate its issue. 
 
 Finally, its fifth and last feature is, that it is accompanied 
 by symptoms of a benign character which, by reason of their 
 preserving the animal functions intact, may serve to deceive 
 the patient and all concerned. 
 
 Now, therefore, we are prepared to define this malignancy 
 as an insidious condition, that is characterized by a disaccord 
 among the symptoms, the overthrow of the vital functions, and 
 by the danger of imminent death from syncope, or by the ar- 
 rest of the chemical process of respiration. 
 
 Let me add, in conclusion, that this condition of malignancy 
 « 
 sometimes takes the form of a pernicious paroxysm, as in in- 
 termittent fever, and in all febrile diseases, like pneumonia, 
 the typhoid and eruptive fevers, etc. ; and again it assumes the 
 continuous type and identifies itself with this or that disease, 
 of which it constitutes a particular form, as in the malignant 
 pyrexias, and in those grave disorders which belong to an in- 
 termediate class, including diphtheria, erysipelas, dysentery, etc. 
 
LECTURE XXXI. 
 
 Summary. — Putrid diphtheria. Premature paralysis. The spasmodic element 
 of croup denied by Bretonneau and his followers, case. Death by syncope 
 can only be explained by the diphtheritic paralysis of the heart. Cyanuret 
 of Mercury, indications for. Is there a preventive treatment for the syn- 
 cope? Alimentation and its difficulties. The poisons : lachesis, vipera and 
 apis, camphora, agaricus mascarius, belladonna and arsenicum. Pneumo- 
 nia and pleurisy from diphtheritic paralysis of the nerves, which preside 
 over the nutrition of the lungs and of the pleura. 
 
 The Putrid Form of Diphtheria. 
 
 Gentlemen : The child that was seized with the putrid 
 type of diphtheria, and which you saw in one of the pri- 
 vate rooms, succumbed very rapidly after the entire disappear- 
 ance of the false membranes, and an improvement in the 
 symptoms, which caused us to hope that she would recover. 
 This is not a rare circumstance in the history of diphtheria, 
 and I wish to take advantage of the case to consider the 
 terrible consequences 'that may result from such a sudden 
 and unexpected death when the doctor and the family may 
 have anticipated a speedy cure. 
 
 The special therapeutics of diphtheria would be much more satisfactory 
 and useful if those who have reported the results of their experience had been 
 careful to give the full facts of the case ; for there is a mild type of the disease 
 that will get well of itself, and there is a malignant form of it that nobody has 
 cured. Between these two extremes there is every possible shade of difference, 
 not only in degree, but also in the kind and quality of its symptoms. 
 
 So that, when we come to consider the question of remedies, if these quali- 
 fying conditions are not given, we have no clinical data upon which we may 
 depend. We must know the type and form of the disease, its peculiar compli- 
 cations, its epidemic mildness or malignancy, the patient's temperament and 
 diathesis, and all the modifying circumstances that attend upon its course, 
 before we can determine that any plan of treatment whatever has really been 
 successful. A clinical report is worse than useless if it does not contain the 
 
THE PUTRID FORM OF DIPHTHERIA. 465 
 
 internal evidence of a careful discrimination on the part of the physician who has 
 prepared and presented it, and of his desire not to mislead his brethren nor to 
 misjudge the value of his remedies. — L. 
 
 You will hear it said that the death in these unfortunate 
 cases is due to diphtheritic poisoning ; but I warn you to 
 free your minds from the mania for hypothetical explana- 
 tions which has been such an injury to Medicine, and, in- 
 stead of being satisfied with a mere figure of speech that 
 will mislead you in the matter of treatment, analyze the 
 facts, and you will become convinced that such fatal termi- 
 nations are always due to a premature diphtheritic paralysis. 
 In this way we confront a tangible reality in therapeutics 
 instead of an empty metaphor, and are not left to look for 
 an antidote which is as uncertain as the existence of the 
 diphtheritic poison itself. 
 
 Before entering upon the history of the case which is 
 the special subject of this lecture, let me recall a fact which 
 I observed in 1859, and which has given me the true mean- 
 ing of certain mortal conditions that may occur in diph- 
 theria and croup. 
 
 A child of five years, which was ' seized with ordinary 
 croup, had been the subject of tracheotomy after a fit of suf- 
 focation with increasing violence. An absolute calm suc- 
 ceeded the operation, and for twenty-four hours there was 
 hope of a cure ; but in a moment, and without any pulmo- 
 nary complication, the fits of suffocation returned. The 
 canula was replaced by another which dilated the wound to 
 its full extent, and which would not permit its obstruction 
 by the false membranes, that could not be seen elsewhere. 
 However, the paroxysms became more frequent and severe. 
 They were accompanied by a characteristic symptom, which 
 is a temporary paralysis of the upper lid of the right eye, 
 
 and a cough, with retraction of the diaphragm during 
 30 
 
466 THE MEDICAL CLINIC. 
 
 inspiration. The child died on the third day, and, in the 
 absence of pulmonary lesions, as well as of obstruction of 
 the trachea, a premature paralysis of the diaphragm afforded 
 the only possible explanation of the fits of suffocation. We 
 might very properly say that the paralysis of the right 
 upper eye-lid was the sign of the paralytic nature of the 
 difficulty. 
 
 At that time those whose minds were dominated by Breton- 
 neau considered the suffocation of croup as entirely due to the 
 mechanical obstacle resulting from the presence of the false 
 membranes. Indeed, this was neither the single nor the least 
 serious of the errors of a leader who to undoubted profes- 
 sional gifts added the most detestable defects. Bretonneau 
 wished to bring the operation of tracheotomy into favor again, 
 and he founded the argument for its necessity upon the suffoca- 
 tion that is due to the presence of the pseudo-membrane. 
 With him, as with Trousseau, all the other causes of death and 
 of dyspnoea signified nothing, and the treatment of diphtheria 
 was embodied in a single precept — to practice tracheotomy as 
 soon as the diagnosis is certain. 
 
 We are far from endorsing this idea, for more modern re- 
 searches have ascribed to the spasms of the muscles of the 
 glottis their rightful importance in the production of the fits of 
 suffocation in laryngeal diphtheria. This role had already 
 been assigned them by physicians before the time of the school 
 of Tours. 
 
 We are of opinion that, besides the mechanical obstacle from 
 the presence of the membranes and the spasm of the glottis, 
 there is still another factor of the dyspnoea and of the suffoca- 
 tion in croup. That element is the premature or the untimely 
 paralysis of the muscles of the glottis and of the diaphragm. 
 We have already elaborated this question in our journal (I? Art 
 Medical), and shall not further insist upon it now. In this 
 
THE PUTRID FORM OF DIPHTHERIA. 467 
 
 lecture we shall limit ourselves to the study of the premature 
 cardiac paralysis of diphtheria. 
 
 The details of the case upon which this lecture is founded 
 are as follows: 
 
 Case LXXXYI. — M , a little girl of five years of age, 
 
 had lost a little sister who died in four or five days after being 
 attacked with diphtheria. She fell sick herself on Friday, the 
 2d of February, 1877, some days after the death of her sister. 
 She had fever, headache, and a sore throat Before resorting 
 to the homoeopathic treatment, her throat had been cauterized 
 with the nitrate of silver. 
 
 Third day. She came into the hospital at evening. She 
 complains very much, and is greatly excited ; the sub-max- 
 illary glands are greatly swollen and painful; the throat, the 
 veil of the palate, the uvula and the tonsils are covered with a 
 grayish membrane, but there is nothing of it in the nostrils; 
 the respiration is nearly normal, but the breath is foetid. The 
 child takes its food pretty readily. Prescription: cyanuret of 
 mercury, 2d trit., twenty centigrammes in 200 grammes of 
 water, a teaspoonful every half-hour. 
 
 Fourth day. The night has been a restless one ; the glands 
 are more swollen, having increased to the size of a turkey's 
 egg', the false membranes are growing thicker; there is con- 
 stipation, and the flow of urine is arrested ; it is very difficult 
 to get her to take her food. Cyanuret of mercury, 2d trit. , and 
 apis met., 2d dil., every half hour, alternately; with milk, 
 broth and wine. 
 
 Fifth day. The same state of aggravation; mucous rales, 
 a thick cough ; the nasal discharge consists of false membranes 
 mixed with blood ; there is extreme agitation and anguish ; the 
 face is pale and puffy, with a livid hue of the lips, and there is 
 considerable dyspnoea, but without any fits of suffocation ; 
 however, I requested Dr. Tessier to be ready to perform 
 tracheotomy. Cyanuret of mercury and arsenicum, 2d trit., 
 every half hour, alternately. We also insisted that she should 
 be forced to take the milk, soup and wine. 
 
 Sixth day. During the day she had some diarrhoeic stools ; 
 
468 THE MEDICAL CLINIC. 
 
 the flow of urine returned; a patch of false membrane was 
 expelled; the swelling of the glands diminished; the expres- 
 sion is better, the agitation less, and the improvement is mani- 
 fest ; she has taken some white wine, broth and milk. The 
 same prescription. 
 
 Seventh clay. The patient wants some food ; the urine, 
 on being analyzed for the first time, shows the presence of 
 albumen very decidedly. In the evening the voice and the 
 cough are hoarse, and there is some, but not a very marked, 
 laryngotracheal whistling ; from time to time she raises her- 
 self quickly, but she does not have any decided paroxysms of 
 suffocation. The same prescription. 
 
 Eighth day. The symptoms improve ; a patch of the mem- 
 brane as big as a dollar has been cast off. The same remedies. 
 
 Nmth day. The false membranes have entirely disappeared ; 
 the glands have returned to their normal size ; the mucous 
 membrane of the throat is very red ; deglutition is painful, and 
 fluids return by the nose. She calls for her mother incessantly. 
 The pupils are slightly dilated. She takes very little nourish- 
 ment because of the pain and the paralysis of the veil of the 
 palate. The urine is still albuminous. The same remedies. 
 
 Tenth day. The general appearance is not bad. In the 
 morning, however, the pulse was very feeble, and it was very 
 difficult to feed her. Nutritive enemata, thick cream ; phos- 
 phorus, 3d dil., and china, 3d dil., in alternation. 
 
 During the day the patient grew weaker very decidedly, 
 and died at 4 p.m. without any shock or asphyxia. 
 
 During the time she was in the hospital she had taken 
 broths containing eggs, milk, wine and biscuit, and she had 
 been nourished as well as possible. 
 
 In this case death occurred without asphyxia, and without 
 any violent fever. Although the nutrition was difficult, yet it 
 certainly was sufficient to sustain life. 
 
 Would it be possible to explain this unfortunate result on 
 the theory of an unknown poison, the sources of which had 
 been exhausted for more than forty-eight hours, because all 
 traces of the false membranes had disappeared two days before 
 
THE PUTRID FORM OF DIPHTHERIA. 469 
 
 death ? To my mind, it is more rational to hold firmly to the 
 idea that the heart, which had become gradually enfeebled, 
 stopped on the tenth day of the disease. The cardiac paralysis 
 was evidently of the same nature and origin as the paralysis ot 
 the pharyngeal muscles. In order to explain this symptom, 
 there is no need of a theory of morbid poisons, especially since 
 careful dissections have disclosed the existence of degeneration 
 of the motor nerves in muscles that have been paralyzed. 
 
 But here is a case of putrid diphtheria, in which death by 
 syncope was still more evident : 
 
 Case LXXXYII. — H. L , a little girl of eight years, 
 
 who had enjoyed good health, and who was of a strong consti- 
 tution, was taken with headache and malaise on the 17th ol 
 March. On the 18th she had some fever and complained of a 
 sore throat, but it was some days before a pseudo-membranous 
 patch was found upon the left tonsil. 
 
 Being under the professional care of a distinguished physi- 
 cian, she was first treated by applications of lemon-juice, then, 
 the diphtheria having invaded the pharynx and the nasal fossse, 
 by injections of lime-water. I was assured that no medicine 
 whatever had been given internally. 
 
 I was called to this child on the 22d of March, which was 
 the fifth day of the disease. She then had the following symp- 
 toms: dorsal decubitus, somnolence, the eyes were half-open, the 
 face was puffed, shining and very slightly livid, the respiration 
 was somewhat accelerated and noisy, and the mouth was open. 
 Both nostrils discharged a grayish liquid, which contained some 
 flocculi, from the false membrane. The movements of respira- 
 tion made this liquid foamy ; the upj)er lip and alee nasi are 
 red and sore ; the pharynx is covered by a large milky looking, 
 thick, and very adherent, false membrane. 
 
 This membrane, which is most developed on the left side, 
 covers the whole isthmus of the fauces and the uvula. There 
 is no decided odor to the breath ; the left sub-maxillary gland 
 is enlarged, is as hard as wood, and painful. On the right side 
 the sub-maxillary gland is much smaller. 
 
470 THE MEDICAL CLINIC. 
 
 The fever is intense; the pulse 116 ; the urine is pale, thick, 
 scanty, and contains albumen. 
 
 The child, deprived of its sleep, has a strong voice, which 
 is not hoarse, and she does not cough, which shows that the 
 larynx is not involved ; she has a great repugnance to taking 
 her food. I prescribed the cyanuret of mercury, 3d trit., twenty 
 centigrammes in 200 grammes of water, a teaspoonful to be 
 taken every hour. I also insisted that she should take the 
 broth, the milk and the wine. 
 
 May 23, sixth day. She had a pretty good night, and other- 
 wise is about the same. There is a remission of the fever ; the 
 morning pulse was 90, and the evening pulse 112. The false 
 membrane has not extended any farther. She has been forced 
 to take the nourishment ordered. The same treatment. 
 
 May 24, seventh day. The night was restless ; the fever 
 has increased very decidedly and seriously ; the false mem- 
 branes exhale a sweetish odor ; the urine is pale, thick and 
 albuminous ; and the facial expression is bad. Hourly alterna- 
 tions of the cyanuret of mercitry with the mother tincture of 
 china in water. 
 
 May 25, eighth day. The night was more calm ; the pa- 
 tient looks better ; the false membrane is the same ; the child 
 had been nourished as thoroughly as possible. The same treat- 
 ment. 
 
 May 26, ninth day. The improvement is slight, but unmis- 
 takable ; the face is less swollen ; the false membrane appears 
 to me to be thinner ; its borders are pared down ; the night has 
 been comparatively good ; the urine is the same as before. 
 
 May 27, tenth day. She is better ; the general condition is 
 much improved ; the sleep is good ; the child eats with some 
 disrelish, but still she does take her food ; the false membrane 
 melts away, little by little, like a piece of ice ; the discharge 
 from the nasal fossae is less free, and is no longer foamy ; two 
 diarrhceic stools. The same treatment. ' 
 
 May 28, eleventh day. The improvement continues ; the 
 mucous membrane of the pharynx and of the uvula can be seen 
 again ; it is so sensitive that deglutition is more painful than 
 ever ; diarrhoea and some vomiting of food ; the pulse re- 
 mains at 100 morning and evening. I continued the cyanuret 
 
THE PUTRID FORM OF DIPHTHERIA. 471 
 
 in alternation with arsenicum, because of the diarrhoea and the 
 albuminuria. 
 
 May 29, twelfth day. She is still better ; there is almost no 
 trace of the false membranes ; the child sits up in its bed ; its 
 expression is natural, but it sometimes vomits its food. The 
 same treatment. 
 
 May 30, thirteenth day. Improving ; the false membranes 
 are gone; the child arose at five o'clock; she has eaten two 
 oysters and some beef-steak, and she has no more fever ; 
 there is paralysis of the veil of the palate ; the voice is nasal, 
 and liquids are returned by the nose ; diarrhoea ; the urine is 
 still albuminous. The same treatment. 
 
 May 31, fourteenth day. The child has passed a good 
 night ; this morning she complained of being a little chilly ; 
 she sat up in her bed to wash her hands ; she called the nurse 
 and cried because she could not see her any longer; the hands 
 were moved convulsively ; she fell back upon the pillow fright- 
 fully pale, and was dead. 
 
 One of the first cases of this disease that we treated, in 1862, was that of a 
 bright, beautiful boy of eight years, who, with a moderately severe attack, had 
 reached the ninth day, and was apparently doing well. The throat was almost 
 clean, and all of his symptoms were favorable. An hour after our visit he 
 asked to be carried to the window that he might look at the snow which was 
 falling. He was lifted very carefully to a seat in his mother's lap by the win- 
 dow. He looked a moment, then asked her to wipe off the pane so that he 
 could see more distinctly. She took her handkerchief to do as he wished, and 
 in a moment he was dead. — L. 
 
 In a prognostic point of view, let us remember the diarrhoea 
 and the vomiting of food from the date of convalescence, the 
 
 paralysis of the veil of the palate, and the persistence of the 
 
 albuminuria. 
 
 The mother of this child was seized on the twelfth day of 
 her little daughter's illness with a comparatively mild attack of 
 diphtheria, which, however, was accompanied with albumi- 
 nuria. And a little brother of five years, who was kept away 
 from his sister, and who, on the second day of her disease, was 
 taken to Epernay, was nevertheless attacked fifteen days later 
 
472 THE MEDICAL CLINIC. 
 
 with a diphtheria that was limited to the right nostril. Dr. 
 Couillaud recognized a thick, gray, false membrane therein, 
 which did not disappear until after eight days' duration. The 
 child was but slightly ill, and had no albuminuria. The treat- 
 ment resorted to by Dr. Couillaud was the internal use of a 
 solution of bromine, and nasal irrigations containing Labar- 
 raque's solution. 
 
 I have said that we cannot explain the rapid death of the 
 child whose case vou have studied in our ward, nor the sudden 
 death of the one whose history I have just given you, except 
 by the cardiac paralysis. 
 
 With one of them the fever had disappeared, and with the 
 other it had greatly diminished; and we cannot, therefore, 
 ascribe the fatal result to the violence of the fever. Whilst, 
 on account of the paralysis of the pharynx, the alimentation 
 was imperfect, nevertheless it was more than sufficient to sup- 
 port life ; and death did not, therefore, result from inanition. 
 
 To claim that these patients succumbed to the malignancy of 
 the disease', or to a diphtheritic poisoning, is to be satisfied with 
 a figure of speech, instead of seeking for the true course and 
 nature of the conditions that have resulted in death. Such a 
 course would make us renounce a positive therapeutics for the 
 sake of employing those antidotes which are as fanciful as 
 they are lacking in efficacy. 
 
 The argument that diphtheria depends upon a blood-poison is founded upon 
 its infectiousness; the possibility of its being conveyed by fomites; its inocula- 
 bility; its having a period of incubation, like the eruptive fevers; its prevalence 
 along with and in complication with other zymotic diseases, as scarlatina, rube- 
 ola, variola and erysipelas; the fact that a whole family or community may have 
 it; its being traceable, in many instances, to defective drainage, bad sewage, 
 bad ventilation, the use of impure water, and to the exhalations from the 
 patient; the tenacity with which its contagion, whatever it may be, clings to 
 certain houses, and even to certain rooms, in which there have been one or more 
 cases of this disease, just as in puerperal septicemia, malignant scarlatina and 
 the small-pox; the possibility of auto-infection during the attack; the fact that 
 it is most frequent among children, and that it has a train of secondary affec- 
 tions or sequelae which are as characteristic as those of any other zymotic 
 disease. — L. 
 
THE PUTRID FORM OF DIPHTHERIA. 473 
 
 The most recent researches in pathological anatomy show 
 that, in diphtheritic paralysis of the veil of the palate, there is 
 not only an alteration of the nervous filaments which are sup- 
 plied to the muscle, but also of the muscular fibres themselves. 
 
 A similar lesion also accounts for the condition of fainting, 
 and the fatal syncope in diphtheria. In this disease, as in 
 typhoid fever, when the lesion is very pronounced, the mus- 
 cular fibres undergo a fatty degeneration, and become incapa- 
 ble of the proper cardiac contractions. 
 
 Whether the cardiac nerves are subject to changes similar 
 to those which occur in the motor nerves of the veil of the 
 palate, is still an open question. 
 
 The cyanuret of 'mercury was the principal remedy in these 
 two cases, and its efficacy in the early stage of the disease will 
 not be denied. The analysis of the symptoms in these cases 
 will show you where the remedy which has been so highly 
 recommended by Beck, of St. Petersburg, is indicated, id est, 
 for false membranes which are thick and putrid, and which 
 occupy the whole throat, and extend into the nasal fossae ; for 
 enormous and painful glandular swellings ; for palor and 
 shining tumefaction of the face, with very decided adynamia. 
 These symptoms, which characterize the most fatal form of 
 diphtheria, were present in both of our cases, and they yielded 
 rapidly to the action of the cyanuret of mercury. 
 
 In an article on the clinical application of this remedy in diphtheria, pub- 
 lished in the American Homceopathist for January, 1878, my friend, Dr. W. H. 
 Burt, has analyzed the toxical symptoms of this drug- very carefully. Quite a 
 number of these symptoms are almost identical with those of diphtheria. He 
 also poisoned a large dog with the cyanuret, by injecting the crude drug be- 
 neath the skin, and the autopsy showed such laryngeal and cardiac lesions as 
 bore a strong resemblance to those of diphtheria. 
 
 Dr. Burt says: "Usually the pseudo-membrane is of a dark-gray color, 
 which I believe to be the true color indicating this drug. I have often seen this 
 dark-gray colored pseudo-membrane not only covering the tonsils but the whole 
 of the soft palate, uvula and fauces, extending up into the nares, completely 
 occluding the nostrils. I have also had a number of cases in which the deposit 
 was wholly confined to both nostrils, — two very recently, — one in a young girl 
 
474 THE MEDICAL CLINIC. 
 
 and one m a young lady, in which cases, for several days, the air could not be 
 drawn through the nose; and, through the influence of this drug, both of them 
 recovered. 
 
 " I have also attended a few cases of the so-called croupal diphtheria. In 
 one marked case, in a lady forty years of age, the voice was lost for six weeks, 
 but she finally recovered. I gave her up to die, and prepared her husband for 
 it, but the cyanuret of mercury as it were snatched her from the grave. 
 
 " Another case of croupal diphtheria was that of a little girl of seven years. 
 The pseudo-membrane extended from the tonsils into the larynx, producing 
 complete aphonia, which lasted for two weeks. One nostril was occluded in this 
 case also, but she made a good recovery." 
 
 Dr. Burt adds: "In several of my cases that have been treated with the 
 cyanuret, during the first two days, in order to subdue the fever, I have given 
 baptisia in alternation with it, and I believe it to be a good plan. I should 
 advise the cyanuret of mercury in from the third to the thirtieth attenuation,, 
 but probably the sixth attenuation will be just what we want." — L. 
 
 But you will observe, gentlemen, that the improvement did 
 not begin until the fourth day of the treatment, which was the 
 sixth day of the disease in the first case ; and on the eighth 
 day of the disease, being the fourth day of the treatment in 
 the second case. I had been called to this case on the fifth 
 day of the disease, after the physician in attendance had 
 declared the case to be hopeless. 
 
 In these very grave cases we must insist upon the value of 
 the cyanuret of mercury, at least during these four days ; and 
 you will recall the precept which I have already given you 
 so often, that it is by persevering with the same remedy that 
 you will obtain the best results. If other indications spring 
 up, and are very decided, try to meet them with whatever 
 else is indicated, but continue the principal remedy, the rem- 
 edy, which, in putrid diphtheria, is the cyanuret of mercury. 
 
 There is a great variety ot opinions on this question of perseverance in the 
 use of remedies in diphtheria. Some writers, who describe the disease from their 
 inner consciousness, insist that unless the patient improves at once we must 
 change the remedy, while others would have us cover the case as nearly as pos- 
 sible with the remedy, and persevere with it to the end. 
 
 In a thesis on diphtheria, presented to the Hahnemann Medical College, of 
 this city, in 1873, by Dr. George Bollen, of South Australia, and published in 
 the United States Medical and Surgical Journal, Vol. VIII, page 261, we find 
 the following paragraph: 
 
 
THE PUTRID FORM OF DIPHTHERIA. 475 
 
 "Any disease like the one we are discussing, which vitiates the blood, all 
 other things being equal, requires the lowest dilutions, and these I have gen- 
 erally used. I believe, also, that in all acute diseases which have no regular 
 period to run, we may not only expect, but must look for, curative action at 
 once; and in this class, which includes diphtheria, we need & frequent repetition 
 of the dose. I also believe that when a constitutional disease sets up local le- 
 sions, as diphtheria does, that it is quite right to meet it at both ends by the 
 alternation of remedies. I have also found, by experience, that a remedy which 
 benefits the case for a day or two seems often to lose its effect. The disease 
 will first come to a standstill, and then return, and that remedy is of no further 
 service in that case. Without pausing to explain this, suffice it to say that I 
 have adopted a rule which has worked admirably with me for a long time, and 
 that is, in diphtheria, never to use a remedy, however much good it may he do- 
 ing, over forty-eight hours consecutively, and in urgent cases over twenty-four 
 hours, without changing ; and then after using other remedies for twenty-four or 
 forty-eight hours, to change hack again, and so on." — L. 
 
 But how shall we avert those fatal terminations which 
 are as terrible as they are unexpected? How shall we pre- 
 vent the snycope that is incident to convalescence % With 
 out doubt the tonic and nourishing regimen which is pre- 
 scribed by all schools of medical belief, is indicated and 
 should certainly have its effect to reduce the proportion of 
 the cases of death by syncope in diphtheria ; but every ex- 
 perienced physician knows how difficult it is to nourish this 
 class of patients. 
 
 It is in just this variety of cases that we encounter such 
 an invincible aversion to food, and such a marked difficulty 
 of swallowing, on account of the paralysis of the veil of the 
 palate, that we may be obliged to nourish the patient through 
 a tube in the oesophagus, in order to prevent death by star- 
 vation ; and it is a very serious question to decide how we 
 shall overcome this condition and keep our patients well- 
 nourished. 
 
 When our patients are old enough, we insist upon their taking a swallow 
 or two of milk every half hour or so, nominally for the throat, but really for 
 their nutrition, also. When the vitality of the mucous membranes is so low, 
 and their secretions are so decidedly changed, it is possible that beef- tea might 
 increase the sepsis by its own decomposition. Ice cream is always grateful in 
 these cases, and might be given freely in the form advised at page 371. — L. 
 
476 THE MEDICAL CLINIC. 
 
 The Materia Medica furnishes a certain number of reme- 
 dies that cause fainting and syncope. The most important 
 of them are the animal poisons, for serpent wounds induce a 
 condition of fainting, and even death, by syncope. Lachesis, 
 crotalus, naja, vipera, and apis melliftca, may, therefore, be 
 indicated. 
 
 Besides these poisons, camphor is one of the medicines that 
 is most certain to cause a fainting condition. Agaricus mus- 
 carius, and its active principle, muscarine, may cause an 
 arrest of the heart's action and death by syncope. {Atro- 
 pine is the best remedy for arousing the action of the car- 
 diac muscle in the case of animals that have been poisoned 
 by muscarine.) 
 
 There are remedies, such as phosphorus and arsenicum, 
 that cause a degeneration of the muscular tissue of the heart, 
 and thereby occasion fainting and syncope. 
 
 The Materia Medica is therefore rich, I should say too rich, 
 in the number of its remedies for syncope ; but before clinical 
 observation has taught us which of these is the most reliable 
 in diphtheritic syncope, I fear that we shall lose many more 
 cases from this cause. 
 
 It is a question whether we should ascribe the pneumonia 
 and the pleurisy, which are always symmetrical, which occur 
 without any accidental cause, and which give rise to an in- 
 significant reaction, to the paralysis that follows diphtheria. 
 
 You are aware that, in a certain 'proportion of cases, a 
 section of the pneumogastric nerve will cause a congestion 
 and even a hepatization of the lung ; that it is impossible to 
 explain these facts by the return of food and of gastric liquids 
 in the windpipe, since it happens with animals whose trachea 
 has been tied upon a tube ; and that the explanation gi^en by 
 Claude Bernard, who held that the congestion in this case must 
 result from the embarrassment of the circulation, is a mere 
 assertion. 
 
THE PUTRID FORM OF DIPHTHERIA. 477 
 
 And we must not forget that, in certain cases, also, the 
 removal of the last cervical ganglion of the great sympathetic 
 gives rise to a violent pleurisy with effusion. 
 
 These facts confirm our belief that when diphtheritic pa- 
 ralysis attacks the great sympathetic, or the pneumogastric, 
 nerves, it may in the first case be the cause of a pleurisy 
 which is not referable to taking cold during the convalescence 
 from diphtheria, and in the second case it may give rise to a 
 pneumonia which is developed under the same circumstances. 
 
 In putrid diphtheria much relief may sometimes be given by throwing a 
 spray of lime-water, or of a solution of the chloride of lime, directly into the 
 throat. The air of the apartment may also be disinfected in the same way. 
 An ingenious method of getting rid of the deposit is to throw a spray of lacto- 
 pepsin into the fauces, so as to digest and dissolve the membrane. — L. 
 
LECTURE XXXII. 
 
 Summary. — Slight albuminuria. Consecutive Bright's disease. Serious albu- 
 minous nephritis in typhoid fever, case. Prolonged typhoid fever, serious 
 albuminuria; inflammation of the parotid gland. Terebinthina ; cure; 
 case. Prolonged typhoid fever; albuminuria with hematuria, phosphoric 
 acid; symptoms of spinal meningitis, sulphate of strychnine, remission 
 of the fever which is rebellious to the sulphate of quinine; cure. Re- 
 lapsing typhoid, case. Its character is not that of a relapsing typhus. 
 The pernicious paroxysms, and their peculiarities in typhoid fever. Ty- 
 phoid fever without fever. 
 
 Albuminuria in Typhoid Fever and in Relapsing Typhoid. 
 
 Gentlemen: The patient who occupies No. 4 in the men's 
 ward has furnished an illustration of serious albuminuria in 
 typhoid fever ; and this complication will be the subject of 
 our lecture. 
 
 A slight and temporary albuminuria is very often met with 
 during the course of typhoid fever. This change of the urine, 
 which arises from a congested state of the kidneys, has not the 
 slightest signification, either in diagnosis or prognosis, and 
 affords no therapeutical indication whatever. It is not of this 
 common form of albuminuria, which is incident to most of the 
 acute diseases, that I mean to speak. I shall also put aside, 
 for the present, the history of the parenchymatous nephritis, 
 which sometimes develops during the convalescence from ty- 
 phoid fever, and which constitutes one of the sources of 
 Bright's disease. Our subject will be more limited: we 
 shall study to-day the albuminuria and the hematuria which 
 belong to a parenchymatous nephritis occurring in the course 
 of the typhoid fever. This is a rare but a serious complica- 
 tion ; for in a memoir which has been recently -published 
 
ALBUMINURIA IN TYPHOID FEVER. 479 
 
 {Archives de Medecine, December, 1876,) MM. Le Groux and 
 Hannot have had five deaths in the case of five patients 
 attacked with typhoid fever complicated with albuminous 
 nephritis. We have only had two cases of this kind, and, 
 under the influence of the homoeopathic treatment, both of 
 them were cured. 
 
 I will first call your attention to the history of a private 
 patient in whom, from the first, the albuminuria was so 
 marked that, for several days, there was some hesitation 
 concerning the diagnosis. At the beginning I thought that 
 it was a case of acute nephritis, and, during the course of 
 the disease, the symptoms of the nephritis, instead of being 
 concealed, or, so to speak, veiled, by those of the typhoid 
 fever, continued as they were at the beginning ; so that with 
 the fever, the stupor, the tympanitis, the diarrhoea and the 
 stomatitis of the typhoid, we had the urine -and oedema of 
 albuminous nephritis. 
 
 Case LXXXVIII. — Typhoid fever ; albuminuria from 
 the outset ; albuminous anasarca / intestinal hemorrhage • in- 
 flammation of the parotid / cure. Mrs. D , aged twenty- 
 five years, widow, with feeble health from misfortune and from 
 chronic catarrhal metritis, was taken ill on the 19th of De- 
 cember, 1876. The attack set in with a decided paroxysm of 
 fever, chill, heat and sweat, and the fever assumed the tertian 
 type. But after the third paroxysm, which occurred on the 
 23d of May, the fever became continuous. 
 
 December 24, fifth day. The morning temperature was 
 103.10°, and the evening temperature 104°. The patient has 
 been tormented with thirst, and by a continual desire to vomit ; 
 she is already very feeble. Ipecac, 3d trit., in 200 grammes 
 of water, a teaspoonful to be taken every two hours. 
 
 Until the tenth day, the 28th of December, her condition 
 was very nearly the same, the morning temperature being 
 103.10°, and the evening temperature 104.5°. Thirst, nausea, 
 and a painful dryness of the tongue ; the diarrhoea set in ; the 
 
480 THE MEDICAL CLINIC. 
 
 typhoid spots were abundant on the abdomen ; but, what was 
 still more characteristic was that, from the fifth day, the urine 
 was bloody and contained a very large quantity of albumen. 
 This symptom was so marked that I was led to consider the 
 case as one of acute nephritis. I prescribed belladonna, 3d 
 dil., which very decidedly allayed the thirst and the nausea; 
 and cantharis, 3d dil., which was continued for twenty-four 
 hours only, because, while it had no effect upon the urine, it 
 brought back the distressing nausea. Broth and milk, and a 
 little wine and water. 
 
 On the eleventh day the temperature dropped a little in the 
 morning, 102.56°, but it rose again at evening to 104.50°. The 
 nausea has disappeared, but the diarrhoea and the bloating of 
 the abdomen are very much increased. The urine still contains 
 blood and albumen. 
 
 The temperature continued at 103.28° in the morning, and 
 104.50° in the evening. The patient was agitated, anxious and 
 depressed. She took arsenicum, 3d trit., twenty centigrammes 
 in 200 grammes of water, a teaspoonful every two hours. 
 
 The febrile heat being very distressing to her, I ordered 
 cold lotions with Veau vinaigree, once in three hours. She felt 
 very much relieved; but the temperature remained the same 
 until the fifteenth day, when it suddenly fell to 100.40°. This 
 change was due to a pretty severe intestinal hemorrhage, that 
 continued for three days. Phosphoric acid, 3d dil., and after- 
 ward in the 1st dil.. checked the flow. During this hemorrhage 
 the temperature varied from 99.5° to 102.20°, the cold lotions 
 being discontinued meanwhile. She had considerable stoma- 
 titis, and gargled her throat incessantly ; the tongue was dry, 
 cracked and bleeding, and the folds and veil of the palate were 
 covered with a pultaceous coating. 
 
 About the time that the hemorrhage ceased, the abdomen 
 became so distended as very decidedly to interfere with respira- 
 tion ; and, at the same time, the diarrhoea stopped. I then 
 gave colocynth in alternation with the phosphoric acid, and 
 these remedies had the effect to relieve the tympanitis and to 
 bring on the stools. 
 
 On the twentieth day, the temperature having returned to 
 103.10°, I prescribed one gramme of the sulphate of quinine, 
 
ALBUMINURIA IN TYPHOID FEVER. 481 
 
 but without any very decided effect. The temperature con- 
 tinued at 101.48° in the morning and at 103.10° in the evening. 
 The same dose of the quinine being given on the twenty-second 
 day, brought both the morning and the evening temperature to 
 100.40°. 
 
 During all this time the urine continued to be highly albu- 
 minous, and, on the twenty-fourth day, the temperature sud- 
 denly mounted to 103. 10°, then to 104°, and an inflammation 
 of the left parotid gland followed. At the same time we also 
 observed a considerable oedema about the loins, in the face, 
 the eyelids, and beneath the conjunctiva of the globe of the 
 eye. Ajpiurn virus and ccmtharis, 3d dil., had no effect upon 
 this latter condition. The swelling of the parotid increased 
 rapidly, the skin being purple and threatening to become gan- 
 grenous. A surgeon, who was called in consultation, could 
 find no fluctuation, and thought best not to interfere with it. 
 
 Twenty-ninth day. The patient presents the following con- 
 dition : incessant, and sometimes involuntary, diarrhoea ; excess- 
 ive abdominal tympanitis ; increasing oedema ; the urine is 
 bloody and albuminous ; the pulse small and frequent, and the 
 temperature varies from 104° to 104.5°. 
 
 For this serious condition we prescribed terehintkina, 1st 
 decimal dil., three drops in 125 grammes of water, one tea- 
 spoonful to be taken every hour. 
 
 Under the influence of this remedy the improvement was 
 very rapid ; the tympanitis subsided ; the urine ceased to con- 
 tain blood, although it continued albuminous ; the oedema dis- 
 appeared ; the temperature did not exceed 101.30°, morning or 
 evening, and the swelling of the parotid seemed to diminish. 
 
 Thirty-fourth day. For the first time the morning tempera- 
 ture fell to 99.86°, but it reacted to 102.20° in the evening; and 
 from this moment the patient improved gradually each day. 
 The temperature dropped to 96.80° in the morning, and came 
 up again at evening to 100.40°. 
 
 From the thirty-sixth day the parotid became slowly soft- 
 ened, and it was lanced on the forty-third day of the disease. 
 The albumen diminished progressively, and finally disappeared 
 about the 20th of February, id est, the seventieth day of the 
 disease. Arsenicum, 3d and 2d trit., was continued until that 
 31 
 
482 the medical clinic. 
 
 time. It is hardly necessary to state that, from the thirty- 
 fourth day, and especially from the time that the abscess of the 
 parotid was opened, the appetite, the sleep and the strength 
 improved progressively. 
 
 You observe, therefore, gentlemen, that parenchymatous 
 nephritis, like pulmonary hepatization and local encephalitis, 
 may exist as a complication of typhoid fever. And you will 
 remember, also, the excellent effect of the terebinthina in this 
 case as a remedy for the hematuria, the involuntary diarrhoea, 
 and the excessive tympanitis of the abdomen. 
 
 Here is the clinical history of the patient occupying No. 4 
 of the men's ward : 
 
 Case LXXXIX. — Typhoid fever of the tedious type; albu- 
 minuria ; and spinal congestion. M. P , aged eighteen 
 
 years, a saddler, was admitted on the 21st of December, 1870, 
 and discharged on the 24th of March, 1877. 
 
 After four or five days of malaise, he was seized, on the 
 10th of December, 1876, with chills, headache, pains in the 
 abdomen and epistaxis, complete anorexia and diarrhoea, on 
 account of which he was compelled to take to his bed. 
 
 Some days later, he does not know exactly when, he began 
 to cough, became quite deaf, and was a little delirious. 
 
 He entered the hospital on the twelfth day of the disease, 
 and until that time had taken nothing but teas. At the even- 
 ing visit the temperature was 104°, the pulse 1 20 ; great pros- 
 tration ; anorexia ; a very dry and sooty tongue, with angina ; 
 pain upon pressure in the right iliac fossa ; slight gurgling ; 
 some rose-colored spots on the abdomen ; deafness ; less head- 
 ache than before ; frequent cough, and bronchitis. 
 
 December 22, thirteenth day. The same condition. Ipecac, 
 6th dil., and bryonia, 6th dil. These medicines were con- 
 tinued for four days. 
 
 December 24, fifteenth day. The expression is a little bet- 
 ter ; the evening temperature has fallen to 102.56°. 
 
 December 26, seventeenth day. Last evening the tempera- 
 ture was 104°. Prescription : arsenicum, 3d trit. 
 
ALBUMINURIA IN TYPHOID FEVER. 4-83 
 
 December 27, eighteenth day. The diarrhoea is very bad ; 
 the general condition is always the same. Prescription : muri- 
 atic acid, 3d dil. 
 
 December 29, twentieth day. No change. Prescription : 
 arsenicum, 3d trit., and bryonia, 3d dil. (These remedies 
 were continued for six days.) 
 
 December 30, twenty-first day. The fever, which has been 
 continuous until now, had a slight remission this morning 
 (101.48°) ; the patient takes a little interest in what is passing 
 about him ; the evening temperature, however, rose to 104°. 
 
 December 31, twenty-second day. Another remission this 
 morning; temp. 101.48°; evening temp/l()2.56°. 
 
 January 5, twenty-seventh day. The morning remission,, 
 which began with the twentieth day, is still more pronounced ; 
 the range of the temperature has increased ; the patient is still 
 prostrated, and inclined to dream ; the gums bleed ; the cough 
 is frequent ; the hoarseness, which amounts almost to aphonia, 
 and which has continued since he entered the hospital, still 
 persists, with some soreness of the throat. Prescription : fifty 
 centigrammes of the sulphate of quinine, and to rest for four 
 days. 
 
 January 10, thirty-second day. The same condition ; phos- 
 phorus^ 12th dil., on account of the aphonia and the cough, for 
 three days. The deafness seems to have diminished somewhat. 
 
 January 13, thirty-fifth day. Since .yesterday the range of 
 temperature from morning to evening has been very marked — 
 from 98.60° to 102.20°. Prescription: sulphate of quinine, 
 seventy-five centigrammes during two days ; then the next- 
 day one gramme, and to rest until the thirty-ninth day. 
 
 January 18, fortieth day. The same condition ; the quinine, 
 given in such large doses, not having changed the febrile move- 
 ment, we returned to phosphorus, 12th dil. 
 
 January 19, forty-first day. The same. (Jhininum sulph., 
 3d trit., for two days. 
 
 January 21, forty-third day. The voice is a little stronger, 
 the deafness is not so bad ; the gums are cleaning ; the appe- 
 tite improves. 
 
 January 22, forty-fourth day . The general condition is bet- 
 ter ; he could raise himself in the bed during the day ; but he 
 
484 THE MEDICAL CLINIC. 
 
 has had slight epistaxis. China, 3d trit., to continue for three 
 days. 
 
 January 26, forty-eighth day. The patient complains of 
 pains which prevent him from sleeping ; these pains are 
 seated in the spinal cord, and follow the distribution of the 
 spinal nerves ; the intermittent type of the fever continues 
 (98.60° in the morning and 102.20° in the evening). Prescrip- 
 tion : colocynth, 1st dil. 
 
 January 27, forty-ninth day- Prescription : belladonna, 3d 
 dil. 
 
 January 28, fiftieth day. The same. 
 
 January 29, fifty-first day. The spinal pains are chiefly 
 located in the lumbar region ; they are very much increased by 
 pressure. Sulphate of strych., 2d trit., to be given for two 
 days. 
 
 January 31, fifty-third day. For two or three days the 
 urine, which from the beginning has contained albumen, has 
 a great deal of blood in it ; at the same time the epistaxis 
 increases, and the gums begin to bleed. Prescription : terebin- 
 thina, 1st trit., for two days. 
 
 February 3, fifty-sixth day. The same. Phosphorus, 6th 
 dil., to be continued for two days. 
 
 February 6, fifty-ninth day. Phosphorus, 3d dil. 
 
 February 9, sixty-second day. The spinal pains continue ; 
 the urine contains albumen and blood ; the fever has ceased. 
 Arsenicum, 3d trit., for two days. 
 
 February 12, sixty-fifth day. No marked change. Phos- 
 phoric acid, 1st dil., ten drops. 
 
 February 14, sixty-seventh day. The urine is less highly 
 colored with blood, and contains less albumen. The same pre- 
 scription, to be continued for four days. 
 
 February 1 9, seventy-second day. There is no more blood, 
 and but little albumen, in the urine. China, 3d dil. 
 
 February 20, seventy-third day. No hematuria, and very 
 little albumen, in the urine ; but there is a relapse of the 
 spinal suffering. Sulph. of strychnia, 2d trit. , to be continued 
 for six days. 
 
 February 27, eightieth day. The albumen has disappeared ; 
 the spinal pains are very much diminished, but there are some 
 
ALBUMINURIA IN TYPHOID FEVER! 485 
 
 rheumatic pains in several of the joints, as the hip, the shoul- 
 der, etc. Chininum sulph., 1st trit., continued for four days. 
 March 3, eighty-fourth day. The rheumatic pains continue. 
 Rhus tox., 3d trit., and arsenicum, 3d dil., were given while 
 he continued in the hospital. The pains diminished gradually, 
 and he was discharged on the 24th of March, completely cured. 
 
 Let us recapitulate briefly the course, and the rather un- 
 usual symptoms which have marked the last part of this pro- 
 longed attack, for the fever continued for more than ten weeks. 
 
 After a decided diminution of the fever (99.5°) following 
 the thirty-fourth day, it assumed an intermittent form of 
 the most pronounced quotidian type (98.60°, and even 97.70° 
 in the morning, and 102.20° to 103.10° in the evening) ; but 
 the quinine failed to have any lasting effect in changing its 
 character. 
 
 On the forty-eighth day the patient began to complain 
 of pains, which did not leave him until the eightieth day 
 of his disease. The fifty-first day he had a copious hema- 
 turia, with epistaxis and diarrhoea, which put his life in dan- 
 ger, and which continued until the seventy-second day. 
 
 Suppose we consider the character of the pains from which 
 he suffered, and also the hematuria. The pains were spinal, 
 id est, they were located along the vertebral column, follow- 
 ing the course of the intercostal nerves, and a little later, 
 the track of the nerves of the arms and of the thighs. Some- 
 times they predominated in the dorsal region, again in the cer- 
 vical region, and again in the lumbar region. Their radia- 
 tions extended to the walls of the thorax, to the abdomen and 
 to the extremities. Pressure upon the spinous processes of the 
 vertebrae greatly aggravated these pains. Touching the skin 
 near the spine, where the congestion was located, with the 
 end of the finger, would extort cries from the patient ; while, 
 on the contrary, a broad and firm pressure upon these same 
 parts lessened the suffering. 
 
486 THE MEDICAL CLINIC. 
 
 These pains were continuous, but they were redoubled at 
 night, so as to make the patient cry aloud. Indeed, his 
 complaints so troubled the other patients in the ward that 
 we were obliged to threaten him with an extreme diet if 
 he did not desist. 
 
 The urine voided by our patient contained albumen from 
 the time of his admission into our wards, but from the fifty- 
 first day there was a decided hematuria. The terebinthina, 
 of which you could appreciate the value in the former case, 
 had only a slight effect in this one. Phosphorus, 6th dil., 
 then 3d dil., and arsenicuw,, 3d trit., were without effect. 
 The diarrhoea that was added to the other symptoms, sug- 
 gested phosphoric acid, 1st dil., on the sixty-fifth day. The 
 next day the symptoms had improved, and, eight days 
 later, the hematuria had entirely disappeared ; but the spinal 
 pain, in all its varieties, grew much worse. It was, however, 
 sensibly relieved by the sulphate of strychnia, 2d trit., con- 
 tinued for six days. Then, these spinal pains were followed 
 by rheumatism of the principal joints. China, 1st trit., and 
 afterward rhus tox., 3d dil., and arsenicum,, 3d trit., disposed 
 of the rheumatism. 
 
 You will observe that the febrile movement, after having 
 descended gradually to 99.68°, on the morning of the thirty- 
 fourth day, rose abruptly to 104° on the same evening ; and 
 that it presented a remittent type (102.20° and 103.10° in the 
 evening, with 97.88° and 98.60° in the morning), until the 
 sixtieth day, when it suddenly ceased. We must add that, 
 whatever the dose in which it was given, the sulphate of 
 quinine failed to break up the fever. 
 
 In this case the symptoms of nephritis were less marked 
 than in the preceding one ; but the hematuria was much worse, 
 for the patient lost a great deal of blood ; and phosphoric acid 
 proved to be the proper remedy for it. 
 
 This patient also afforded us a very rare example of intense 
 
RELAPSING TYPHOID. 487 
 
 congestion of the spinal meninges. For the relief of this com- 
 plication the sulphate of strychnia was very effectual. The 
 intermittent type of the fever persisted throughout the later 
 weeks of the illness. This was also true in the first of these 
 cases ; and it has been observed very often during this year in 
 the prolonged or more tedious form of typhoid fever. 
 
 Relapsing- Typhoid. 
 
 I will now direct your attention to a case of relapsing 
 typhoid, which will give you some practical hints. During 
 the first part of her illness this patient was under the pro- 
 fessional care of our friend and colleague, Dr. Gonnard, and 
 we borrow our notes from his record. 
 
 Case XC. — Relapsing typhoid fever • the second paroxysm 
 is an exact copy of the first / pernicious complications during 
 
 loth these attacks. Marie H , aged twenty-six, a domestic, 
 
 was admitted on the 18th of October, or the seventh day of the 
 disease. The diarrhoea, the prostration, the eruption, the fever 
 (104.72°), told what the disease was. The tongue was broad 
 and moist. Typhomania, subsultus, a pinched expression and 
 a complaint of violent and constant headache were symptoms 
 also. Besides, in order to get a clear and definite answer from 
 her, it was necessary to repeat the questions several times. 
 
 October 19, eighth day. I prescribed helladonna, 6th dil., 
 and muriatic acid, 6th dil., alternately. The heat of the skin 
 being of a burning character, she was ordered to be sponged 
 with an aqueous solution of aromatic vinegar. 
 
 October 20, ninth day. The temperature fell during the 
 night from 104°, last evening, to 103.10° this morning; the 
 pulse is 98, full and non-dicrotic ; the tongue is dry at the tip, 
 and there is some perspiration. The same treatment. 
 
 October 21, tenth day. Last evening the temperature ex- 
 ceeded 104°; this morning the patient is delirious, the head 
 is tossed about, the limbs tremble, and she tries to get up and 
 go away ; the skin is cold, the respiration panting, and the 
 pulse not discernible ; this paroxysm began about midnight. 
 
488 THE MEDICAL CLINIC. 
 
 Prescription : one gramme of quinine to be taken as soon as 
 there is a remission. This period having arrived at noon, the 
 medicine was given. The next day the paroxysm was less se- 
 vere, but she is still cold and delirious. The same prescription. 
 
 October 23, twelfth day. There is less agitation ; the pulse 
 is 120 ; she makes some sensible replies during her wander- 
 ings, and always complains of a violent headache ; the head is 
 moved to and fro regularly. The same prescription. During 
 this crisis of three days, a paralysis of the bladder made it 
 necessary that the catheter should be used. 
 
 October 25, fourteenth dav. The head is not tossed about 
 any longer, and the facial expression is more calm ; the heat 
 has fallen to 101.12°; the pulse is firm at 112; headache and 
 constipation ; contraction of the pupils, and profuse sweats. 
 Opium, 6th dil. 
 
 October 26, fifteenth day. There were large stools during 
 the night ; the evening was calm and quiet, but the morning 
 has been an excited one, and the hands are cold. Quinine. 
 
 October 27, sixteenth day. There is the same contrast be- 
 tween the restful state in the evening and the disquiet of the 
 morning, which condition should be reversed. The same treat- 
 ment. 
 
 October 30, nineteenth day. Although the headache per- 
 sists, the mind is much more clear ; for three days the regu- 
 lar tossing of the head has been going on again ; the general 
 appearance is improved; the temp. 102.20°. Arsenicum, 3d 
 trit., which was continued without interruption for two weeks. 
 
 November 2, twenty-second day. The balancing of the 
 head has stopped, and the bladder has relieved itself of an 
 abundant flow ; the patient wants milk, which is given her 
 mixed with water. The evening temperature is still high, 
 104.72°. 
 
 November 4, twenty-fourth day. The heat is 102.20°, the 
 pulse 108 ; the headache is less severe, and the sleep has re- 
 turned ; at her own request she had some broth instead of 
 milk. 
 
 In proportion with the decline of the fever, and the ability 
 to sleep, and with due consideration for the caprices of the 
 appetite, she was nourished with increasing liberality. 
 
RELAPSING TYPHOID. 489 
 
 On the thirty-first day of the disease the temperature dropped 
 suddenly from 101.84° to 98.60°. China, 3d trit. 
 
 November 13, thirty-eighth day. The patient, who has 
 grown very thin, is fully convalescent, without eschars or ab- 
 scesses. 
 
 Being without fever, and able to eat well, she was up and 
 about the ward for nearly a week, when, without any appre- 
 ciable cause, the disease returned. And here follows the history 
 of the second attack: 
 
 November 25, 1876. The patient being too weary on ac- 
 count of walking in the ward, or possibly from having eaten 
 improperly, the fever returned, and the temperature reached 
 104.18° in the evening; the pulse was 120. Ai'senicum, 3d trit., 
 and bvyonia, 3d dil., to be continued for five days. 
 
 For that period the temperature continued to be high, and 
 without any morning remission. 
 
 November 80, the sixth day of the relapse, the morning 
 temperature dropped to 101.84°, and the evening temperature 
 to 103.64°. 
 
 December 1, seventh day. The same remission. Bella- 
 donna, 3d dil., and arsenicum, 3d trit. 
 
 December 2, eighth day. The same. Hyoscyamus, 3d dil., 
 for three days. 
 
 December 3, ninth day. The evening temperature, 104.36°; 
 in the morning, chilly ; in the evening, delirious. 
 
 December 4, tenth day. The temperature the same as yes- 
 terday ; the face is bluish, and the delirium is very violent. 
 
 December 5, eleventh day. For three days past there has 
 been a paroxysm, the pernicious character of which is marked 
 not only by a difference of about 3.5° between the morning 
 and evening temperature, but also by a coldness of the extremi- 
 ties, a cold sweat, an asphyxiated hue of the countenance, and 
 a violent delirium at night. For this condition we did not 
 hesitate to prescribe the sulphate of quinine at our morning 
 visit. After taking this remedy the delirium subsided, and the 
 temperature was raised only a few tenths of a degree. The 
 quinine was continued during four days. 
 
 December 9, fourteenth day. The delirium has almost 
 entirely ceased ; the tongue is more moist, and the patient per- 
 spires freely. China, 3d trit., for two days. 
 
490 THE MEDICAL CLINIC. 
 
 December 11, seventeenth day. Nothing new to record, 
 excepting that the evening temperature is 103.10°. Carbo- 
 vegetabilis, 12th dil., for two days. 
 
 December 14, twentieth day. She is becoming excoriated, 
 and there is an eschar. Lachesis, 3d trit., for three days. 
 
 December 17, twenty-third day. She is much better, and 
 there is no more fever. Lachesis, 12th dil., to be continued 
 for a fortnight. 
 
 After a month's convalescence in the wards the patient was 
 discharged, January 22. She took china, 3d dil., and then the 
 6th dil. 
 
 This case is full of instruction: first, it is a good example 
 of a relapsing typhoid, which is a form of the fever that phy- 
 sicians have frequently encountered in the epidemic of 1876- 
 77, and upon which we published some observations in VArt 
 Medical in September, 1863, under the title: "Of relapses 
 during the convalescence of typhoid fever." 
 
 The next point of interest in this case is the advent of the 
 pernicious paroxysm at the beginning of the second week. 
 These paroxysms had already been present in the first edition 
 of the fever, if we may use such an expression. Let us ex- 
 amine these two points a little. 
 
 The relapsing typhoid is a rare form of the disease. Al- 
 though Thierfelder has reported eight cases of this kind, we 
 believe that we were the first to describe it clearly and particu- 
 larly in 1863, when we published two cases in support of our 
 views. In the epidemic of that year the examples were more 
 frequent, and we could describe its clinical history more per- 
 fectly, which we did in our first publication. The febrile 
 movement recommences with the same symptoms as it had at 
 first ; the relapse is very analogous in every respect to the first 
 attack, for there are the same complications and the same 
 contingencies. A glance at the facts just given will convince 
 you of the truth of this remark. The. rose-colored spots are 
 
RELAPSING TYPHOID. 491 
 
 habitually reproduced, and the autopsies made in the hospitals 
 have shown that the intestinal lesion reappears and runs its 
 course over again. 
 
 The second attack is habitually shorter than the first, and 
 usually terminates in recovery. However, these patients, ex- 
 hausted by a second assault, do sometimes succumb. Finally, a 
 few very rare cases have been observed in which a third attack, 
 similar to both the others, has occurred. This fact has given 
 rise to the theory of a typhus with relapses ; but the idea 
 should be discarded altogether, because the symptoms and 
 the lesions of the latter disease are entirely different from 
 those of typhoid fever. 
 
 I wish to call your attention to the pernicious paroxysms 
 that may occur in typhoid fever. Observe, firstly, that they 
 are not characterized uniformly by a difference of temperature, 
 whether great or small, between the morning and the evening. 
 Thus the patient mentioned in Case LXXXIX had a fever 
 which was decidedly intermittent. For almost thirty days the 
 temperature rose at evening to 102.02°, and dropped in the 
 morning to 98.60°; and yet, despite the gravity of the prog- 
 nosis, based upon the signs of an intense nephritis and of 
 spinal congestion, we had no thought of a pernicious state. 
 You remember very clearly, no doubt, that the strongest doses 
 of the sulphate of quinine had no effect upon that condition. 
 
 What is it, therefore, which characterizes the pernicious 
 paroxysm, when it occurs in the course of disease in general, 
 and of typhoid fever in particular ? It is the return, under a 
 type which is almost regular, of the signs of malignancy. 
 For example, with our patient, the fits were not only marked 
 by a great difference of temperature between morning and 
 evening, but by a coldness of the extremities, with cold sweats, 
 discoloration of the face, asphyxia and violent delirium. At 
 the same time, the pulse was extremely small and frequent, 
 
492 THE MEDICAL CLINIC. 
 
 the debility excessive, and the patient was evidently almost 
 moribund from embarrassment of respiration and of the heart's 
 action. 
 
 In this condition the sulphate of quinine is the remedy 
 which is indicated above all others; but we must not, as 
 in the mild remittants which so often occur at the end of 
 a typhoid fever, prescribe it in small doses. ~No ; for this 
 is the kind of a case that requires strong doses, and one 
 gramme, at least, should be given to an adult. You will 
 repeat this dose daily, for several days in succession, and 
 see to it that the patient takes it during the remission. In 
 the particular case which we have cited this remedy acted 
 heroically, and, as a result, the pernicious contingencies were 
 immediately arrested and did not return. 
 
 Still another remark, which, d jjropos of this case of re- 
 lapsing typhoid, is, that it was at the tenth day of the first 
 attack that the pernicious paroxysms began, and at the 
 ninth day they showed themselves in the second attack ; 
 or, in other words, in both cases they began during the sec- 
 ond week. These pernicious paroxysms had similar symp- 
 toms in both cases, and in both, also, they yielded rapidly 
 to the quinine ; but in the relapse they were decidedly less 
 violent. We were, therefore, correct in saying that, as a 
 rule, the repetition is milder than the first attack. 
 
 To complete my reference to the epidemic of typhoid 
 fever of 1876 and 1877, I must call your attention to the 
 existence of a form in which the disease may be said to be 
 defaced (forme fruste), as Trousseau has named it, and in 
 which I have proved, by the aid of the thermometer, the 
 complete absence of fever. I have observed this in my pri- 
 vate practice. 
 
 It may be thought that we should not apply the name 
 of typhoid fever to a pathological condition in which the 
 
RELAPSING TYPHOID. 493 
 
 i 
 
 fever is lacking. But every physician has observed cases of 
 measles and of scarlatina without fever. And why may not 
 typhoid fever present itself under a similar form ? 
 
 These pathological departures, happening during an epi- 
 demic of typhoid fever, have been characterized by malaise, 
 extreme lassitude, loss of appetite, a furred tongue, some- 
 times by a diarrhoea or a cough, by insomnia, by headache 
 and a duration of at least two weeks. 
 
 I do not hesitate to consider these patients as suffering 
 from typhoid fever of a very mild type. 
 
 As in all good clinics, the incidental instruction given in these lectures 
 is of great value. We are quite confident that the author's experience in 
 the relapsing typhoid, and in the spurious or imperfect form of the disease 
 in which the fever is lacking, will be confirmed by physicians in America, 
 more especially in the west and south. — L. 
 
TABLE 
 
 FRENCH AND ENGLISH WEIGHTS AND MEASURES 
 
 1 Milligramme 
 1 Centigramme 
 1 Decigramme 
 1 Gramme 
 
 .015 grs. 
 .15 grs. 
 1.54 grs. 
 15.43 grs. 
 
 1 Millimetre = .039 inches. 
 
 1 Centimetre = .39 inches. 
 
 1 Decimetre = 3.93 inches. 
 
 1 Metre - 39.37 inches, or 1 yd. 3.7 in. 
 
 1 Litre 
 
 = 1 pt. 15 oz. 2 drs. Ill m. 
 
INDEX. 
 
 ABSCESS of the cornea, case, 252 
 Abscess of the liver, case, 167 
 
 aspiration in, 167, 168 
 Accessory symptoms in chronic aor- 
 titis, 118 
 Acetate of iron in chlorosis, 109 
 Acid mur. in typhoid fever, 364, 365 
 Acid nit. in typhoid fever, 367 
 Acid phos. in typhoid fever, 365, 367 
 Aconite causes lesions of the mitral 
 
 valves, 88 
 Aconite in acute articular rheumatism, 
 85 
 
 in chronic aortitis, 122, 125 
 
 in hemoptysis, 189, 190 
 
 in pelvi-peritonitis, 276-279 
 
 in puerperal p. peritonitis, 292 
 
 in pelvic hematocele, 321 
 
 in rubeola, 88 
 
 in typhoid fever, 367, 373 
 
 in rheumatism, 416 
 
 in hemorrhagic variola, 460 
 Acute articular rheumatism, 18, 83, 
 431 
 
 chin, sulph, in, 84 
 
 aconite in, 85 
 
 bryonia in, 85 
 
 china in, 85 
 
 mercurius in, 85 
 
 case of, 431 
 Acute tephro-myelitis in rheumatism, 
 
 416 
 Acute tuberculosis of the larynx, 150 
 Adhesive pelvi-peritonitis, 266 
 iEsculus hip. in hemorrhoids, 204, 205 
 Agaricus muse, in diphtheria, 476 
 Aggravation of cough by phos., 81 
 
 by sulph., 81 
 Aggravation of symptoms from cactus, 
 
 17 
 Albuminous anasarca in typhoid fever, 
 
 479 
 Albuminuria in chronic aortitis, 117 
 Alcohol in pneumonia of old people, 
 
 384 
 Amenorrhceaand hemoptysis, note, 188 
 Ammon. mur. in hepatic congestion, 
 
 239 
 Amyloid degeneration of the liver. 15 
 
 Anaemia in pelvi-peritonitis, 271 
 Andral's Clinique, 73 
 Aneurism, aortic, and hemoptysis, 185 
 Angina, erythematous, 30 
 
 mere. corr. locally in, 129 
 Angina pectoris with chronic aortitis, 
 
 131 
 Angiotenic fever, note, 111 
 Animal poisons in diphtheria. 476 
 Antimonial preparations, the, 33, 34 
 Antimony, arseniate of, in asthma, 141 
 Angustura in dysentery, note, 71 
 Aortic aneurism and hemoptysis, 185 
 Aortitis, acute, Bizot's cases of, 111 
 Aortitis, chronic, 90, 110 
 
 Tessier on, 111 
 
 common form of, 112 
 
 Broussais on deposits in, 113 
 
 Virchow on deposits in, 113 
 
 and carditis compared, 114 
 
 progress of, 115 
 
 oedema in, 116 
 
 insomnia in, 117 
 
 spigelia in, 133 
 
 mode of death in, 117 
 
 albuminuria in, 117 
 
 accessory symptoms of, 118 
 
 physical signs of, 119 
 
 aconite and spigelia in, 122, 125, 
 130 
 
 carbo. veg. in, 123, 125, 128 
 
 cuprum in, 123 
 
 arsenicum in, 125, 128, 133 
 
 belladonna in, 125 
 
 ipecac, in, 126 
 
 in a gouty subject, 126 
 
 cantharis in, 128 
 
 bryonia in, 128 
 
 nux vomica in, 131 
 
 lachesis in, 130 
 
 the swallowing of solids in, 129 
 
 with angina pectoris, 131 
 Aortic dilatation and contraction ex- 
 plained, 114, 115 
 Apex of the lung, pneumonia at the, 
 
 95 
 Apis in abscess of the cornea, 253, 254 
 
 in keratitis, 259, 260 
 
 in pelvi-peritonitis, 289 
 
496 
 
 INDEX. 
 
 Apis in post- climacteric asthma, note, 
 142 
 
 sometimes unreliable, 260, 261 
 Apis inel., why so often unreliable, 427 
 
 Dr. Craig's preparation of, 427 
 
 in hydrarthosis, 435 
 Apium virus in scrofulous keratitis. 
 427 
 
 in hydrarthrosis, 436 
 
 instead of apis mel., 260, 261 
 Argent, nit. in progressive locomotor 
 ataxia, 420, 423 
 
 Dr. Pennoyer's experience with, 
 420 
 
 Dr. Fellows' views upon, 426 
 
 in gastric ulceration, 94, 95 
 Argentum oxydat. in metrorrhagia, 41 
 Argument lor a poison in diphtheria, 
 
 472 
 Arnica in hemoptysis, 188, 189, 190 
 
 in puerperal p. peritonitis, 292 
 Ars. and china in intermittent hypo- 
 chondria, 242 
 Arsenicum alb. in asthma, 23 
 
 in dysentery, 70 
 
 in simple gastric ulceration, 94, 95 
 Arsenicum in asthma, 135, 137, 138 
 
 in dyspepsia, 224 
 
 in hemorrhoids, 206 
 
 in chronic gastritis, 224 
 
 in chronic aortitis, 125, 128, 133 
 
 in diphtheria, 476 
 
 in typhoid fever, 486 
 
 in eczema, 336 
 
 in typhoid fever, 366 
 
 in pneumonia, 388 
 
 in asthma, 441 
 
 in hemorrhagic variola, 460 
 
 in gastralgia, 224 
 
 in keratitis, 259, 262 
 
 in pelyi-peritonitis, 276, 284, 288 
 
 in periodical fevers, 13 
 
 in transitory emphysema, 59 
 
 physical signs of, 91, 92 
 
 and plumbum in nephritis, 77 
 Arteries, radial, ossification of, in aor- 
 titis, 92 
 Arthritic eczema, 328 
 Articular rheumatism, acute, 431 
 Articular rheumatism with endo-peri- 
 
 carditis, 18 
 Ascites, china in, 51, 73, 74 
 Ascites from hepatic degeneration, 15 
 
 differential diagnosis of, 16, 51, 73 
 Asiatic cholera, dysentery after, note, 71 
 Aspiration in hepatic abscess, 167, 168 
 Asthma, 9, 23, 58, 89 
 Asthma at the climacteric, note, 139 
 
 post-climacteric, note. 142 
 
 post-climacteric, sanguinaria in, 
 142 
 
 Asthma, cases of, 135, 136, 138, 139, 
 
 140 
 cuprum and nux vom. in, 23 
 ars. alb. in, 23, 89 
 arsenicum in, 135, 137, 138, 139, 
 
 140 
 cuprum in, 135 
 bryonia in, 136, 138, 140, 141 
 belladonna in, 138, 139 
 ipecac, in, 140, 141 
 nux vomica in, 141 
 arseniate of antimony in, 141 
 jodium in, 89 
 iodide of potass, in, 90 
 with hemoptysis, 438, 443 
 with epileptiform vertigo, 438, 439, 
 
 441 
 with hemoptysis and vertigo, 440, 
 
 441 
 clinical rule in, note, 441 
 arsenicum in, 441, 443 
 with laryngeal spasm, 442 
 with neuralgia, arsenicum in, 138 
 with transitory emphysema, 58 
 Atroph. sulph. locally, Dr. Vilas on, 
 
 430 
 Attenuation, choice of the, 142 
 Hartmann on, 142 
 rules for, 145 
 and different doctors, 146 
 Jousset's late views on, 147 
 Auruin in abscess of the cornea, 254 
 in intermittent hypochondria, 241, 
 
 242 
 
 BAPTISIA tinct. in typhoid fever, 
 368, 374 
 Barker on peculiar effects of triliin, 41 
 Barth on meningo-encephalitis in ty- 
 phoid fever, 376 
 Bazin's fixed form of scrofula, 68 
 
 theory of eczema, 325 
 Beck, Dr., on the cyan, of mere, in 
 
 diphtheria, 473 
 Belladonna in nephritis. 77 
 in sciatica, 103 
 in chronic aortitis, 125 
 in gastralgia, 227 
 in scrofulous ophthalmia, 248 
 in keratitis, 259 
 in typhoid fever, 364 
 Bennett's statistics in pneumonia, 391. 
 
 392 
 Bernutz and Nonat on pel vi- periton- 
 itis, 267 
 Bichat's opinion of the Materia Medica, 
 
 . 79 
 " Bilious" and "mucous " fevers, 42 
 
 Bismuth in dysentery, 71 
 
 Bizot's aortitis and Bright's disease, 
 
 111 
 
INDEX. 
 
 497 
 
 Blepharitis scrofulous, 244 
 Blunder in diagnosis, a, 150 
 
 in frank avowal of, 151 
 Bollen's treatment of diphtheria, 474, 
 
 475 
 Borde's expectant statistics, 100 
 Bowels, the, in typhoid fever, 368 
 Bradyspepsia, 217 
 Brande's expectant statistics, 100 
 Bretonneau's theory of diphtheria, 466 
 Bright's disease and Bizot's aortitis, 
 
 111 
 Bromide of potassium in hysteria, 89 
 Bronchitis, 13 
 
 capillary, chelidonium in, 50 
 Bronchitis, ipecac, and bryonia in, 14 
 
 grave, or lobular pneumonia, 35, 
 49 
 
 grave, ipecac, and bryonia in, 35 
 
 with phthisis-pulmonalis, 262 
 Broussais and gastralgia, 216 
 Broussais on deposits in aortitis, 113 
 Bryonia and rhus in typhoid fever, 365 
 
 and ipecac, in pneumonia, 72 
 
 in rubeola, 88 
 
 in bronchitis, 14 
 
 in intercostal neuralgia, 51, 52 
 
 in transitory emphysema, 58 
 
 in dysentery, note, 71 
 
 in phthisis, etc., 262 
 Bryonia and phosphorus in pneumo- 
 nia, 98 
 
 and phosphorus in phthisis, 152 
 
 in hemoptysis, 180 
 
 in dyspepsia, note, 228 
 
 in pelvi-peritonitis, 289 
 Bryonia in asthma, 136, 140, 141 
 
 in pneumonia, 73, 98 
 
 in puerperal pleurisy, 82 
 
 in acute articular rheumatism, 85 
 
 in rubeola, 88 
 
 in sciatica, 103 
 
 in chlorosis and phthisis, 108 
 
 indications for in phthisis, 104 
 
 in chronic aortitis, 128 
 
 in phthisis and bronchitis, 262 
 
 in typhoid fever, 365, 367, 373, 375 
 Burns' operation in vaginismus, 450 
 Burt on cyanide of mere, in diphtheria, 
 473, 474 
 
 CACHEXIA, the, in chronic aor- 
 titis, 116 
 the, of pelvi-peritonitis, 271 
 Cactus, aggravation from, 17 
 
 in rheumatic endocarditis, 17, 86, 
 87 
 Calcarea carb. in scrofulous ophthal- 
 mia, 246 
 in keratitis, 262 
 Camphor for diphtheritic syncope, 476 
 
 32 
 
 Cancer of the stomach and gastritis, 
 
 211 
 Cantharis in chronic aortitis, 128 
 
 in eczema, 336 
 
 in nephritis, 77 
 
 in pelvi-peritonitis, 276, 285 
 
 in peri-uterine hematocele, 321 
 
 in pleurisy, 12 
 
 in puerperal pelvi-peritonitis, 292 
 Capillary bronchitis, chelidonium in, 
 
 50 
 Capsicum in hemorrhoids, 207 
 Carbo-veg. in chronic aortitis, 123, 128 
 
 in dyspepsia, 222 
 
 in hemorrhoids, 206 
 Cardiac hemoptysis, 412 
 
 millefolium in, 412 
 Cardiac paralysis in diphtheria, 467 
 Cardo-aortitis, 112 
 Cases of purulent diphtheria, 465, 467, 
 
 469, 471 
 Catarrh, Kerme's mineral in, 34 
 Cellulitis, pelvic, diagnosis from pelvi- 
 peritonitis, 275 
 Certainty in therapeutics, 78 
 Chamomilla in gastralgia, 227 
 
 in sciatica, 103 
 Change of climate in phthisis, 109 
 Chelidonium in capillary bronchitis, 50 
 China in ascites, 51, 73, 74 
 
 in acute articular rheumatism, 85 
 
 in dyspepsia, 223 
 
 in pelvi-peritonitis, 288 
 
 in typhoid fever, 367, 375, 486 
 
 in rheumatism, 411 
 Chininum sulph. in articular rheuma- 
 tism, 83, 84 
 
 in typhoid fever, 367 
 
 in pelvi-peritonitis, 287 
 Chlorosis and phthisis, 108 
 
 acetate of iron in, 109 
 
 change of climate for, 109 
 
 bryonia in, 108 
 
 iron contra-indicated in, 108 
 
 sea-bathing- in, 109 
 
 sepia in, 108 
 Chlorotic dyspepsia, 229 
 
 ferr. met. in, 229 
 
 nux and graphites in, 229 
 Chlorotic neuralgia, 13 
 Choice of climate in phthisis, 110 
 Choice of remedies, the, 157 
 
 illustrations of, 159, 160 
 Choice of the attenuation, 104 
 Choice, the, of attenuations, 142 
 
 Hartmann on the, 142 
 
 Mure on, 143 
 
 rules for, 145 
 
 varies with different doctors, 146 
 Chomel and Valleix on typhoid fever. 
 362 
 
498 
 
 INDEX. 
 
 Chomel on meningoencephalitis in ty- 
 phoid fever, 376 
 Chronic aortitis, 90, 110 
 
 the common form of, 112 
 
 Peters on, 112 
 
 complicated with endocarditis, 113 
 
 Broussais and Virchow on depos- 
 its in, 113 
 
 the cachexia in, 116 
 
 oedema in, 116 
 
 insomnia in, 117 
 
 and carditis compared, 114 
 
 arsenicum in, 125, 128 
 
 belladonna in, 125 
 
 ipecac, in, 126 
 
 in a gouty subject, 126 
 
 cantharis in, 128 
 
 bryonia in, 128 
 
 the swallowing of solids in, 129 
 
 lachesis in, 130 
 
 digitalis in, 130 
 
 nux vomica in, 131 
 
 spigelia in, 133 
 
 mode of death from, 117 
 
 with angina pectoris, 131 
 
 albuminuria in, 117 
 
 accessory symptoms of, 118 
 
 physical signs of, 119 
 
 aconite and spigelia in, 122, 130 
 
 carbo-veg. in, 123, 125, 128 
 
 cuprum in, 123 
 Chronic disease, incurability of, 57 
 
 note on, 57 
 Chronic pleurisy, case, 168 
 
 thoracentesis in, 170 
 Chronic rheumatic endocarditis, 86 
 Clifton's case of hypertrophic paraly- 
 sis, 423 
 Climacteric, asthma at the, note, 139 
 Clinic, the, 1 
 
 Clinical experience in the choice of the 
 dilution, 144 
 
 in " individualization,' ' 161, 162. 
 163 
 
 and the new remedies, 163 
 Clinical rule in asthma, note, 441 
 Clinical thermometry in typhoid fever, 
 
 350, 351 
 Cocculus in gastralgia, 222 
 
 in cramps of the stomach, 222 
 Cold affusions in hysteria, 54, 55 
 Colic and pain in pelvi-peritonitis, 
 
 note, 268 
 Collinsonia can. in hemorrhoids, 205, 
 
 207 
 Colocynth in dysentery, 70 
 
 in pelvi-peritonitis, 276, 281, 
 284 
 
 in sciatica, note, 103 
 Colocynth in peri-uterine hematocele. 
 321 
 
 Common symptoms of typhoid fever r 
 
 355, 356 
 Complications of typhoid fever, 352 
 Comstock's case of hematocele, 321 
 
 of peri-uterine hematocele, 321 
 Confirmed emphysema, 33 
 
 in infantile pneumonia, 50 
 Congestion, chronic, of the liver, case r 
 231 
 
 lachesis, 232, 237, 238 
 
 nux vomica, 233 
 Conium in pelvi-peritonitis, 285 
 Conjunctivitis, scrofulous, 246 
 Constitutional affection, scrofula a,76 
 Contraction and dilatation, aortic, ex- 
 plained, 114, 116 
 Contra-indications for the vegetable 
 
 diet, 153 
 Contraries, the law of, and the law of 
 
 similars, 175 
 Constipation in hemorrhoids, 198 
 Cough, aggravation of by phosphorus 
 81 
 
 by sulph., 81 
 Cough of phthisis, drosera in, 104, 106- 
 
 bryonia in, 104. 106 
 Cornea, abscess of, case, 252 
 Corrigan's pulse, 18 
 Couillaud on bromine in diphtheria,472 
 Craig, Dr., trituration of apis mel., 427 
 Crepitant rales, 73 
 
 Cornil on, 73 
 
 treatment of, 86, 87, 88 
 Critical days in typhoid fever, 352 
 Croup, case of, 148 
 
 tracheotomy in, 149 
 
 cyanide of mercury in, 149 
 
 and oedema of the glottis, 150 
 Cuprum acet. in rubeola, note, 88, 89 
 Cuprum in asthma, 135 
 
 in chronic aortitis, 123 
 Cyanuret of mercury in diphtheria, 473 
 
 DARTROUS eczema, 328 
 Davasse completes Broussais', 
 216 
 Death, mode of in chronic aortitis, 117 
 
 in pelvi-peritonitis, 274 
 Decision in filling an indication, 166 
 Deglutition of solids in chronic aortitis, 
 
 129 
 Delayed menstruation, puis, and fer- 
 
 rum in, 48, 55 
 Diabetes with eczema, note, 325 
 Diadem a in intermittent hypochondria, 
 
 241 
 Diagnosis, errors in, 98 
 
 Hippocrates on errors of, 150 
 of typhoid fever, 349, 356, 363 
 of pelvi-hematocele from pelvi- 
 peritonitis. 312 
 
INDEX. 
 
 499 
 
 Diagnosis of pelvi-hematocele from 
 ovarian cysts, 313 
 of pelvi-hematocele from uterine 
 
 fibroids, 316 
 of pelvi-peritonitis, 275 
 of pelvi-peritonitis from cellulitis, 
 
 275 
 a blunder in, 150 
 
 a blunder in, frank avowal of, 151 
 Dietl's expectant method, statistics of, 
 
 100 
 Diet, the, in typhoid fever, 371 
 Diet, the vegetable, in phthisis, 151, 
 154, 155, 156, 157 
 the vegetable, explained, 153 
 the contra-indications for, 153 
 Dieulafoy's aspirator in chronic pleu- 
 risy, 170, 171 
 Digestive troubles and hemorrhoids, 
 
 200 
 Digitalis in pelvic hematocele, 320 
 in scrofulous ophthalmia, 246 
 Dilatation and contraction of the aorta 
 explained, 114, 115 
 in vaginismus, 450 
 Dilutions, extreme, Hartmann's idea 
 of, 144 
 shall we fix a limit to the, 144 
 clinical experience as a guide, 144 
 vary with the disease and the rem- 
 edy, 146 
 rules for the choice of, 145 
 should vary with the patient, 146 
 effects of vary with different doc- 
 tors, 146 
 Diphtheria, the putrid form of, 464, 
 469 
 types, forms and complications of, 
 
 464 
 premature paralysis in, 465 
 cases of, 465, 467, 469, 471 
 Bretonneau's theory of, 466 
 tracheotomy in, 466 
 cardiac paralysis in, 467 
 not from a specific poison, 468 
 Couillaud, use of bromine in, 472 
 argument for a poison in, 472 
 paralysis of velum palati in, 473 
 cyanuret of mercury in, 473 
 Dr. Beck on the cyan, of mere, 
 
 473 
 Dr. Burt on the cyan, of mere, 473 
 the persistent use of remedies in, 
 
 474 
 Dr. Bollen's treatment of, 474, 475 
 nutrition in, 475 
 animal poisons in, 476 
 camphor in, 476 
 agaricus muse, in, 476 
 phosphorus and ars. in, 476 
 paralysis as a sequel of, 476 
 
 Diptheria, lime-water in, 477 
 
 spray of lacto-pepsin in, 477 
 Director of Public Assistance, report 
 
 of, 99, 100 
 Diurnal temp, in typhoid fever, 485, 
 
 486 
 Doses, the, vary with the disease and 
 
 the remedy, 146 
 Dr. Clifton's case of, 423. 426 
 Drinks in typhoid fever, 372 
 Drosera, indications for in phthisis, 104 
 Drosera in phthisis pulmonalis, 61, 62 
 Duality of phthisis, the, 65 
 Duchenne's pseudohypertrophic pa- 
 ralysis, -423 
 Dulcamara in eczema, 338, 339, 340 
 Dupuytren, Tessier's autopsy of, 111, 
 
 113, 114 
 Duration of action of remedies, 44 
 Dynamization, the theory of, 143 
 Dysentery, 69 
 
 Trousseau's opinion of, 69 
 
 mercurius sol. in, 69 
 
 mercurius corr. in, 69 
 
 ipecac, in, 70 
 
 arsenicum in, 70 
 
 phosphorus in. 70 
 
 colocynth in , 70 
 
 secale cor. in, 70 
 
 bryonia in, 71! 
 
 veratrum alb. in, 71 
 
 angustura in, 71 
 
 as a sequel to cholera, note, 71 
 Dyspepsia, chlorotic, case of, 229 
 
 chlorotic, nux and graphites in, 
 229,230 
 
 diagnosis of, 217 
 
 flatulent. 217 
 
 acid, 217 
 
 masked form of, 217 
 
 nux vomica in, 220 
 
 carbo-vegetabilis in, 222 
 
 bryonia in. 228 
 
 china in, 223 
 
 nux and graphites in, 228 
 
 arsenicum in, 224 
 
 lycopodium in, 225 
 
 sulphur in, 226 
 
 Pulsatilla in, 226 
 
 plumbum in, 227 
 
 graphites in, 228 
 
 diagnosis from chronic gastritis, 
 217 
 
 diagnosis from gastralgia, 218 
 
 and gastritis, clinical history of. 
 215,216 
 Dyspnoea in chronic aortitis, 115 
 
 ECZEMA, 324 
 definition of, 324 
 a constitutional affection, 324 
 
500 
 
 INDEX. 
 
 Eczema, Bazin's theory of, 325 
 
 with diabetes, case, 325 
 hemorrhoids, 326 
 
 stages of eruption, 326 
 
 forms of, 327 
 
 impetiginoides, 327 
 
 fissurum, 327 
 
 scrofulous, 327 
 
 dartrous, 328, 329 
 
 arthritic, 328. 330, 337 
 
 cases of 329, 331, 337, 341 
 
 treatment of, 333 
 
 rhus tox. in, 334 
 
 rhus rad. in, 336 
 
 cantharis in, 336 
 
 arsenicum in, 336 
 
 comparative use of remedies in, 
 338 
 
 plumbago in, 338 
 
 mezereum in, 338, 339 
 
 dulcamara in, 338, 339, 340 
 
 viola tricolor in, 338, 340 
 
 sepia in, 338, 342 
 
 mere, jodatus in, 340 
 
 sulphur in, 342 
 
 natrum mm*, in, 342 
 
 external treatment of, 343 
 Eczematoge'nes, 325 
 Endocarditis, rheumatic, 17, 406 
 heart-sounds in, 407, 408 
 Endopericarditis, rheumatic, 18, 36 
 
 chin, sulph. in, 19, 21 
 
 cactus grand, in, 21, 36 
 
 spigelia in, 37 
 Entero-gastritis, 215 
 Emphysema and phthisis in the same 
 
 subject, 152 
 Empiricism, the legitimate role of, 7 
 Empyema, case, 168, 171 
 Emphysema, varieties of, 9, 33, 90 
 
 diagnosis of, 10, 33 
 
 special pathology of, 32, 33 
 
 transitory, with asthma, 58 
 Epi-cystitis, 291 
 Epileptiform vertigo, 441 
 
 from fibroma of the larynx, 442 
 Erecthites in typhoid fever, 367 
 Errors in diagnosis, 98 
 Erythematous angina, 30 
 Eupatorium perf. in typhoid fever, 375 
 Expectant method, statistics of the, 
 
 99, 100 
 Expectant method, the, in pneumonia, 
 388 _ 
 
 statistics of, 389 
 Experience, clinical, and the new rem- 
 edies, 163 
 
 clinical, and the early homoeo- 
 paths, 161 
 
 clinical, in the choice of dilutions, 
 144 
 
 Experimental Materia Medica, the, 164 
 
 illustration of, 173 
 Explanation of "individualization," 
 
 160, 161 
 External treatment in eczema, 343 
 Euphrasia in scrofulous ophthalmia, 
 
 246, 248 
 
 FAHNESTOCK on dysmenorrhcea 
 and angina, 205 
 Fellows' letter on arg. nit., 426 
 Ferrum and puis, in delayed menstru- 
 ation, 48, 55 
 perchlor. in hemoptysis, 189 
 perchlor. in hemorrhoids, 206 
 metal, in chlorotic dyspepsia, 229 
 Fever, typhoid; see typhoid fever 
 a mild case of, 42 
 typhoid, can it be aborted ? 43 
 typhoid alias acute phthisis, 107 
 typhoid alias acute phthisis, ars. 
 
 in, 107, 108 
 typhoid, case, 134 
 typhoid, alvine and urinary arrest 
 in, 135 
 Fevers, " bilious" and "mucous," 42 
 
 gastric and mucous, 348 
 Formula sim. similibus curantur, 157 
 sim. interpretation of, 157, 158. 
 
 GALEN'S definition of an indica- 
 tion, 166 
 Gastralgia, 215, 216, 218 
 
 lycopodium in. 225 
 
 diagnosis of, 218 
 
 arsenicum in, 224 
 
 nux vomica in, 220 
 
 ignatia in, 221 
 
 cocculus in, 222 
 
 and dyspepsia, 215, 216 
 
 differential diagnosis of, 217 
 
 chamomilla in, 227 
 
 belladonna in, 227 
 
 veratrum in, 227 
 Gastric and mucous fevers, 348 
 Gastric fever, Niemeyer on, 216 
 Gastritis and dyspepsia, clinical history 
 
 of, 215 
 Gastritis, acute, 215 
 
 chronic, cases, 209, 211, 212 
 
 nux and graphites in, 210 
 
 nux vomica in, 211, 212, 213, 220 
 
 Dr. Small's case of, 212 
 
 diagnosis from dyspepsia, 217 
 
 diagnosis from gastralgia, 218 
 
 simulating cancer, 211 
 
 treatment of, 219 
 
 arsenicum in, 224 
 
 lycopodium in, 224, 225 
 
 sulphur in, 226 
 
 plumbum in, 227 
 
 
INDEX. 
 
 501 
 
 Gastro- enteritis, 215 
 Gelsemium in typhoid fever, 375 
 Glottis, oedema of the, and croup, 150 
 Gout, 90 
 
 and hemorrhoids, 201, 202 
 Gouty subject, chronic aortitis in a, 
 
 126 
 Graphites in dyspepsia, 228, 229 
 
 and nux in dyspepsia, 228, 229 
 Graves, Dr., of Dublin, epitaph for,109 
 Guerin's case of pelvi-peritonitis, 267 
 
 HAHNEMANN foreshadowed by 
 others, 3 
 Hahnemann's discovery of the law 
 
 similia, 4 
 Hahnemann, the precursors of, 178 
 Haller and homoeopathy, 3 
 Hamamelis in hemorrhoids, 196, 205 
 in menorrhagia, 34 
 in pelvi-peritonitis, 289 
 in typhoid fever, 367 
 in rheumatism, 416 
 Hartmann on the choice of attenua- 
 tions, 142 
 Hartmann's idea of the extreme dilu- 
 tions, 144 
 Hawkes on phos. in hematuria, 454 
 Hematemesis, the diagnosis of, 183, 
 
 184, 185 
 Hematocele, peri-uterine, cases, 307- 
 331 
 treatment of, 319 
 from retention, 302 
 from rupture, 301 
 from menorrhagia, 301, 308 
 from dysmenorrhoea, 303 
 Virchow's theorv of, 304 
 the tumor. in, 305, 313 
 Hematuria and rheumatic endocar- 
 ditis, 413, 415 
 in typhoid fever, 485 
 phosphorus in, 454, 459 
 Hemorrhage in hematocele, sources, 
 
 301 
 Hemorrhage, intestinal, in typhoid fe- 
 ver, 479 • 
 Hemoptysis and amenorrhoea, note, 188 
 periodical and habitual, 188 
 Niemeyer's view, 192, 194 
 and phthisis, 192, 193 
 asthmatic, 438, 443 
 with asthma and vertigo, 440, 441 
 cases, 179, 181, 195 
 ferrum perchlor. in, 189 
 ipecac, in, 180, 181. 191 
 aconite in, 189, 190 
 bryonia in, 180 
 nux vomica in, 189 
 phosphorus in, 180, 182, 189 
 ledum in, 191 
 
 Hemoptysis, millefolium in, 181, 190, 
 191 
 
 ipecac, and millefolium in, 182, 192 
 
 arnica in, 188, 189, 190 
 
 hamamelis in, 189, 191 
 
 in rheumatism, 411 
 
 Jaccoud's view of, 193, 194 
 
 the diagnosis of, 183, 184, 185 
 
 and mitral disease, 185 
 
 aortic aneurism, 185 
 
 varieties of, 186. 187 
 
 indications in, 188 
 
 hamamelis in, 189, 191 
 Hemorrhagic variola, 451 
 
 cases of, 453, 459 
 
 modified by vaccination, 452 
 
 phosphorus in, 453, 454 
 
 nose-bleed in, 454 
 
 uterine epistaxis in, 454 
 
 intractable vomiting in, 459 
 
 aconite in, 460 
 
 arsenicum in, 460 
 
 normal pulse in, 460, 461 
 
 temperature in, 461 
 Hemorrhoids, 90 
 
 and vaginismus, 447 
 
 cases of, 196 
 
 are they local or general? 197, 199 
 
 constipation in, 198 
 
 in warm climates, note, 199 
 
 Virchow's theory of, 199 
 
 only a symptom, 200 
 
 in general paralysis of insane, 200 
 
 in locomotor ataxia, 200 
 
 and respiratory diseases, 200 
 
 and digestive troubles, 200 
 
 common in gouty subjects, 201, 202 
 
 treatment of, 203 
 
 hamamelis in, 196, 205 
 
 nux vomica in, 203 
 
 nux and sulphur in, 203 
 
 sulphur in, 204 
 
 sesculus hip. in, 204, 205 
 
 collinsonia can. in, note, 205, 207 
 
 millefolium in, 205 
 
 ferr. perchlor. in, 206 
 
 phos. acid in, 206 
 
 mur. acid in, 206 
 
 arsenicum in, 206 
 
 carbo-veg. in, 206 
 
 borax and mere, in, 206 
 
 capsicum in, 207 
 
 sedum teleph. in, 208 
 
 sedum acre in, 208 
 
 with eczema, note, 326 
 Hepar sul. in scrofulous keratitis, 429 
 
 in scrofulous ophthalmia, 245, 246 
 
 in keratitis, 261 
 Hepatic abscess, case, 167 
 
 aspiration in, 167, 168 
 
 remarkable case of, note, 195 
 
502 
 
 INDEX. 
 
 Hepatic congestion, chronic, case, 231 
 
 physical signs of, 236 
 
 pain in, 237 
 
 lachesis in, 232, 237. 239 
 
 ammon. mur. in, 239 
 Hereditary entailment in scrofula, etc., 
 
 69 
 Hervieux on puerperal pleurisy, 81 
 Homoeopathic hospital, the Leopol- 
 
 stadt, 101 
 Homoeopathy, hist, of in Paris, 99, 100 
 
 its place in therapeutics, 2 
 
 what is it? 2 
 
 indications and strong doses in, 147 
 Hot-water irrigation in pelvi-periton- 
 
 itis, 290 
 Hippocrates on errors of diagnosis, 
 
 150 
 Hughes, Dr. Richard, on col. can., 207 
 
 sesculus hip., 204 
 
 nux vomica, 220 
 
 cocculus, 222 
 Hughes, Dr., on colocynth in periton- 
 itis, 231 
 
 on plumb, in vaginismus, 450 
 Huguier's first account of vaginismus, 
 
 445 
 Huxham and Stohl's inflammatory 
 
 fever, 111 
 Hydrarthrosis, cases of, 434, 436, 437 
 
 diagnosis from white swelling, 435 
 
 j odium in, 435 
 
 apis mel. in, 435 
 
 apium virus, 436 
 
 periodical, 437 
 
 periodical with menorrhagia, 437 
 
 sea-bathing in, 438 
 Hydropathy in hysteria, 55 
 Hygienic care in pelvi-pentonitis, 290 
 Hygroma, a suppurating, 28 
 Hyoscyamus in typhoid fever, 367 
 Hyper- thermic states in puerperality, 
 
 note, 174 
 Hypochondria, intermittent, case, 239 
 
 diadem a in, 241 
 
 tarentula in, 241 
 
 nux vomica in, 241 
 
 aurum met. in, 241, 242 
 
 china and ars. in, 242 
 
 forms of, 240 
 Hysteria, 53 
 
 ignatia in, 57 
 
 bromide of potass, in, 89 
 
 with vaginismus, 447 
 Hysterical vomiting, 47 
 
 remarkable case of, 47 
 
 reposit the uterus in, 49 
 
 TMPETIGINOIDES eczema, 327 
 _L Inflammatory fever, Huxham and 
 Stohl's, note, 111 
 
 Ignatia in gastralgia, 221 
 
 in hysteria, 57 
 Incisions in vaginismus, 450 
 Incurability of chronic diseases, 57 
 Indication, definition of, 166 
 Indications, homoeopathic, and strong 
 doses, 147 
 
 fanciful, 160 
 
 for remedies, 164, 165 
 Individualizing in pneumonia, 384 
 Individualization, 160, 161, 162, 163 
 
 explained, 160 
 
 clinical experience in, 162, 163 
 
 and the early homoeopaths, 161 
 Infantile pneumonia, chel. in, 50 
 
 note, 387 
 Insane, general paralysis of and hem- 
 orrhoids, 200 
 Insomnia in chronic aortitis, 117 
 Intercostal neuralgia, 51 
 
 bryonia in, 51 
 
 nux vomica in, 51 
 Intermittent fever with menorrhagia, 
 45 
 
 tarentula in, 46 
 Intermittent hypochondria, 239 
 Interstitial nephritis, remedies for, 77 
 
 and the higher altitudes, note, 
 77 
 
 railroad men are subject to, note, 
 77 
 
 case, 75 
 
 special pathology of, 76 
 Intestinal hemorrhage in typhoid fever, 
 
 479 
 Introduction of homoeopathy into the 
 
 Paris hospitals, 99, 100 
 Iodide of potassium in syphilis, 14 
 Ipecac, action of in asthma, 11 
 
 Prof. See on, 11 
 
 Trousseau on, 12 
 
 and bryonia in bronchitis, 14 
 
 in dysentery, 70 
 
 and bry. in phthisis, etc., 262 
 
 in pneumonia, 72 
 
 in rubeola, 88 
 
 in chronic aortitis, 126 
 
 in keratitis, 259, 260 
 
 in asthma, 140, 141 
 
 in hemoptysis, 180, 181, 191 
 
 and millefolium in hemoptysis, 
 182, 192 
 
 in scrofulous ODhthalmia, 247, 248, 
 250, 251 
 
 in abscess of the cornea, 253 
 
 in rubeola, 88 
 
 in typhoid fever, 367 
 
 in scrofulous keratitis, 429 
 Iron, contra-indicated in phthisis, 108 
 
 Trousseau's opinion of, 109 
 
 acetate of, in chlorosis, 109 
 
INDEX. 
 
 503 
 
 TACCOUD on hemoptysis, 193 
 
 Jaccoud's theory of the duality of 
 
 phthisis, 65 
 Jahr on vaginismus, 449 
 Jessen's prize essay on eczema, note, 
 
 324 
 Jodium in hydrarthrosis, 435 
 in phthisis pulmonalis, 62 
 in asthma, 89 
 Jousset's latest views on choice of po- 
 tency, 147 
 on tracheotomy in 1844, 151 
 criticism of Valleix, 100 
 
 KALI CARB. in keratitis, 260 
 Keratitis, scrofulous, 248 
 Keratitis, 427 
 
 opium in, 262 
 
 double, with ophthalmia, 255 
 
 calcarea carb. in, 262 
 
 apis in, 259, 260 
 
 ipecac, m, 259, 260 
 
 arsenicum in, 259, 262 
 
 belladonna in, 259 
 
 phosphorus in, 259 
 
 protox. of iron in, 259 
 
 hepar sulph. in, 261 
 
 puerperal dyscrasia in, 260 
 
 kali carb. in, 260 
 
 apium virus in, 427, 429 
 
 apis unreliable in, 427 
 
 case of, 428 
 
 choice of remedies in, 429 
 
 hepar sulph. in, 429 
 
 ipecac, in, 429 
 
 atroph. sulph. locally, 430 
 
 warm water compresses in, 430 
 Kerato-conjuntivitis, case of, 428 
 Xermes' mineral, 1st trit., in asthma, 24 
 
 in catarrh, 34 
 
 LACHESIS in congestion of the 
 liver, 232, 233, 237, 239 
 Laennec on sea-air in phthisis, 109 
 Laennec's pulmonary apoplexy, 193 
 Laryngeal phthisis, 46 
 
 spasm, with asthma, 442 
 vertigo, 442 
 Larynx, acute tuberculosis of, 150 
 Law of contraries and the law of simi- 
 lars, 175 
 Law of cure, Hahnemann's discovery 
 
 of, 4 
 Law of positive indications, the, 164, 
 
 178 
 Ledum in hemoptysis, 191 
 Ledum palustre in sciatica, 104 
 
 in typhoid fever, 367 
 Leopolstadt Homoeopathic Hospital, 
 the, 101 
 
 Lime water in diphtheria, 477 
 Liver, abscess of the, 167 
 
 aspiration in, 167, 168 
 
 chronic congestion of, 231 
 
 ammon. mur. in, 239 
 
 nux vomica in, 233, 239 
 
 lachesis in, 232, 233, 239 
 
 complications of, 234 
 
 physical signs of, 236 
 
 pain in, 237 
 
 prognosis in, 237 
 Lobular pneumonia, or grave bronchi- 
 tis, 35, 48 
 
 ipecac, and bryonia in, 35 
 Locomotor ataxia and hemorrhoids, 
 
 200 
 Louis on meningo-encephalitis in ty- 
 phoid fever, 376, 379 
 Ludlam's case of p. hematocele, 303 
 Lumbago, 30 
 
 actea racemosa in, 30 
 
 macrotin in, 30 
 
 argentum in, 63 
 Lung, apex of the, pneumonia at the, 
 
 95 
 Lycopodium in gastritis, 224, 225 
 
 in dyspepsia, 225 
 
 in gastralgia, 225 
 
 "A/TALIGNANCY in typhoid fever, 
 
 Malignancy, the, of disease, 461 
 
 type of, 462 
 
 peculiarities of, 462 
 
 ancient theory of, 462 
 
 mode of death from, 463 
 
 in pernicious fevers, etc., 463 
 Materia Medica, Bichat's opinion of 
 the, 79 
 
 the experimental, 164 
 
 pura, 164 
 Meadows 1 , Dr., directions for operating 
 
 in p. hematocele, 321 
 Medicinal aggravations, 22 
 Medicinal aggravation from cactus, 
 
 17, 21 
 Medication, palliative, 7 
 Meningo-encephalitis in typhoid fever, 
 376 
 
 Chomel, Louis and Barth on, 376 
 
 Tessier's description of, 377 
 
 symptoms of, 377 
 
 morbid anatomy of, 377 
 
 reply to Louis on, 379 
 Menopause, asthma at the, note, 139 
 . sanguinaria in, 142 
 
 apis mel. in, 142 
 Menorrhagia, hamamelis in, 34 
 
 with intermittent fever, 46 
 
 tarentula in, 46 
 
 nitric acid in, 46 
 
504 
 
 INDEX. 
 
 Menstruation, delayed, puis, and fer- 
 
 rum in, 47 
 Mercurius corr. in dysentery, 69 
 
 Orfila and Tardieu on, 69 
 
 in nephritis, note, 77 
 
 locally in angina, 129 
 Mercurius in acute articular rheuma- 
 tism, 85 
 
 in scrofulous ophthalmia, 245 
 Mercurius sol. in dysentery, 69, 71 
 Merc. viv. in typhoid fever, 375 
 Metrorrhagia, argent, oxydat. in, 41 
 
 trillin in, 41 
 Metrorrhagia in pelvi-peritonitis, 271. 
 
 289 
 Mezereum in eczema, 338, 339 
 Michon's operation in vaginismus, 446 
 Millefolium in cardiac hemoptysis, 412 
 
 in hemoptysis, 181, 190, 191 
 
 and ipecac, in hemoptysis, 182, 192 
 
 in hemorrhoids, 205 
 Milcent's fixed form of scrofula, 68 
 Mineral remedies in uterine disorders, 
 
 433 
 Mitral constriction in rheumatism, 411 
 Mitral disease and hemoptysis, 185 
 Mitral valves, aconite and the, 88 
 Monneret's outline of the liver, 235 
 Mono-articular rheumatism, case, 410 
 Morbid anatomy of meningo-enceph- 
 
 alitis, 378 
 Mur. acid in typhoid fever, 364, 365 
 
 in hemorrhoids, 206 
 Mure on the choice of attenuations, 143 
 
 "ATT ATRUM mur. in eczema, 342 
 _JJN Nephritis, interstitial, case, 75 
 Nephritis, interstitial, ars. alb. in, 77 
 belladonna in, 77 
 cantharis in, 77 
 ars. alb. and plumb, in, 77 
 mere. corr. in, note, 77 
 and the higher altitudes, note, 77 
 railroad men and travelers subject 
 
 to, 77 _ 
 with ossification of the arteries, 129 
 often a gouty affection; 129 
 in typhoid fever, 367, 375 
 special pathology of, 76 
 Nephritis in typhoid fever, 482 
 Neuralgia, citrate of iron and strych. 
 in, 13 
 intercostal, bryonia in, 51, 52 
 intercostal, Dr. D. S. Smith on, 52 
 trifacial, belladonna in, 13 
 intercostal, nux vomica in, 51 
 stannum in, 52 
 ranun. bulb, in, 52 
 rhus rad. in, 52 
 from over-lactation, 13 
 with asthma, belladonna in, 138 
 
 Neuralgia, with chlorosis, 13 
 Niemeyer's views of hemoptysis, 192, 
 194 
 
 of gastric and mucous fevers, 
 216 
 Nitric acid in intermittents with me- 
 norrhagia, 46 
 
 in typhoid fever, 367 
 Nose-bleed in hemorrhagic variola, 
 
 454 
 Nutrition in diphtheria, 475 
 Nux and sulphur in hemorrhoids, 203 
 Nux vomica and cuprum in asthma, 23 
 
 in intercostal neuralgia, 51 
 
 in fits of suffocation, 92 
 
 in simple gastric ulceration, 94 
 Nux vom. and graphites in gastritis, 
 210 
 
 in dyspepsia, 228 
 
 in chlorotic dyspepsia, 230 
 
 in dyspepsia, 220 
 
 in gastralgia, 220 
 
 in chronic gastritis, 211, 212, 213, 
 220, 221 
 
 in congestion of the liver, 233 
 
 in intermittent hypochondria, 241 
 
 in sciatica, 104 
 
 in chronic aortitis, 131 
 
 in neuralgia with asthma, 138 
 
 in hemoptysis, 189 
 
 in hemorrhoids, 203 
 
 OPHTHALMIA, scrofulous, 243 
 chronic, 243 
 
 stages of, 244 
 
 Pulsatilla in, 245, 246, 248 
 
 hepar sulph. in, 245, 246 
 
 silicea in, 245, 246 
 
 mercurius in, 245 
 
 euphrasia in, 246, 248 
 
 senega in, 246 
 
 calc. carb. in, 246 
 
 digitalis in, 246 
 
 staphysagria in, 246 
 
 ipecac, in, 247, 248, 250, 251 
 
 belladonna in, 248 
 
 sulphur in, 248 
 
 with double keratitis, 255 
 (Edema in chronic aortitis, 116 
 Opium in keratitis, 262 
 
 in typhoid fever, 367 
 Orfila, on mercurius corr., 69 
 Ovarian irritation in vaginismus, 447 
 
 PAIN in pelvi-peritonitis, 269, 270, 
 289 
 
 in hepatic congestion, 237 
 intercostal, in phthisis, 28 
 Palliative medication, 7 
 Palpation and the touch in pelvi-peri- 
 tonitis, 270 
 
INDEX. 
 
 505 
 
 Paralysis, acute, spinal, plumb, in, 420 
 
 infantile, confirmed, plumb, in, 420 
 Paralysis as a sequel of diphtheria, 476 
 Paralysis, general, of the insane, and 
 
 hemorrhoids, 200 
 Paralysis of vel. palati in diphtheria, 
 
 473 
 Paraplegic rheumatism, 418 
 Parenchymatous nephritis in typhoid, 
 
 482 
 Paris, history of homoeopathy in, 99, 
 
 100 
 Paris hospitals, mortality in from pneu- 
 monia, 79 
 Parotitis in typhoid fever, 479 
 Pelvi-peritonitis, cases, 265, 281 
 
 adhesive, 266 
 
 suppuration in, 266, 272. 273, 286 
 
 Bernutz and Nonat on, 267 
 
 Guerin's case of, 267 
 
 causes, 268 
 
 cause of pain and colic in, 268 
 
 rheumatism complicated with, 286 
 
 is symptomatic, 268 
 
 forms of, 269. 272, 274 
 
 pain in, 269, 270, 289 
 
 signs of, by touch, 270 
 
 signs of by palpation, 270 
 
 pulse and temperature in, 270 
 
 the tumor in, 270, 271 
 
 metrorrhagia in, 271 
 
 ansemia in, 271 
 
 cachexia of, 271 
 
 mode of death in, 274 
 
 diagnosis of, 275 
 
 diagnosis from cellulitis, 275 
 
 treatment of, 276 
 
 aconite in, 276, 277. 278, 279 
 
 arsenicum in, 276, 283, 284, 288 
 
 colocynthin, 276, 281, 284 
 
 cantharis in, 276, 285 
 
 conium in, 285 
 
 sulph. quinia in, 287 
 
 china in, 288 
 
 bryonia in, 289 
 
 apis mel. in, 289 
 
 hamamelis in, 289 
 
 thlaspi in, 289 
 
 sabina in, 289 
 
 hot water irrigation in, 290 
 
 hygienic care in, 290 
 
 puerperal, 291 
 
 case of, 293 
 
 synonyms of, 291 
 
 treatment of, 292 
 
 aconite and arnica in, 292 
 
 cantharis in, 292 
 
 terebinthina in, 293 
 Pemphigus, rhus. and cantharis in, 28 
 Pennoyer's cases of locomotor ataxia, 
 420, 422 
 
 Peters on chronic aortitis and angina 
 
 pectoris, 111 
 Peri- cystitis, puerperal, 291 
 Periodical and habitual hemoptysis, 
 
 188 
 Periodical hydrarthrosis, 437 
 
 and menorrhagia, 437 
 Peri-uterine hematocele, 300 
 
 varieties of, 300, 301 
 
 sources of hemorrhage in, 301 
 
 from rupture, 301 
 
 from retention, 302 
 
 from menorrhagia, 303, 305, 308 
 
 and dysmenorrhcea, case, 303 
 
 Virchow's theory of, 304 
 
 the tumor in, 305, 306, 313 
 
 peritonitis in, 306 
 
 cases of, 303, 307, 310, 315, 321 
 
 menorrhagic, 308 
 
 causes of, 309 
 
 absorption of. 309 
 
 diagnosis of, 311, 312, 313 
 
 conclusions in, 317 
 
 blunders in, 318 
 
 treatment of, 319 
 
 digitalis in, 320 
 
 terebinthina in, 320 
 
 the puncture of the tumor, 320. 
 321 
 
 aconite in, 321 
 
 colocynth in, 321 
 
 cantharis in, 321 
 
 Dr. Comstock's case of, 321 
 Pernicious paroxysms in typhoid fever, 
 
 491 
 Phosphoric acid in hemorrhoids, 206 
 
 in typhoid fever, 365, 367, 486 
 Phosph. and ars. in diphtheria, 476 
 Phosphorus and bryonia in phthisis, 
 
 152 
 Phosphorus in diphtheria, 476 
 
 in dysentery, 70 
 
 aggravation of cough by, 81 
 
 in pneumonia, 98, 99 
 
 in hematuria. 454 
 
 in keratitis, 259 
 
 in hemorrhagic variola, 453 
 
 in typhoid fever, 367, 486 
 Phthisis and chlorosis, 108 
 
 bryonia in, 108 
 
 sepia in, 108 
 
 iron contra-indicated in, 108 
 
 acetate of iron in , 109 
 
 sea-bathing in, 109 
 
 change of climate for, 109, 110 
 Phthisis and hemoptysis, 192, 193 
 Phthisis following puerperal pleurisy. 
 12, 24, 34, 80 
 
 and the vegetable diet, 26, 39 
 
 incipient, 26 
 
 preceded by pleurisy, 39 
 
506 
 
 INDEX. 
 
 Phthisis of the larynx, 47 
 pulmonalis, 6i 
 
 " drosera in, 61 
 
 " jodium in, 62 
 
 chronic, with caseous pneumonia, 
 
 62 
 the duality of, 65 
 Phthisis pulmonalis with bronchitis, 
 
 262 
 Phthisis, the common form of, 104 
 drosera in, 104 
 
 the vegetable diet in, 151, 264 
 phosphorus and bryonia in, 152 
 and emphysema in the same pa- 
 tient, 152 
 Physical diagnosis may fail in pneu- 
 monia, 383, 387 
 in infantile pneumonia, 387 
 Physical outline of the liver, 236 
 signs of hepatic congestion, 236 
 signs of pelvi-peritonitis, 270 
 Physical signs of chronic aortitis, 119 
 Physiological effect of aconite on the 
 
 mitral valves, 88 
 Pinel and angiotenic fever, 111 
 Pinel-Grandechamp on vaginismus, 
 
 446 
 Pleurisy and phthisis after labor, 12, 
 
 24, 34 
 Pleurisy, chronic, case, 168 
 
 puerperal, and phthisis, 12, 24, 
 
 34, 80 
 puerperal, note on, 81, 82 
 bryonia in, 82 
 thoracentesis in, 170 
 Plumbago in eczema, 338 
 Plumb, europ. in eczema, 332 
 Plumbum in confirmed paralysis of in- 
 fants, 419, 420 
 in acute spinal paralysis, 420 
 in progressive muscular atrophy, 
 
 420 ' 
 in muscular paralysis, 419 
 Dr. Hughes' ideas of, 420 
 Dr. Fellows' ideas of, 426 
 in vaginismus, 450 
 in dyspepsia, 227 
 in sciatica, 103 
 Pneumonia, 380 
 
 cases of, 380, 385, 393 
 cured on the ninth day, 380 
 cured without defervescence, 383 
 physical diagnosis may fail to de- 
 tect, 383, 387 
 tartar emetic in, 384 
 arsenicum in, 384 
 alcohol in, of old people, 384 
 individualizing in, 384 
 with spinal sclerosis, case, 385 
 infantile, physical signs in, 387 
 decline under horn, remedies, 388 
 
 Pneumonia, the expectant method in, 
 388 _ 
 
 statistics of various methods in, 388 
 
 Bennett's statistics in, 391, 392 
 
 caseous, with phthisis, 62 
 
 caseous, diagnosis of, 64 
 
 mild, case, 72 
 
 mild, ipecac, and bryonia in, 72, 
 73 
 
 mild, tartar emetic in, 72 
 
 variations of temperature in, 97 
 
 therapeutics of, 98 
 
 bryonia and phosphorus in, 98, 99 
 
 lobular, 35, 49 
 
 in the Paris hospitals, 79 
 
 puerperal, case, 393 
 
 autopsy, 394 
 
 clinical lecture on, 395, 402 
 Pneumonia at the apex of the lungr, 95 
 Positive indications, the law of, 178 
 Post-climacteric asthma, note, 142 
 
 sanguinaria in, 142 
 
 apis in, 142 
 Podophyllin in typhoid fever, 375 
 Premature paralysis in diphtheria, 465 
 Prognosis in hepatic congestion, 237 
 Progressive locomotor ataxia, 420 
 
 arg. nit. in, 420, 421, 422, 423 
 
 Dr. Pennoyer's cases of, 420, 422 
 
 Dr. Clifton's case of, 423, 426 
 
 Dr. Fellows' note on, 426 
 Progressive muscular atrophy plumb. 
 
 in, 420 
 Protox. of iron in keratitis, 259 
 Pulmonary apoplexy, 193 
 
 in hemoptysis, 180, 182, 189 
 Pulsatilla in dyspepsia, 226 
 
 in scrofulous ophthalmia, 245, 246, 
 248 
 
 in delayed menstruation, 48, 55 
 
 in rubeola, 88 
 Pulse and temperature in pelvi-peri- 
 tonitis, note, 270 
 
 in hemorrhagic variola, 461 
 Pulse, normal, in hemorrhagic variola, 
 
 461 
 Puncture of tumor in hematocele. 320, 
 
 321 
 Puerperal dyscrasia, the, in keratitis, 
 
 260 
 Puerperal hyper-thermic conditions, 
 
 note, 174 
 Puerperal pelvi-peritonitis, 291 
 
 treatment of, 292 
 
 aconite and arnica in, 292 
 
 cantharis in, 292 
 
 terebinthina in, 293 
 Puerperal pleurisy followed by phthisis, 
 12, 24, 34, 80 
 
 frequency of, 81, 82 
 
 is not puerperal fever, 82 
 
INDEX. 
 
 507 
 
 Puerperal pneumonia, case, 393 
 
 autopsy in, 394 
 
 clinical lecture on, 395, 402 
 Puerperal sepsis, note, 174 
 
 QUININE sulph. in typhoid fever, 
 492 
 
 ~D ADIAL ARTERIES, ossification 
 
 _L\j of, in aortitis, 92 
 
 Ran. bulb, in intercostal neuralgia, 
 
 52 
 Relapsing typhoid, case, 487 
 
 Thierfelder's account of, 490 
 
 Jousset's account of, 490 
 
 date of relapse, 492 
 
 epidemic of, in 1876-7, 492 
 Remedies, persistent use of, in diph- 
 theria, 474 
 
 the choice of, 157 
 
 indications for, 158, 164 
 
 illustrations of, 159, 160 
 
 fanciful indications for, 160 
 Remedy, on the suspension of the, 44 
 
 in chronic diseases, 44 
 
 when to withhold the, 45 
 
 in menstrual disorders, 46 
 Repetition of the dose, 43 
 Report of M. Devaine on Homoeopathy, 
 
 99, 100 
 Repositing the uterus in hysterical 
 
 vomiting, 49 
 Respiratory diseases and hemorrhoids, 
 
 200 
 Rheumatic endocarditis, 17, 36 
 
 cactus in, 17 
 Rheumatic endocarditis and hematu- 
 ria, 413 
 Rheumatism, 403 
 
 cases of, 403, 410, 411, 413, 416 
 
 and chronic disease, 406 
 
 with endocarditis, 406 
 
 heart- sounds in, 407 
 
 physical signs in cardiac. 408 
 
 mono-articular, case, 410 
 
 acute articular, case, 403, 411 
 
 china in, 411 
 
 hemoptysis in, 411 
 
 mitral constriction in, 411 
 
 cardiac hemoptysis, 412 
 
 millefolium in, 412 
 
 hematuria in, 413 
 
 hamamelis in, 416 
 
 spigelia in, 416 
 
 aconite in, 416 
 
 parenchymatous myelitis in, 416 
 
 spinal, 418 
 
 paraplegic, 418 
 
 plumbum in, 419 
 
 acute articular, 36, 83, 431 
 
 acute articular, case, 431 
 
 Rheumatism, acute articular, scrofula 
 in, 432, 433 
 
 acute articular, sal croisici in, 433 
 
 chin, sulph. in, 83, 84 
 
 complications and sequelae of, 84 
 Rheumatism in pelvi-peritonitis, note, 
 
 286 
 Rhodod. in intercostal neuralgia, 52 
 
 in pleurodynia, 52 
 Rhus rad. in intercostal neuralgia, 52 
 
 in eczema, 336 
 Rhus tox. and canth. in pemphigus, 28 
 Rhus tox. in eczema, 334 
 
 in sciatica, 103 
 
 in typhoid fever, 486 
 Rubeola, the remedies in, 88 
 
 aconite in, 88 
 
 Pulsatilla in, 88 
 
 ipecac, and bryonia in, 88 
 
 cuprum acet. in, 88, 89 
 Rules for choice of the attenuation, 145 
 
 SABINA in pelvi-peritonitis, 289 
 Sal croisici in articular rheuma- 
 tism, 433 
 Scanzoni's plan in vaginismus, 450 
 Scarron and the Old School, 177 
 Schmidt's expectant statistics, 100 
 Sciatica, case, 101 
 
 rhus tox. in, 102, 103 
 
 bryonia in, 102, 103 
 
 plumbum in, 103 
 
 colocynth in, note, 103 
 
 chamomilla and bell, in, 103 
 
 sulphur in, 103 
 
 nux vomica in, 104 
 
 veratrum in, 104 
 
 ledum pal. in, 104 
 Scientific frontier against empiricism, 7 
 Scrofula, 67 
 
 a constitutional affection, 67 
 
 Tessier's fixed form of, 68 
 
 in articular rheumatism, 432, 433 
 Scrofulous blepharitis, 244 
 
 conjunctivitis, 246 
 
 keratitis, 248 
 Scrofulous eczema, 327 
 Scrofulous keratitis, 427 
 
 apium virus in, 427, 429 
 
 apis not reliable in, 427 
 
 case of, 428 
 
 choice of remedies in, 429 
 
 hepar sulph. in, 429 
 
 ipecac, in, 429 
 
 atrop. sulph. locally, 430 
 
 warm water compresses, 430 
 Scrofulous kerato-conjunctivitis, case, 
 
 428 
 Scrofulous ophthalmia, 243 
 
 stages of, 244 
 
 silicea in, 245, 246 
 
508 
 
 INDEX. 
 
 Scrofulous ophthalmia, Pulsatilla in, 
 245, 246, 248 
 
 hepar sulph. in, 245, 246 
 
 mercurius in, 245 
 
 euphrasia in, 246, 248 
 
 senega in, 246 
 
 calc. carb. in, 246 
 
 digitalis in, 246 
 
 staphysagria in, 246 
 
 ipecac, in, 247, 248, 250, 251 
 
 belladonna in, 248 
 
 sulphur in, 248 
 Sea-bathing in hydrarthrosis, 438 
 
 in phthisis and chlorosis, 109 
 Secale cor. in dysentery, 70 
 Sedum acre in hemorrhoids, 208 
 Sedum acris in anal fissures, 7 
 Sedum teleph. in hemorrhoids, 208 
 Senega in scrofulous ophthalmia, 248 
 Sepia in chlorosis and phthisis, 109 
 
 in eczema, 342 
 Siiicea in scrofulous ophthalmia, 245, 
 
 246 
 Similars, the law of, and the law of 
 
 contraries, 175, 177 
 Similia, the formula of, 157, 158 
 Sims 1 first notice of vaginismus, 445 
 
 operation in vaginismus, 450 
 Small, Dr., case, gastritis, 212 
 
 on typhoid fever, 372 
 Smith, Dr. D. S., on intercostal neu- 
 ralgia, 52 
 Solids, the deglutition of, in chronic 
 
 aortitis, 129 
 Sphygmographic tracings, 19, 20, 36, 
 37, 91, 122, 125 
 
 remarks upon, 38 
 
 signs of chronic aortitis, 122 
 Spigelia in chronic aortitis, 122, 133 
 
 in rheumatism, 416 
 Spinal congestion in typhoid fever, 482, 
 
 485 
 Spinal disorders and vaginismus, 447 
 Spinal pains in typhoid fever, 485 
 Spinal rheumatism, 418 
 Spinal sclerosis with pneumonia, 385 
 Spray of lacto-pepsin in diphtheria, 477 
 Stannum in intercostal neuralgia, 52 
 Staphys. in scrofulous ophthalmia, 246 
 Statistics in pneumonia, 100, 389 
 St. Arnaud, Tessier's autopsy of. 111 
 Stohl and Huxhaui's inflammatory fe- 
 ver, 111 
 Stomach, simple ulcer of, 93 
 
 nux vom. in, 93, 94, 95 
 
 arsenic um in, 94 
 
 argentum nit. in, 94 
 
 there are medicines for the, 219 
 
 ulceration of, may be reflex, note, 
 94, 95 
 Stramonium in typhoid fever, 367 
 
 Suffocation, fits of, with hemorrhoids, 
 
 nux vomica in, 92 
 Sulphur, aggravation of cough by, 81 
 
 in chronic gastritis, 226 
 
 in dyspepsia, 226 
 
 in scrofulous ophthalmia, 248 
 
 in abscess of the cornea, 254 
 
 in hemorrhoids. 204 
 
 and nux vom. in hemorrhoids, 203 
 
 in eczema, 342 
 
 in sciatica, 103 
 Sulph. strych. in typhoid fever, 486. 487 
 Suppuration in pel vi- peritonitis, 266, 
 
 272, 273, 286 
 Syphilides, crusty, 14 
 Syphilis, 14 
 
 Symptoms, accessory, in chronic aor- 
 titis, 118 
 
 the totality of, explained, 158 
 
 TABLE of weights and measures, 
 494 
 Tardieu on mercurius corr., 69 
 Tarentula in an intermittent with 
 menorrhagia, 46. 
 in hysteria, 53, 56 
 in intermittent hypochondria, 241 
 Tartar emetic in catarrh, 34 
 
 in pneumonia, 72, 97, 388 
 Temperature and pulse in pelvi-peri- 
 
 tonitis, 270 
 Temperature in hemorrhagic variola, 
 460 
 variations of in pneumonia, 97 
 Temperatures, high, in puerperality, 
 
 note, 174 
 Terebinth, in puerperal pelvi-periton- 
 itis, 293 
 in pelvic hematocele, 320 
 in typhoid fever; 367, 486 
 Tessier, jr., performs tracheotomy, 
 
 149, 151 
 Tessier's description of meningo-en- 
 cephalitis, 377 
 fixed form of scrofula, 68 
 treatment for pneumonia. 98 
 statistics in pneumonia, 98, 99 
 trial of homoeopathy in the Paris 
 
 hospitals, 99, 100 * 
 statistics, 101 
 on chronic aortitis, 111 
 autopsv of Dupuytren and St. Ar- 
 naud, 111, 113, 114 
 version of Hahnemann's views, 6 
 Therapeutics for the sick and not for 
 the doctors, 8 
 of hemoptysis, 188 
 of pneumonia, 98 
 on certainty in, 78 
 Thermometry in typhoid fever, 350, 
 351 
 
INDEX. 
 
 509 
 
 Thlaspi bursse in metrorrhagia, 7 
 
 in irritable bladder, 7 
 
 in pelvi-peritonitis, 289 
 Thoracentesis in chronic pleurisy, 170, 
 
 173 
 Tilt's operation in vaginismus, 450 
 Totality of the symptoms explained, 
 
 i58 
 Touch and palpation in pelvi-periton- 
 itis, 270 
 Tracheotomy in croup, 149, 151 
 
 Jousset on, in 1844, 151 
 
 in diphtheria, 466 
 Transitory emphysema, 38 
 Treatment of hemorrhoids, 203 
 
 of pelvi-peritonitis, 276 
 Trillin in metrorrhagia, 41 
 
 in a harassing cough, 41 
 
 in an incidental neuralgia, 41 
 
 rare effects of, note, 41 
 Trousseau is opposed to iron in phthi- 
 sis, 108, 109 
 Trousseau's opinion of dysentery, 69 
 Tuberculous form of pelvi-peritonitis, 
 
 274 
 Tuberculosis of the larynx, 46 
 Tumor, the, in pelvi-peritonitis, 270, 
 
 271 
 Types, lorms, etc., of diphtheria, 464 
 Typhoid fever, 344 
 
 cases of, 344, 346, 356 
 
 is not gastiic or mucous. 348 
 
 differential diagnosis of, 348 
 
 the thermometer in, 349, 350, 351 
 
 complications of, 350, 354 
 
 critical days in, 352, 353 
 
 common symptoms ot, 355. 356 
 
 nece.^sity for diagnosis in, 356, 363 
 
 forms of. 360 
 
 protracted form of. 356, 359 
 
 Valleix and Chomel on, 362 
 
 treatment of, 364 
 
 muriatic acid m, 364, 365 
 
 belladonna in, 364, 367. 374 
 
 phosphoric acid in, 365, 867 
 
 bryonia in, 365, 367, 373 
 
 rhus tox. in, 365, 367. 373 
 
 bryonia and rhns in, 365 
 
 arsenicum in, 366 374 
 
 aconite in, 367, 373 
 
 ipecac, in, 367 
 
 phosphorus in. 367, 374 
 
 terebinth, in. 367 
 
 opium in, 367 
 
 hyoscyamus in, 367 
 
 stramonium in. 367 
 
 nitric acid in, 367 
 
 hamamelis in. 367 
 
 china in, 367, 375 , 
 
 ledum pal. in, 367 
 
 erecthites in, 367 
 
 Typhoid fever, nux vomica in, 367. 375 
 chin, sulph. in, 367, 369, 370 
 condition of bowels in, 368 
 baptisia tinct. in, 368, 374 
 diet in, 371 
 drinks in, 372 
 
 Dr. Small's experience in, 372 
 gel semi um in, 375 
 mercurius viv. in, 375 
 podophyllin in, 375 
 eupatorium perf. in, 375 
 meningoencephalitis in, 376 
 albuminuria in, 478 
 cases of, 479, 482 
 albuminous anasarca in, 479 
 intestinal hemorrhage in, 479 
 parotitis in, 479 
 
 parenchymatous nephritis in, 482 
 spinal congestion in, 482, 485 
 spmal pains in, 485 
 diurnal temperature in, 485, 486 
 hematuria in, 485 
 terebinthina in, 486 
 phosphorus in, 486 
 pernicious paroxysms in, 491 
 arsenicum in, 486 
 sulph. of strych. in, 486, 487 
 china in, 486 
 rhus tox. in, 486 
 phosphoric acid in, 486 
 spinal meninges, congestion of, 487 
 alias acute phthisis, 107 
 ars. in, 107, 108 
 case of, 134 
 
 alvine and urinary, arrest in, 135 
 a mild type of, 41 
 and its abortion, 42 
 • an eruptive disease, 42 
 relapsing type of, 487 
 
 ULCER, simple, of the stomach, 
 93 
 may be reflex, note, 94, 95 
 Uterine fibroids, argentum oxy-dat. 
 in, 41 
 trillin in, 41 
 Uterine disorders, mineral remedies in. 
 433 
 epistaxis in hemorrhagic variola, 
 454 
 Uterus reposit, the, in hysterical vom- 
 iting, 49 
 
 VACCINATION modifies variola, 
 452 
 Vaginismus, 445 
 
 cases of, 448, 451 
 
 Huguier's first description of, 445 
 
 Pinel-Grandechamp's do. 446 
 
 Michon's do. 446 
 
 Visca's memoir upon, 446 
 
510 
 
 INDEX. 
 
 Vaginismus, Sims' first notice of, 
 445 
 
 linked with hysteria, 447 
 
 linked with spinal disorders, 447 
 
 with hemorrhoids, 447 
 
 causes of, 447 
 
 symptoms of, 447 
 
 following- labor. 449 
 
 treatment of, 449, 450 
 
 remedies in, 449 
 
 Jahr, on, 449 
 
 ovarian irritation in, 447, 450 
 
 plumbum in, 450 
 
 dilatation in, 450 
 
 incisions in, 450 
 
 Burns' operation in, 450 
 
 Sims' operation in, 450 
 
 Tilt's operation in, 450 
 
 Scanzoni's operation in, 450 
 Valleix and Chomel on typhoid fever, 
 
 362 
 Valleix, Jousset's criticism of, 100 
 Valleix's critique on Tessier's statis- 
 tics-, 100 
 Variola hemorrhagic, cases of, 453, 
 459 
 
 Vegetable diet in phthisis, the, 151, 
 155, 156, 157, 264 
 
 explained, the, 153 
 
 contra-indications, for, 153 
 
 how does it act? 155 
 
 prejudices against, 156 
 
 in phthisis, 26, 39 
 Veratrum alb., in dysentery, note, 71 
 Veratrum, in sciatica, 104 
 
 in gastralgia, 227 
 Vienna statistics on homoeopathy, 100 
 Vilas on atroph. sulph. locally, 430 
 Viola tricolor in eczema, 338, 339, 340 
 Virchow on deposits in aortitis, 113 
 
 on hemorrhoids, 199 
 Visca's memoir on vaginismus, 446 
 Vomiting in hemorrhagic variola, 459 
 
 in hysteria, 46 
 
 "TTT ARM CLIMATES, hemorrhoids 
 
 VV in, note, 199 
 Warm water locally in scrofulous ke- 
 ratitis, 430 
 White swelling, 40 
 argentum in, 40 
 diagnosis from hydrarthrosis, 435 
 
 
 


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