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G. A. ZACHARIN. 
 
CLINICAL LECTURES 
 
 DELIVERED BEFORE THE STUDENTS 
 
 OF THE 
 
 IMPERIAL MOSCOW UNIVERSITY 
 
 BY 
 
 G. A. ZACHARIN, M.D. 
 
 Late Professor cEaieritus) of Clinical Medicine and Director of the Therapeutical 
 
 Faculty Clinic of the Imperial Moscow University, Honorary Member of 
 
 the Imperial Academy of Sciences at St. Petersburg 
 
 TRANSLATED FROM THE FIFTH RUSSIAN EDITION 
 
 BY 
 
 ALEXANDER ROVINSKY, M.D. 
 
 Member of the Massachusetts Medical Society 
 
 BOSTON 
 
 DAMRELL & UPHAM 
 
 1899 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/clinicallecturesOOzakh 
 
PREFACE. 
 
 It is tlie purpose of these lectures to serve, as far as it is pos- 
 sible to do so in print, the same aims as are pursued by clinical 
 mstruction, namely : by proceeding from the picture of the mor- 
 bid condition as it presents itself in the patient and as obtained 
 by interrogation, physical examination and from the collected 
 data concerning his past, to diagnosticate this morbid state, in 
 whatever peculiar and complex form it may appear, to prescribe 
 a plan of treatment for the same, and to execute this plan 
 before and with the participation of the students. In rela- 
 tion to these last and to the practising physician, the clinical 
 lecture is also intended to serve as a specimen of methodical 
 practical activity, "teaching the processes of interrogation, 
 diagnosis, treatment and observation of the given disease or 
 of the given class of diseases." Aiming first of all to make 
 of his students practical physicians, the clinical instructor 
 should offer to the future practitioners only w^hat is essential, 
 preeminently practical and absolutely requisite : methods of 
 doubtful utility, whether of diagnosis or treatment, unneces- 
 sary superfluity of details and supposititious theorizing, have 
 no place in the teaching of the true, conscientious clinician. 
 The printed clinical lecture is distinguished by the same 
 characteristics. 
 
 The following reasons induced the author to devote to the 
 first case a much greater number of pages (35—120) than to 
 any other: being the first case presented, it required ipso facto 
 a detailed circumstantial analysis — as regards both diagnosis 
 and treatment — and observation to the very end ; it was. 
 moreover, a complex case, presenting a combination of various 
 morbid conditions ; further, the space was largely devoted to 
 the mmeral waters, a subject of great importance in thera- 
 
IT 
 
 peutics, which is unfortunately very little appreciated or 
 even entirely neglected in the United States. The reader 
 will find these reasons more fully explained by the author 
 in his " Introduction to Clinical Exercises." 
 
 I have followed the author's original intention (as explained 
 by him in the preface to the Russian edition) of omitting to 
 designate at the head of each lecture the particular diagnosis 
 of the disease under discussion. This is but in conformity 
 with the general character of the work, which aims to be as 
 like a lecture, or rather a demonstration, in the clinic, as 
 possible. Says the author in his preface : " The clinical in- 
 structor, on presenting a patient before his class, does not 
 announce the diagnosis of the morbid affection at once, but 
 gradually unfolds it, as it were, in an evolutionary manner. 
 If he were to announce the diagnosis at the beginning, and 
 then proceed to examine the patient, he would only be proving 
 a known proposition, instead of finding the unknown ; whereas 
 his students, as future physicians, will always have to find the 
 unknown, which will demand solution. . . . Moreover, to an- 
 nounce the diagnosis beforehand, thus giving the solution of 
 the problem, would deprive the student of that mental stimu- 
 lus, which spurs him on to seek for the solution." For the 
 convenience of the reader I have marked the diagnosis of the 
 cases in the list of contents, and have compiled an index of the 
 same. 
 
 As regards the method of examination adopted by the 
 author, the reader will find a detailed description of it in 
 the author's Introduction. It is only necessary for me to 
 state briefly the following : with the great progress of recent 
 years in all the domains of the healing art, the various and 
 rapidly increasmg methods of what is known as physical ex- 
 amination have driven farther and farther into the background 
 the individuality of the patient himself ; we are threatened 
 with the approach of a period in medicine, when diseases will 
 be treated per se, as such, without any regard to the charac- 
 teristic peculiarities of the patient afilicted by them. It is 
 a well-known fact, that one and the same disease will take 
 on different forms in different individuals, all departing more 
 
or less from the type, though similar to it in the essentials. 
 It is, therefore, necessary to become acquainted with the per- 
 sonality of the patient as thoroughly as possible, or, in other 
 words, we must individualize each and every case. A syste- 
 matic examination by inquiry, i. e. mterrogation conducted ac- 
 cording to a certain method, is the only means that will enable 
 us to obtain a true and reliable insight into the characteristic 
 peculiarities of the patient, which cannot be obtained by anj^ 
 means offered to us by the so-called physical methods of 
 examination. This will frequently enable us to distinctly fix 
 the setiology of the disease (by interrogating the patient on 
 his condition and mode of living), and greatly assist in arriving 
 at a general as well as a minutely particular diagnosis ; it will 
 often also supply us with valuable material for treatment. 
 This method of interrogation, which, as fulh' worked out by 
 the author in his Introduction, was highly praised (and also 
 adopted by many prominent clinical teachers) by the well- 
 known French clinician Henri Huchard,* is by no means a 
 mechanical putting together of various facts, out of the sum- 
 mary of which a sort of mathematical deduction is made 
 forming the diagnosis ; it is, on the contrary, " an active, 
 searching condition of mind " : for while the facts are being 
 collected, they are at the same time classified in the interroga- 
 tor's mind, and the diagnosis is being evolved, so that by the 
 time the data are fully collected, the diagnosis either formu- 
 lates itself in the mind, or is easily formulated. It is true 
 that the process of interrogating the patient will be in the 
 beginnmg somewhat slow and laborious ; however, once ac- 
 quired, the practitioner will need but little time for mterrogat- 
 ing his patient in as thorough a manner as the case may re- 
 quire. He will also soon be able to distinguish from among 
 the data communicated to him by the patient, the necessary 
 from the superfluous ones. There are, moreover, cases, as 
 those of neurasthenia, hysteria, and the like, in which inter- 
 rogation is the only means by the aid of which we may hope 
 
 * He calls the chief characteristic of Zacharin's school " rinterroga- 
 toire, qui ent eleve () I'hauteur d'un art '' (Expose de V Enaeignement clinique, 
 par Zakharine, Introduction par Henri Huchard, p. 3, Paris, 1891). 
 
to reach any diagnostic conclusions, for in these affections 
 physical methods of examination play but a subordinate role. 
 It is at the same time self-understood that we must avoid 
 extremes in either relying altogether on interrogation to the 
 neglect of physical methods of examination, or in allowing 
 these last to entirely overshadow or exclude the interrogatory 
 examination; a judicious combination of the two is a sine qua 
 non of a successful diagnosis and treatment. 
 
 The author of these lectures, Gregory Antonovitch Zacha- 
 rin, was connected, in the capacity of instructor and professor, 
 with the Medical Department of the Imperial Moscow Univer- 
 sity for a period extending over thirty-five years (1861-1896).* 
 A man of indomitable energy and very pronounced individu- 
 ality, he is considered as the founder of what is known in the 
 Russian medical world as the Zacharin school of practical 
 medicine (we touched above on some of the prominent charac- 
 teristics of this school), in whose tenets were brought up 
 several generations of physicians scattered in every nook and 
 corner of the Great Empire. He came of a poor, but very old 
 family of nobility, and was compelled from his early student- 
 years to struggle with want and privation ; but thanks to the 
 possession of an iron will and unswerving determination, he 
 rose to a position equal to that occupied by Botkin and Piro- 
 goff, the greatest medical minds of Russia. It may be truly 
 said that Pirogoff, Botkin and Zacharin form the great triad of 
 Russian clinical medicine of the nineteenth century. 
 
 Zacharin's most pronounced characteristic trait was probably 
 his independence. " The physician should be independent, 
 even more so than the poet or the artist, for to him we entrust 
 our most valuable possession, namely, our health, our very 
 life " ; and for the practical realization of this ideal he struggled 
 unremittingly his whole life. Being a leader of men, his stand 
 has greatly contributed to the elevation of the name and the 
 position of the medical profession in Russia. To form an ap- 
 
 * His death, which occurred January 5, 1898, just when this translation 
 was being completed, delayed its appeai'ance until now. 
 
proximate idea of those obstacles which Zacharin had to over- 
 come in establishing for himself and for his calling an indepen- 
 dent, respected social position, it will suffice to introduce here 
 the following few sentences from the address delivered by Prof. 
 Sneguireff at the Zacharin Memorial Meeting of the Moscow 
 Physio-Medical Society : 
 
 " We all remember the time when the physician was not 
 allowed to sit down in the presence of his social superiors, how 
 some of us were only allowed to treat serfs or servants, how 
 others served on the gentlemen and the ladies, appearing every 
 morning to inquire after their 'graces" health, for which they 
 were paid by occasional gifts of flour, grain, fowls, etc, ; a phy- 
 sician was considered as an accessory to the rich household, 
 never as a necessity, and his labor, advice and time as trifling 
 and superfluous." 
 
 Zacharin may justly be called a public hygienist, for he first 
 of all insisted, and very rigidly at that, on the necessary changes 
 in the patient's mode of life and surroundings, if any cure was 
 to be obtained at all. In this regard his minute and precisely 
 given instructions were not to be trifled with, and " Zacharin 
 said so ! " was a dictum not to be lightly disobeyed by his pa- 
 tients, whom he always took the trouble to personally instruct 
 minutely in individual hygiene. As his personal practice was 
 very extensive and his followers numerous, we can easily ap- 
 preciate the influence of such instructions on the health of so- 
 ciety at large. 
 
 He was a true therapist and a staunch believer in remedial 
 agencies and their efficiency. It is said, that at his death-bed, 
 when the question of consultation was being discussed (he died 
 of acute bulbar paralysis caused by haemorrhage into the me- 
 dulla oblongata, which was early diagnosed by himself), he ob- 
 served quietly, but firmly : " Why consultations ? Have you 
 not done all in your power ? You have cleared the bowels, ap- 
 plied leeches and Spanish flies, and administered bromides : 
 therapy has done everything ; the rest is beyond our power." 
 
 Although laconic, concise and precise in examining a pa- 
 tient, he would sometimes spend two or even three hours of 
 closest scrutiny and inquir3% thus forming in his mind a per- 
 
fectly clear and distinct picture of the patient's condition and 
 Kis surroundings, and thanks to his phenomenal memory this 
 picture was stored up in his mental reservoir, to be sometimes 
 called up in its entirety before the astonished patient after five 
 or six years, thus inducing the latter to repose implicit confi- 
 dence in his knowledge and skill. Besides being a great teacher 
 (he was uninterruptedly professor at the University until 1896, 
 when he was compelled to resign for reasons into which we 
 cannot enter here), he was also instrumental in assisting the 
 establishment of various special clinics, and especially the one 
 in gynaecology. 
 
 He was the attendant physician to the late Emperor Alexan- 
 der III in his fatal illness — acute interstitial nephritis. 
 
 Some time before his death Zacharin donated one quarter 
 million dollars (one half million roubles) for the parochial 
 schools in Russia. 
 
 I take here the opportunity to express my gratitude to Mme. 
 E. P. Zacharin and to Prof. N. Th. Golouboff, of the Imperial 
 Moscow University, whose valuable information and advice 
 have greatly aided me in my work. 
 
 These lectures, which in the original passed through five edi- 
 tions in the period of a few years, were partly translated into 
 both German (^Klinisehe Ahhandlungen : iiber den klinischen Un- 
 terricht, die Oalomel-Therapie, etc. Von Prof. Dr. G. Sacharjin. 
 Berlin, 1890, August Hirschwald; and KUnische Vortrdge, 1892, 
 same publisher) and French (^U Expose de V Enseignement eli- 
 nique, par Zakharine, avec une Introduction par Henri Huchard. 
 Paris, 1891, O. Doin, editeur; and Legons cliniques sur les Ma- 
 ladies ahdominales^ etc., traduit de la deuxieme edition russe par 
 le Dr. Oelsnitz (de Nice), 1893. Same publisher, also preface 
 by H. Huchard). 
 
 Alexaintder RovEsrsKY, M. D. 
 
 Boston, Mass., U.S.A., January, 1899. 
 
CONTENTS. 
 
 Preface, iii. 
 
 INTRODUCTION^ TO cli:nical EXEECISES. 
 
 (thkee lecttjkes.) 
 
 The importance of the clinic in medical education, 1 ; clinical exercises in 
 their relation to medical education, 2 ; the necessary requisites of clini- 
 cal instruction : a regular method and a system of individualization, 
 3; varieties of clinics : conforming to the grades of medical studies, 
 3, 4; by their contents; the general clinic, 4: the character of its 
 content and its principal aims, 5, 6; the scope of clinical exercises. 6; 
 examination of the patient, 7; examination embraces status prsesens 
 and anamnesis, 8; status prsesens consists of interrogation and objec- 
 tive examination, 8, 9; interrogation about the patient's mode of liv- 
 ing, 9, 10 ; interrogation about patient's condition conducted according 
 to an adopted plan, embracing : appetite and thirst, the tongue, teeth, 
 etc., 10; circumstantial inquiry necessary regarding the condition of 
 the evacuations, 11 ; the anus ; the urinary bladder, male genital or- 
 gans; history of syphilis, and so on, 12-16; Anamnesis, also parents' 
 health, 17; Objective examination, VJ ; avoid unnecessary minuteness 
 and supei-fluity of details, 17, 18; tact a requisite, 18; Diagnosis: how 
 arrived at, 18; diagnosis of the disease (diagnosis morbi), of the pa- 
 tient (diagnosis segri), and differential diagnosis (diagnosis per exclu- 
 sionem), 19; Prognosis: its importance in the hospital as compared 
 with that in private practice, 19; as regards the i^atient, 20, 21 ; as re- 
 gards the patient's relatives, 21; conciseness in wording a prognosis: 
 not serious, serious, dangerous and hopeless, 22; Treatment : method 
 and a system of individualization necessary, 22; therapeutic nihilism 
 and undue enthusiasm for certain drugs; neglect of hygienic treat- 
 ment, 23; simultaneous emj)loyment of many drugs to be avoided, 
 24; characteristics of hospital therapy, 2.5; observations of the course 
 of the malady, 26; the making up of deficiencies in the students'' knowl- 
 edge, 26; importance of autopsies, 27; the importance of the clinic in 
 scientific medicine, 27, 28; the duties of the clinical instructor: dis- 
 eases taken up in order for clinical instruction, 28, 29 ; participation 
 of students in the clinical exercises, 26, 30; duties of clinical assist- 
 ants, :30 ; business of students: to conduct the history of the disease, 
 and the description of the same; service in the clinic, 30, 31. 
 
CLINICAL LECTURES. 
 
 ABDOMINAL DISEASES AND FUNCTIONAL DISTURBANCES OF 
 
 THE NERVOUS SYSTEM. — THE INTERNAL USE OF 
 
 MINERAL WATERS. 
 
 FiKST Case. — Chronic gastro-intestinal catarrh, biliary calculi, renal 
 colic, oxaluria, probably movable kidney, Kseconclary nervous disturb- 
 ances, etc., 35-121. 
 
 Anamnesis, 40, 41 ; Course of disease, 37-40, 45, 55, 66, 81, 97, 117, 
 120, 121 ; Diagnosis, 55-5S, 60, 67-69, 70, 72; Diet, 37, 74, 75, 78, 81, 98; 
 Hygiene, 43, 73, 74; Mode of living, 35, 36; Objective examination, 45- 
 49; Prognosis, 73; Treatment, 37, 45, 50-54, 67, 78-80, 82, 98, 117-120. 
 
 The internal use of mineral waters: sodium bicarbonate and 
 chloride in various catarrhal conditions, 86; the unreplaceability of 
 the natural mineral waters by artificial ones, 87; the use of mineral 
 waters at every season of the year, 83; the action of the curative 
 agencies of the mineral waters: water, carbonic acid, bicarbonate and 
 chloride of sodivim, laxative salts, 90-92. 
 
 Table of mineral watei'S, 93; Ems, 94; Franzensbad, Kissingen, 
 Karlsbad, Vichy, 95; Yessentucki, Obersalzbrunnen, 96, 97; Marien- 
 bad, 95, 99-101 ; compared to Ems, 101 ; compared to Vichy, 102 ; to Kis- 
 singen, 103; to Karlsbad, 102-104; Franzensbad Salzquelle, 104; indica- 
 tions for Vichy, 104, 105; for Yessentucki, 105; Contrex(^ville, 97, 106. 
 
 The reliability of the combinations of remedial agencies, as con- 
 tained in the mineral waters, 107; the routine method of drinking 
 the waters at the resorts, 109, 110; the quantity of the daily dose de- 
 pending on the effect desired — Ems, Obersalzbrunnen, Vichy, 111, 
 112; Yessentucki and Karlsbad, 112, 113; Marienbad, Kissingen, 113; 
 the length of the coarse of treatment, 113, 114; the distribution of 
 the quantity of the water over the course of the day, 114; as regards 
 meals, 114, 115; indications for cold and warm waters, 115; the diet 
 while drinking the waters, 115, 116; contraindications to the use of 
 waters, 116, 117. 
 
 Second Case. — Clironic gastric catarrh, gastric ulcer, nervous dyspepsia, 
 dilatation of the stomach, 122-138. 
 
 Anamnesis, 123, 124; Course of the disease, 125, 126, 138; Diag- 
 nosis, 127. 128; differential, 129; Diet, 124, 125, 138; Mode of living, 
 122, 123 ; Objective examination, 126, 127 ; Prognosis, 130 ; Treatment, 
 124. 1:30-132. 
 
 Gastric lavage: effects of, 132, 133; indications for, 133; not an 
 indifferent procedure, 133; mistaken employment of lavage, 134; typ- 
 ical cases in which it fails, 134, 135 ; wrongly applied, 136, 137. 
 
 Thikd Case. — Nervous dyspepsia, 139-155. 
 
 Anamnesis, 139, 140 ; Course of disease, 140-142, 144, 154, 155 ; 
 Diagnosis, 143; Diet, 142; Hygiene, 145, 146: Mode of living, 139; Ob- 
 jective examination, 141 ; Prognosis, 144, 145 ; Treatment, 140, 142, 
 143, 14.5-149, 154, 1.55. 
 
Varieties of gastro-intestinal disorders in neurasthenia, 149; diet 
 in nei'vous dyspepsia, 149, 150; treatment of constipation, 152, 154; 
 douclies, massage, etc., in nervous dyspepsia, 151; drugs, 151, 152; 
 the various laxatives, 152, 153 ; clysters, 153, 154. 
 
 FoTJKTH Case. — Atrophic gastric catarrh, cancer of the duodenum, 156- 
 161. 
 
 Anamnesis and mode of living, 156, 157; Autopsy, 160; Course of 
 disease, 157, 158; Diagnosis, 158; differential, 159, 160; Objective ex- 
 amination, 157; Treatment, 158, 160. 
 
 Fifth Case. — Cancer of the pancreas, 162-165. 
 
 Anamnesis and mode of living, 162 ; Autopsy, 165 ; Course of dis- 
 ease, 163, 165; Diagnosis, differential, 163, 164; Prognosis, 164; Treat- 
 ment, 163, 164. 
 
 Sixth Case. — Biliary calculi and cholangitis, 166-181. 
 
 Anamnesis and mode of living, 166, 167; Course of disease, 168, 
 175, 177, 178; Diagnosis, 168, 169, 171, 174; Objective examination, 
 168; Prognosis, 176; Treatment, 167, 176-181. 
 
 Biliary calculi : cause of formation, 169, 170, 176 ; relation to neu- 
 ralgia of the hepatic plexus, 171, 173, 174 ; differential diagnosis, 172, 
 173 ; symptoms aggravated at the beginning of treatment with Karls- 
 bad, 175 ; duration of course of treatment, 179, 180. 
 
 Seven^th Case. — Hypertrophic venous cirrhosis and cholangitis, 182-192. 
 Anamnesis and mode of living, 182, 183 ; Course of disease, 183, 
 184, 192 ; Diagnosis, 185, 186 ; differential, 187, 188, 190 ; Objective ex- 
 amination, 184-186 ; Prognosis, 191, 192 ; Treatment, 183, 184, 191, 192. 
 Hepatic diseases: differential diagnostication necessary, 187 ; na- 
 ture of the various cirrhoses of the liver, 188, 189 ; clinical data con- 
 cerning same, 189, 190. 
 
 Eighth Case. — Biliary calculi, cholangitis and slight hypertrophic bil- 
 iary cirrhosis, 193-196. 
 
 Anamnesis and mode of living, 193 ; Course of disease, 193, 194, 
 JL95 ; Diagnosis, 194; Objective examination, 194; Prognosis, 194; 
 Treatment, 195. 196. 
 
 Ninth Case. — Echinococcus cyst of the liver, slight peritonitis, 197-201. 
 Anamnesis and mode of living, 197, 198 ; Course of disease, 198, 
 200 ; Diagnosis, 198, 199 ; Objective examination, 198 ; Prognosis, 199 ; 
 Treatment, 199, 200. 
 
 Tenth Case. —Syphilis of the liver, 202-208. 
 
 Anamnesis and mode of living, 202 ; Course of disease, 202, 203, 
 206, 207, 208; Diagnosis, 203, 204, 205; Objective examination, 203; 
 Prognosis, 205 ; Treatment, 205, 206, 208. 
 
RHEUMATISM AND GOUT. 
 Eleventh Case. — Acute articular rheumatism, 209-214. 
 
 Anamnesis and mode of living, 207 ; Course of disease, 209, 210, 
 211,214; Diagnosis, 210 ; Prognosis, 210; Treatment, 209. 210, 211, 212. 
 
 Acute articular rheumatism an infectious disease, 212 ; its rela- 
 tion to gout, 213, 214. 
 
 Twelfth Case. — Polyarthritis chronica (chronic articular rheumatism)' 
 and predisposition to gout, 215-224. 
 
 Anamnesis and mode of living, 215 ; Course of disease, 216, 221, 
 223 ; Diagnosis, 216, 217; Prognosis, 222; Treatment, 222, 223. 
 
 The inapplicability of the term chronic articular rheumatism, 
 necessity for precise nomenclature, 217-219 ; nature of affections em- 
 braced under the current name of chronic rheumatism, 219, 220 ; 
 change of term recommended, 221. 
 
 Thibteexth Case. — ^Gout (arthritis urica), 224-230, 
 
 Anamnesis and mode of living, 224, 225 ; Course of disease, 225, 
 226,229,230; Diagnosis. 226 ; differential, 227; Prognosis, 227; Treat- 
 ment, 225, 226, 227, 228, 229, 230. 
 
 Fourteenth Case. — -Gout, nephrolithiasis, biliary calculi, fatty liver, 
 etc., 231-236. 
 
 Anamnesis and mode of living, 231,232; Course of disease, 231, 
 2132, 233, 234, 235, 236; Diagnosis, 2:33, 234, 235; Prognosis, 235; Treat- 
 ment, 235, 236. 
 
 DISEASES OF THE KIDNEYS. 
 Fifteenth and Sixteenth Cases,* 237-247. 
 
 Fifteenth Case. — -Chronic interstitial nephritis. 
 Anamnesis and mode of living, 236; Course of disease, 238, 247; 
 Diagnosis, 244, 245: Prognosis, 245; Treatment, 246. 
 
 Sixteenth Case. — ^Parenchymatous nephritis. 
 
 Anamnesis and mode of living, 238, 239; Course of disease, 239, 
 240, 241, 242, 247; Diagnosis, 245; Prognosis, 245; Treatment, 239, 
 240, 246. 
 
 Nature of chronic nephritis, 242 ; symptoms of the interstitial as 
 compared with the parenchymatous variety, 242, 243; prognosis of 
 either variety, 243, 244; course of, 243, 244. 
 
 ANiEMI^. 
 SEVENTEE>fTH Case. — Clilorosis, 248-257. 
 
 Anamnesis and mode of living, 24S; Course of disease, 248, 249; 
 Diagnosis, 249; differential, 249, 250; Prognosis, 253,254; Treatment, 
 254-257. 
 
 * Erratum on p. 237 : Should be fifteenth and Bixtoenth cases, instead of six- 
 teenth and seventeenth. 
 
Chlorosis : unsatisfactory classification of, in the text-books, 250, 
 251 ; the nervous system in relation to chlorosis, 251, 252; sexual ma- 
 turity in relation to chlorosis, 252 : Brown-Sequard's theory, 252; hae- 
 moglobin in chlorosis, 253 ; hysteria and chlorosis, 253 ; iron and ar- 
 senic in chlorosis, 255, 256; treatment of constipation in chlorosis, 
 256 ; of the nervous system, 257. 
 
 Eighteenth Case. • — ChloranaBniia and inciijient pulmonary tuberculosis, 
 258-262. 
 
 Anamnesis and mode of living, 2.58, 259; Course of disease, 2-59, 
 262 ; Diagnosis, 260, 261 ; Objective examination, 259 ; Prognosis. 261 ; 
 Treatment, 261, 262. 
 
 THORACIC AND INFECTIOUS DISEASES. 
 
 Nii^ETEENTH Case. — Tuberculous pleurisy, 263-273. 
 
 Anamnesis and mode of living, 263,264; Course of disease, 264, 
 270,271,272; Diagnosis, 265, 236; Objective examination, 264; Prog- 
 nosis, 266 ; Treatment, 264, 270, 271, 272, 273. 
 
 Pleurisy: Eichhorst's treatment, 267; author's treatment, 267, 
 268; treatment of the fever with antipyretics and with calomel, 268, 
 269; to further absorption of exudations, 269, 270. 
 
 Twentieth and Twenty- first Cases, 27'4-283. 
 
 Twentieth Case. — Chronic pulmonary tuberculosis. 
 Anamnesis and mode of living, 274, 275 ; Course of disease. 275, 
 276, 278, 281, 282; Diagnosis, 277, 278, 280, 231 ; Objective examination, 
 276; Prognosis, 276 ; Treatment, 275. 
 
 Twenty-first Case. — Chronic tubercular broncho-pneumonia and 
 chronic bronchial catarrh. 
 
 Anamnesis and mode of living, 278, 279 ; Course of disease, 279, 
 230, 232, 283; Diagnosis, 282; Objective examination, 280; Prognosis, 
 289 ; Treatment, 279, 282, 283. 
 
 How the invasion of the lungs by tuberculosis takes i^lace, 277. 
 
 GrSNEKAL REMARKS CONCEENING THE DIAGNOSIS OF CHRONIC TUBER- 
 CULOSIS OF THE Lungs, 283-290. — Varieties of chronic tuberculosis 
 and their complications, 284; pulmonary phthisis as compared with 
 incipient tuberculosis, 285; the nature and cause of the hectic fever, 
 2!i5, 286; pneumoniae complicating chronic pulmonary tuberculosis: 
 croupous, 286; catarrhal and caseous, 287; galloping phthisis, 287, 
 288: acute miliary tuberculosis, 288; peculiarities in the course of 
 tuberculosis depending on the nature of the organs affected, 288. 
 2S9; prognosis of tuberculosis pulnionum, 239, 290. 
 
 Treatment of Chronic Pulmonary Tuberculosis, 200-298. 
 
 Definition of a speciJic remedy, 291; symptomatic treatment: 
 haemoptysis, 291, 292; fever, 292; employment of koumyss, 292, 293; 
 kourayss sanatoria, 294; cod-liver oil, keffir, etc., 294; arsenic, 295; 
 creosote, guaiacol and guaiacol carbonate, 295, 296, 297; the last 
 stage, 297; modern bacteriology in its relation to the ti-eatment of 
 tuberculosis, 297, 298. 
 
The Climatic Treat.mbn't of Chkoxic Pulmon^ary TtiBEBCULOsia, 
 298-316. 
 
 ^feglect of the subject, 293 ; climate in relation to climatic therapy, 
 298, 299; the complexity of climatic influences, 299; Webber's classi- 
 fication of climates, 299. 
 
 The Elements of Climate, 300-303. — The temperature, 300; sun- 
 light, air, etc., 300-303. 
 
 Former climatic treatment of tuberculosis, 303 ; by residence in 
 the mountains, 303, 304; the supposed curative agencies of high 
 altitudes, 304; Brehmer and his sanatorium at Gorbersdorf, 304, 305; 
 his theories and their refutation; his success, 305, 306; Davos as 
 compared with Gorbersdorf and other sanatoria, 303, 307; change in 
 the climatic treatment of tuberculosis, 307; Russia as compared 
 vrith Western Europe as a resort for tuberculous patients, 308, 309; 
 climatic treatment at home : cases illustrating same, 309-315 ; cases 
 for which trips are indicated, 316. 
 
 TwEXTY-SECOND Case. — -Croupous pneumonia, 317-324. 
 
 Anamnesis and mode of living, 317 ; Course of disease, 318, 323, 
 324; Diagnosis, 318; differential, 319; Objective examination, 318; 
 Prognosis, 319; Treatment, 320, 323, 324. 
 
 Treatment of high temperature in pneumonia, 320, 321 ; of dysp- 
 noea, pains and cough, 321, 322, 323. 
 
 A Few Notes on Objective Examination, 325-331. — The importance 
 of morbid symptoms in semiotics, as compared to those necessary for 
 diagnosis, 325 ; their necessary differentiation, 326 ; the nature of the 
 vesicular respiratory murmur, 327 ; of the bronchial respiratory mur- 
 mur, 327; the indefinite respiratory murmur, rough breathing, 327, 
 328; varieties of rales, 328, 329; the percussion sound, 329; determi- 
 nation of dimensions of heart, liver and spleen, 329, 330; the pulse, 
 330, 331. 
 
 ELEMENTS OF BALNEOTHERAPY. 
 
 Balneotherapy for the Practical Physician, 332-355. 
 
 Necessity for clinical individualization of balneotherapy, 332, 
 333 ; the differences in the external and internal employment of min- 
 eral waters, 333; the effect of the temperature of the water, 335-338; 
 effects of the component parts of the waters: sodium chloride and 
 carbonate, carbonic acid, sulphur, organic acids, etc., 338, 339; the 
 effect of mechanical influences during the external employment of 
 mineral waters, 339; the various classes of waters: 1. the chemically 
 indifferent, their effects and use (Schlangenbad, Ragatz, Gasteiu, etc.), 
 340; individualization necessary in their employment, 340; mineral 
 moor, 341, 342; the influence of climate at the watering-ijlaces, 342; 
 conditions of life there, 343; 2. salt loaters, their use and effects, 
 (Kreutznach, Wiesbaden, Soden, Ischl, Gmunden, Reichenhall, etc.), 
 343, 344; 3. carbonated waters, indications for employment, 345; 4. 
 salt waters which are at the same time carbonated, 345 ; 5. mineral muds 
 employed in the form of mud-baths, indication for use in diseases of 
 women, :?45, 346; mineral muds employed directly as such, 346; sea- 
 
bathing, its effective agencies, 346, 347; hot-air baths, fir-tree baths, 
 347; hydrotherapy, modes and effects of application, 347, 348; half- 
 baths, rubbings, etc., 349; possibility of balneotherapeutic treatment 
 at home, 349; the Russian bath, 349, 350; seasons of the year for 
 balneotherapeutic treatment, duration of course of same, 350; out- 
 line of the diseases in which balneotherapy is employed, ;350-355. 
 
 CHOLERA, PARTICULARLY ITS TREATMENT. 
 
 Pages 356-384. 
 Introductory notes, 356, 357; the nature of cholera, 358; the former clas- 
 sification of infectious diseases and its unreliability at the present 
 time, 358, 359; the three important factors in the development of a 
 cholera epidemic, 359; Pettenkofer's theories concerning the influ- 
 ence of the soil-water, 359; Hueppe's investigations as to the spread 
 of the epidemic in Hamburg, 360; Koch's failure to recognize the im- 
 portance of the surrounding conditions of life, 361 ; Huepi^e's theories 
 concerning the influence of the intestinal tract on the growth of the 
 bacteria, 361,362; the unreliability of experimentation, 362; occur- 
 rence of cholera among washerwomen, 362; the basis for considering 
 cholera as a contagious disease, 362, 363; varieties and course of the 
 disease: choleraic diarrhoea, cholerine, 363, 364; genuine cholera, 
 symptomatology, 364, 365; causation of the algid stage, 365, 366, 1367; 
 reaction period and its attendant disturbances, 367, 368; preventive 
 measures: quarantine in Europe and Asia, 368, 369; over the Suez 
 Canal, 369; the individual quarantining of patients, 369, 370; disin- 
 fective measures, 370; supervision over arrivals, 370, 371; the results 
 of these measures in various parts of Russia during the recent cholera 
 epidemic, 371; the individual measures of precaution, 371, 372; the 
 treatment: the unreliability of statistics as regards the value of the 
 various methods of treatment, 372, 373; absence of any specific, 373, 
 374; the necessity for distinguishing the symptomatic from the rou- 
 tine treatment, 374 ; treatment of diarrhoea : its varieties, 375 ; laxatives, 
 376 ; calomel not an " anti-choleraic " remedy, 376, 377 ; opium in diar- 
 rhoea and the reasons for its employment, 377, 378; bismuth, clysters, 
 etc., 379, 380; Cantani's treatment of choleraic diarrhoea, 380; effect 
 of enteroclysmata. 380, 381 : warm baths, etC/, 381 ; treatment of chol- 
 erine, 381, 382; of the algid stage of cholera proper, 382,383; of the 
 reaction period, 383, 384; nature of cholera nostras, 384. 
 
 SUPPLEMENTS. 
 
 Ox Bloodletting, 387-406. 
 
 The recent history of bloodletting and its present condition, 387, 
 388; neglect of the subject, 388, 389; former failures in its employ- 
 ment and reasons for same, 389, 3^0; opposition to it, 390; depletive 
 and derivative effects, 391; depletive bloodletting: venesection in dis- 
 turbances of the cerebral circulation, :391, :392; in threatening apo- 
 plexy, 392 ; in diseases of the heart, 392 ; in croupous pneumonia, 393 ; 
 local bloodletting, :593; method of application, 394; wet cups, 394; 
 their effect, 394, :395 ; where applied, 395; care in applying necessary, 
 
395; local depletive blood-extraction, 396; derivative bloodletting: 
 nature of liaemorrboids, 396; an angioneurosis. 397; case proving this 
 supposition, 397; etiology of hsemorrlioids, 398; how derivative blood- 
 letting from the anus originated, 398; effects of this bloodletting, 399; 
 case v^here it was employed. 399, 400; care in using tamponade of na- 
 sal cavity for nosebleed, 400; indications for derivative bloodletting: 
 1. in the region of the head, 401, 402; 2. in the region of the spinal 
 column, 402, 403; 3. in the region of the chest, in various hsemopty- 
 ses, 403, 404; in the abdominal region, in inflammation of large 
 haemorrhoidal nodes, 404; the method of employing derivative blood- 
 letting, 404, 405; the time of the day, position of the patient, site of 
 operation, number of leeches, etc., 405, 406; repetition of derivative 
 bloodletting, 406. 
 
 2. Calomel. — In hypertrophic cirrhosis of the liver and in general thera- 
 
 py, 407-435. 
 
 History of calomel therapy in England, Germany and Eussia, 407, 
 408; author's experience with calomel, 408; physiological action of 
 the drug according to Binz, Shiffi, Weiss and Sokoloff, 408, 409 ; the 
 English practice as regards calomel, 409, 410 ; calomel in severe, es- 
 pecially febrile cases of colic from biliary calculi: cases, 410, 411-415 ; 
 Method of employing the drug, 415, 416, 417; calomel compared with 
 castor oil, 417; case of hypertrophic cirrhosis of the liver, 417-427 ; 
 calomel in facial erysipelas, 427 ; in typhoid fever, 428 ; in croupous 
 pneumonia, 428; in acute nephritis, 429; in diseases of the biliary 
 passages, 430, 431; diagnosis of biliary calculi, 431,432; calomel in 
 catarrhal jaundice, 432-435. 
 
 3. Syphilis of the Lungs, 436-445. 
 
 Pulmonary tuberculosis in syphilitic patients, 437; cases of syphi- 
 litic pneumonia, 437; diagnosis of, 441; syphilitic pneumonia com- 
 Ijlicated by pulmonary tuberculosis, 441-444; treatment of, 445; case 
 exemplifying this treatment, 445. 
 
 4. Syphilis of the Heakt, 446-459. 
 
 Lack of knowledge on the clinical aspect of cardiac syphilis, 447; 
 cases of syphilis of the heart (syphilitic myocarditis, syphilitic affec- 
 tion of the cardiac muscle), 447, 448 ; character of the majority of cases 
 of cardiac syphilis, 449; case presenting a type of syphilitic car- 
 diac affection (contemporaneous syphilitic affection of the cardiac 
 muscle and nerves), 449-451 ; its treatment, 451 ; failure of digitalis in 
 same, 452 ; condition of the nervous system of the patient, 452 ; data 
 for diagnosis of cardiac syphilis, 454; its treatment, 454, 455; the 
 milk treatment of disease of the heart, 455; Spanish flies in angina 
 pectoris, 456 ; case of aneurism of the aorta due to syphilitic aortitis, 
 457-459. 
 
 5. Treatment of Fevee, 460-463. 
 
 Certain symptoms, among them fever, as protecting agencies to 
 the organism, 460 ; treatment of fever in acute infectious diseases, 460, 
 461 ; use of cool baths, 462 ; cold sheet, 462 ; use of antipyrine, anti- 
 febrine and phenacetine, 462; use of quinine, 463; fever in pulmonary 
 tuberculosis, 463 ; in septicasmia and pyaemia, 463. 
 
INTRODUCTION 
 
 TO 
 
 CLINICAL EXERCISES. 
 
 THREE LECTURES. 
 
 Gentlemen : — 
 
 Before we begin our clinical exercises, it is necessary that 
 we understand the nature of the clinic and its importance in 
 the matter of medical education and in scientific medicine. 
 The duty of explaining this importance devolves principally on 
 me, as the teacher at the Faculty Therapeutical Clinic, this 
 last being, as we shall see later, the first general, as contrasted 
 with the special, clinic, which you come to attend. 
 
 The Importance of the Clinic in Medical Education. — 
 You desire to become physicians, that is, to learn the art of 
 treating and preventing diseases. — It is impossible to learn 
 this without the knowledge of disease and of therapeutic means. 
 You cannot interpret disease, unless you know what constitutes 
 the normal condition. The course of medical studies is there- 
 fore such as to teach you first what constitutes the normal 
 condition (Anatomy and Physiology), and later the nature of 
 diseases, their treatment and the nature of the remedies (gen- 
 eral and special Pathology, and Therapeutics with Pharmacol- 
 ogy). Until the present you have occupied yourselves with 
 the above-mentioned sciences ; now, in due order, follows your 
 acquaintance with diseases and their treatment in practice : 
 this necessity of medical education is fulfilled by the clinic, i. e. 
 by clinical instruction and clinical exercises.* What is the in- 
 
 * " Clinic " is derived from the Greek kXlvtj, a bed, a couch, on which 
 the patient reposes ; as used in these lectures it refers to a hospital con- 
 nected with the medical school for purposes of practical teaching. 
 
_ 2 — 
 
 fluence of clinical exercises or generally of observation and 
 treatment of the sick, even when outside of the clinic, on the 
 course of medical education? 
 
 The student, on his coming to the clinic, is well informed, 
 but in a purely abstract manner, of all the possibilities of a 
 pathological process, and the potentialities of therapeutic ac- 
 tion. All this information is, as it were, evenly distributed in 
 his mind : there is no occasion for one certain part of it to be- 
 come more prominent than another. 
 
 In the clinic, as generally in practice, the phenomena of the 
 pathological processes, and the reasons for therapeutic action, 
 as well as the action itself, present themselves not in an ab- 
 stract form, but under all the conditions of a given case ; the}^ 
 may appear to one physician in a greater number than they do 
 to another, but they never will appear to one m such numbers 
 and varieties as to exhaust all the possibilities indicated by 
 pathology and therapeutics. Under such an influence of the 
 clinic or of practical activity m general, certain medical infor- 
 mation will take precedence over others in the mind, and will 
 thus come forward, at the same time grouping itself otherwise 
 than in the systematic studj^ of pathology and therapeutics : 
 for, whereas in this last the etiological and anatomo-pathologi- 
 cal points of view are chiefly predominant, in clinical and in 
 practical work in general the diagnostic and therapeutic con- 
 siderations al'e chiefly taken into account. Systematic exposi- 
 tion starts with the definition of the disease in the direction of 
 its picture ; ^vhereas in the clinic we begin with the picture of 
 the disease and deduct its definition therefrom. This difference 
 creates the practical physician, who. knowing the real nature of 
 the disease and the influence of medical means thereon, appre- 
 ciates correctl}' the extent of the pathological process and the 
 degree of effectiveness of the remedial agencies : he is thus 
 enabled to quickly concentrate his mind on the two most 
 important aims of practical medicine, namely, the recognition 
 of the disease and its treatment. (3n the other hand, this same 
 difi^erence may naturally become the foundation of a future 
 routine tendency in medical practice. — Comprehending then 
 the influence of clinical and of practical activity in general, and 
 
the possibility of the two above-named results therefrom — a 
 desirable and an undesirable one — what must be the aims of 
 clinical teaching ? To educate the students into practical and 
 as perfect physicians as possible, the teacher must see to it that 
 they acquire a regular method^ following a laid-out plan, accord- 
 ing to which the clinical exercises, that is, practical medical ac- 
 tivity, are to be conducted, thus avoiding irregular clinical 
 teaching. To prevent the development of a routine habit, he 
 must individualize his cases, that is, point out their special char- 
 acteristics. Of course, the mastering by the future physician 
 of a method and the acquisition of the skill in individualizing 
 is a rather slow process at the beginning ; but once acquired, 
 their possessor finds them at his command sooner and to greater 
 advantage, than the man who is not habituated to them. The 
 acquisition by the students of a method and of skill m individu- 
 alizing must be the chief aim of the teacher, as contrasted with 
 the tendency to convert the clinic into a kaleidoscope, and to 
 show in a short space of time — always limited — all the diseases 
 o'f the special branch of pathology in all their varieties, combina- 
 tions, and under all conditions. It is impossible to show all in 
 one year, — not even in ten ; and to insist upon an impossibility 
 is unreasonable. — Whoever has acquired a method and the 
 habit of individualizing, will quickly familiarize himself with any 
 new case which may present peculiarities unknown to him be- 
 fore ; and such new cases are met with quite frequently even 
 by the very experienced physician, the more so by the beginner : 
 for such is the peculiarity of the medical, as of every other prac- 
 tice, that is, of an activity amidst conditions of real life. The 
 teacher should, surely enough, introduce to his students the 
 principal morbid varieties and typical cases of that particular 
 branch of pathology, to which his clinic is especially devoted. 
 
 In accordance with their aims the clinics are divided into 
 different varieties: — 
 
 A. Those conforming to the grades of medical studies. — 
 1, The Propcedeutic Clinic (introductory, from Greek TrpoTraiSeu'etv, 
 teach beforehand), which is, properly speaking, practical semi- 
 otics, i. e. it familiarizes the students with the signs of diseases 
 and with the groups of signs in real life. In such a clinic the 
 
— 4 — 
 
 teacher cannot, while devoting his time to this subject, conduct 
 any thorough clinical investigation concerning the diagnosis, 
 prognosis, and treatment of a case ; besides, the students are 
 not sufficiently prepared to profit by it. 
 
 2. The Faculty Clinic is the first complete clinic, in which 
 the teacher conducts before his hearers the above-mentioned 
 medical acts, methodically and individualizing each case, and 
 presents, therefore, a smaller number of patients. 
 
 3. The Hospital Clinic. — In this the teacher can do his work 
 more rapidly, and goes over a greater number of cases, thus in- 
 creasing the experience of the students, who had been prepared 
 for this by the preceding clinic. 
 
 4. Clinic for the out-patients (ambulator3^) — While the more 
 serious affections are usually to be seen in the hospitals, in the 
 out-patient department we see a great many others ; namely, 
 the less serious ones, that do not go to the hospital, and the 
 serious forms at their beginning. The out-patient department 
 affords also opportunities for observing the course and treat- 
 ment of diseases not under hospital conditions, but under the 
 variable surroundings of every-day life ; as their attendance 
 requires a certain degree of practical maturity, they should be 
 in charge of those students who have gone through the station- 
 ary clinics (the preceding ones) ; but this is not always adhered 
 to, nor is it always possible to do so. 
 
 B. As to their contents, clmics are divided mto general and 
 special. The reason for the existence of the special clinic 
 lies in the great general law of progress : the subdivision of 
 labor. As a result of the clinician's ability to confine his work 
 to one special branch of pathology, he perfects himself in it, 
 becomes better able to teach it, and assists in advancing it 
 more rapidly as a science. The number of special clinics is 
 therefore continually on the increase : thus in the last few de- 
 cades the former special clinics in surgery, obstetrics and oph- 
 thalmology, were increased by the addition of those in gynae- 
 cology, nervous diseases, insanity, skin diseases, venereal and 
 diseases of the genito-urinary tract. 
 
 It is rather more difficult to define the character of the gen- 
 eral clinic. What is it. and what are its aims ? The name 
 
— 5 — 
 
 general clinic can only be applied to the clinic of internal 
 diseases. The ailments usually treated in such a clinic refer 
 to organs whose functional activity forms the basis of animal 
 metabolism, namely, the organs of nutrition, respiration, circula- 
 tion and of the secretions, — then disturbances of the processes 
 of the animal metabolism itself, acute and chronic contagious 
 diseases, functional disturbances of the nervous system which 
 are inevitably met with in all these disorders (we can leave aside 
 the organic diseases of the nervous system that belong properly 
 to the clinic of nervous diseases), and at times diseases belong- 
 ing to the special clinics, particularly affections of the female 
 genital organs. 
 
 What conditions have secured for the clinic of internal 
 diseases its significance and its contents ? The question natu- 
 rally arises, whether it were not possible and more advantageous 
 to distribute all that the clinic of internal medicine claims, over 
 special clinics for diseases of the chest, abdomen, etc. ? There 
 is not the slightest doubt but that clinics of such a nature 
 would be just as useful as any other special clinics ; but they 
 could not possibly replace the clinic of internal diseases in its 
 present form. The fact is, that the special clinic suffers from 
 one radical defect : the difficulty that the specialist clinician 
 experiences even in satisfactorily determining, in the given 
 case, the general condition, the condition of other parts of the 
 organism, after he had recognized in the most thorough manner 
 the defect of the organ of his specialty ; and the more perfect 
 the specialist, the greater this difficulty, as devotion to his 
 specialty must needs have alienated him from the others. The 
 specialists are well aware of this defect, point at and struggle 
 against it, but, as every-day experience proves, cannot remove 
 it, because it is organically connected with the very nature of 
 specialization. 
 
 What would become of medical teaching and of medical sci- 
 ence, if, possessing only special clinics, we were deprived of one, 
 that would have as its principal aim the teaching of the import- 
 ance of connecting all the phenomena of a given case, so that 
 a general conclusion about it may be arrived at, and thus lead 
 us to the physician's chief duty — application of remedial agents? 
 
— 6 — 
 
 Without such a clinic the education of a phj'sician is not to be 
 thought of. And such a clinic is the one of internal diseases 
 with the above-mentioned contents ; occupying itself with the 
 simultaneous ohservation of disorders of those portions of the 
 organism that are chiefly concerned in connecting all its parts 
 in common ; that is, the simultaneous observation of disturbances 
 of functions that form the basis of animal metabolism, of the 
 metabolism itself and of the functions of the nervous sj^stem. 
 This it is that characterizes the pieculiarity of the clinic of inter- 
 nal diseases and entitles it to the name of a general clinic. Not- 
 withstanding the importance of the surgical clinic, it does not 
 have the character of a general one, as the subjects of its treat- 
 ment do not possess the same importance in the comprehension 
 of the common connection of pathological phenomena, as do the 
 subjects treated of in a clinic of internal diseases. You will see 
 from the above, that the pediatric clinic has the character of a 
 general one. Our university, as also the majority of universities, 
 has two clinics of internal diseases — the faculty clmic and the 
 hospital clinic. As you attend the faculty clinic first, it — the 
 faculty clinic of internal diseases — consequently is the first 
 complete and at the same time general clinic which the student 
 sees : it is the true clinical school of the medical department. 
 From this fact it derives its importance and in it is laid the 
 basis of your future medical activity. 
 
 While discussing the importance of the clinic and of clinical 
 exercises in the course of medical education, we must make some 
 necessary remarks of a general nature on the method of con- 
 ducting these exercises. 
 
 What is principally embraced by clinical exercises ? We usu- 
 all}^ have to define the nature of the disease (^examination and 
 diagnosis^, its future course and its termination (prognosis'), and 
 to order a plan of treatment and execute it, being guided by the 
 course of the disease (ohservation). The clinical exercises, as 
 we explained above, must be conducted according to a method 
 and to a process of individualization. As regards a method, I 
 have, after several attempts in the beginning of my clinical 
 and practical activity, adopted the following one as the 
 best : — 
 
— 7 — 
 
 1. Examination. — I begin my inquiry with: What ails the 
 patient^ and for hoiv long a time / The patient, in the majority 
 of cases, does not distinguish in his history the present from 
 the past, confounds the symptoms referable to diseases of one 
 portion of the body with those of another, the course of the 
 disease with the results of the applied treatment, supplies you 
 with unnecessary information, and is generally incoherent. 
 
 In the beginning of my practice I used to listen to these tales, 
 and have concluded that they are of no value and only tend to 
 fatigue both the ph3"sician and the patient. On those rare occa- 
 sions when your patient is either an intelligent layman or a physi- 
 cian, stating his case in a connected, sensible manner, there is the 
 danger that the examiner may accept, alongside with the history 
 of the case, also a conclusion about the disease and its treatment, 
 
 — a conclusion which had been formulated either by the patient 
 himself or by his physicians, as even the manner of relating the 
 history of the case reflects this preconceived opinion. Such a 
 preconceived conclusion will interfere with your further investi- 
 gation and may prevent you from arriving at a correct and proper 
 idea about the disease and its treatment. 
 
 With this in view, I usually interrupt the patient's narrative, 
 explaining to him that I desire to be informed in a concise 
 manner of the most prominent symptoms he suffers from (as 
 dyspnoea, pains, weakness, etc.), and of their duration (in 
 weeks, months, etc.), that I will later conduct the inquiry in 
 due order, after which I shall be ready to listen to his story. 
 With this I beg the patient to answer as explicitly as possible, 
 thus : first, to affirm or deny only what he is certain of, what he 
 remembers well, otherwise to say : " I do not know, I do not 
 remember ; " and second, to answer the question^ and that only^ 
 without mixing in foreign matter not related to it, and not to 
 be carried away by his own tale, thus distracting the physician's 
 attention from the principal subject. From among the in- 
 numerable multitude of inaccurate answers let me instance for 
 clearness' sake such a one : " Do you drink any tea, and if yes, 
 how much?" Answer: " I am not a particular lover of tea " ; 
 
 — and only after two, three or more questions the physician finds 
 that, although not a " lover of tea," the patient imbibes so many 
 
glasses or cups per day. More time still is wasted uselessly in 
 listening to answers which become tales of subjects unconnected 
 with the case. I advise the beginner not to permit any such 
 distractions. As a circumstantial examination requires time 
 and energy, the above-named deviations will bring it about that 
 at the end, when the important point will have been reached as 
 to what treatment is to be applied by the physician, the latter 
 will have become mentally fatigued just at the moment when 
 his whole energy, judiciousness and mental clearness are to be 
 put to test. However, in the majority of cases it is only neces- 
 sary at the beginning to correct the patient's answers, to state 
 explicitly what is wanted of him, namely, as concise and direct 
 answers as possible, and the further interrogation will proceed 
 smoothly. It is self-evident, that to receive such answers the 
 physician in his turn must put direct, concise and simple ques- 
 tions. 
 
 The examination of the patient consists of inquiries as to his 
 present condition (^status prcesens) and inquiries relating to his 
 past (anamnesis). When examining a chronic case, I usually 
 begin with the status prcesens., as the information obtained facili- 
 tates the inquiries about the past, and makes the data concern- 
 ing anamnesis itself more intelligible. In recent cases, where, 
 for instance, the patient has been ill only for a few days, and 
 where the anamnesis is on this account short, it is much more 
 convenient to begin with the latter. It would, however, be 
 mere pedantry to strictly circumscribe each method of examina- 
 tion : particularly so, when in examining the present state we 
 are sometimes compelled to make special inquiries concerning 
 the past without going into a full examination of the latter. 
 
 The examination of the present condition (status prwsens^ 
 consists of interrogation and the so-called objective examination, 
 or examination through the sense-organs. At the beginning 
 both interrogation and to some extent objective examination 
 are resorted to simultaneously, the latter by easily accessible 
 means, as, for instance, in inspecting the tongue, feeling of the 
 pulse, or while talking to the patient, the physician cannot 
 help noticing the latter's condition, the state of nutrition 
 (whether fat or thin), the appearance of the superficial tissue 
 
_ 9 — 
 
 (whether plethoric or anaemic, cyanotic, icteric, cachectic, etc.), 
 his physical and mental condition (movements of the body, 
 facial expression, mode of speaking, etc.). But a complete 
 objective examination, when it becomes necessary to undress 
 the patient or to resort to such means as the examination of 
 the urine, sputum, etc., is much more convenient to make after 
 you will have finished your inquiries about his present and 
 past condition. 
 
 In interrogating about the status prcesens I first of all seek for 
 information about the most important conditions surrounding the 
 patient's life, and about his mode of living. 
 
 1. The locality. — Whether damp, malarial, or dry, dusty : 
 whether open to winds or not, and so on. 
 
 2. The dwelling-place. — Dimensions, flooring, position of bed- 
 room, temperature and ventilation, condition of water-closet, 
 and so on. Where is the work of the day performed ? 
 
 3. How does the patient wash himself? Outdoor bathing, 
 public hot baths, simple house-bathing, sponging? 
 
 4. Clothing in general and particularly the protection of the 
 abdomen (sashes and corsets) and feet (covering — warm or 
 cold, roomy or tight). 
 
 5. What nervines is the patient addicted to : tobacco, tea, 
 coffee, wine, whiskey, beer ? 
 
 6. What drinks: ordinary water, or alkaline (soda, seltzer), 
 kvass,* milk? 
 
 7. Food — meat or otherwise ; light or heavy, frequency of 
 meals ? 
 
 8. Family life, single, retired. 
 
 9. Children, abortions. 
 
 1(X Does the patient get sufficient aleep or not? Duration 
 of the sleeping hours. How often is he sleepy ? 
 
 11. Mental and physical activity f Rest? 
 
 12. How much of the day is spent out of doors and how much in 
 confined rooms ? 
 
 * A fermented drink in general use in Russia, taking the place of beer 
 of other countries. Common kvasa is made from an infusion of raised 
 rye-flour or dough, or of other flour or baked bread, with malt. Finer 
 kinds are made from apples, raspberries, or other fruit, without malt. — 
 Century Die. 
 
— 10 — 
 
 We next inform ourselves of the patient's condition by carry- 
 ing our inquiries along an ad opted plan, which is, of course, the 
 essence of systematic examination. The beginner, without 
 having acquired this method, and not appreciating the necessity 
 of it, conducts his inquiries without order, and is therefore 
 liable to be influenced in arrivmg at the diagnosis by the first 
 impression produced on him by the patient's complaints (as, for 
 instance, difficulty in breathing, pain in the side, cough), on the 
 strength of which he is led to think of a certain disease ; and 
 without going into details about the condition of the whole or- 
 ganism, he hopes to quickly diagnosticate the case with the 
 aid of a few questions relating to his assumed ailment. But 
 bitter experience will teach him — if he only be capable of self- 
 improvement — that such reasoning is deceptive and is justly 
 condemned by experience, and that the only reliable — although 
 somewhat slower and more laborious — method of examination, 
 is the complete one, conducted in accord with a certain, once 
 established order. In the basis of my system of examination, 
 which experience has taught me to consider the best, I put the 
 union of two prmciples : the physiological one (systems and or- 
 gans), and the topographical one (neighboring parts). There 
 may be others, but the first condition of ever}' method requires 
 that the questions include all that is most important. 
 
 1. Appetite and thirst. 
 
 2. The tongue, teeth, mouth and throat. 
 
 3. The stomach. Is the introduction of food followed by 
 belching, burning, heaviness, paui, nausea, vomiting ; any pains 
 when the stomach is empty ? 
 
 4. Intestines. Character of stool, regular (i. e, daily), of 
 sufficient quantity, evacuation of normal consistency and form, 
 — or irregular ? If the latter, do not content yourself with the 
 general statement of an existing constipation or diarrhoea, but 
 inquii"e fully as to just what irregularity there is. With this 
 m view, take a certain period of time previous to the examina- 
 tion, saj^ a week or more, if the patient can call it to his 
 memory, and inquire about the condition of the stool on each 
 day of this period : whether a constant diarrhoea, or a constant 
 constipation, that yielded only to injections and laxatives, or. 
 
— 11 — 
 
 what is most frequent, both coustipatioii and diarihfjea alternat- 
 ing with each other. If the movements of the bowels were of 
 late exceptionally regular, or constipated, or loose, inform your- 
 self of their usual condition. If the patient resorts to laxatives, 
 find what they are and in what doses. If he uses enemata, — 
 of what and at what time: at bed-time, when the system is 
 fatigued, and the nervo-muscular apparatus in general, as well 
 as that of the intestinal tract, reacts less readily, — or in the 
 morning, after a night's rest and the morning tea or coffee, 
 when the patient feels an inclination to stool not of itself suffi- 
 cient to clear the bowels, but strong enough to do so effectually 
 with the aid of an mjection. Does not the patient, as a general 
 thing, resist the tirst inclination to stool, thus preventing the 
 emptying of the bowels (the most important and frequent 
 cause of constipation^ '! Does he empty at stated times the 
 bowels, when constipated, so as to avoid overloadhig of the 
 same and the possibility of a consequent diarrhoea? What 
 kind of food or drmk, or what conditions in general produce 
 constipation or diarrhoea? Such a circumstantial inquiry will 
 at once lead to a full recognition of the irregularities in the 
 case, — irregularities, that are so important by their frequency 
 and influence on the rest of the organism : you will seldom in- 
 deed find a patient, whatever the disease he may be suffering 
 from, who has perfectly regular stools. The same mquiry will 
 also furnish you with verj" valuable information regarding the 
 therapy and, even more important, in respect to the hygiene of 
 the given part of the organism. How many times, for instance, 
 have I succeeded in effecting a cure of a rebellious constipation, 
 by simply enjoining upon the patient not to resist the first in- 
 clination to stool ; or in persons habituated to no other drinks 
 but warm tea, by advising to diminish the quantity of the latter 
 and to take half a glassful of water of ordinary temperature, 
 from one to three times a day, each time one and one-half oi 
 two hours before a meal. The reason for mv dilating' on the 
 subject of irregular rectual evacuations lies in the fact that we 
 are often liable to pass over this subject and its treatment in a 
 rather hasty and superficial mamier. 
 
 5. The anus. Any lumps? Do any haemorrhages take place 
 
— 12 — 
 
 from the anus, and by what phenomena in the rest of the or- 
 ganism are they accompanied? 
 
 6. How does the urinary bladder empty itself? Is the urine 
 ever red and turbid? It is here that I inquire about swelling 
 of the lower extremities (the parts of the body in which the 
 phenomena of dropsy make their first appearance). 
 
 7. The male genital organs : the condition of jyoientia virilis. 
 How frequent are the connections ? Does the patient feel 
 weak after them (this is very important in neurasthenia) ? 
 Masturbation, past or present ; pollutions. Also inquire about 
 diseases (past or present) that originate most frequently through 
 sexual contact, as gonorrhoea, chancre, syphilis, iis regards 
 this last, I consider it of paramount importance to be convinced 
 as to whether the patient is syphilitic or not; and it is quite 
 superfluous, I think, to dispute the necessity for this. If con- 
 venient, I inquire of the patient whether or not he had syphilis, 
 but do not rely entirely upon either the positive or the nega- 
 tive reply, but verify it by inquiring as to whether the patient 
 (if a woman) has had any children, or abortions and miscar- 
 riages; whether he had any falling of the hair (particularly 
 from the eye-brows and beard), not ascribable to any cause ; any 
 eruptions, and of what nature; are there any scars left? 
 Were there before or are there now any nocturnal pains in the 
 bones and articulations ; any chronic catarrh, etc. ? If, on the 
 other hand, it is either inconvenient or useless to put the ques- 
 tion directly, as, for instance, to a woman, m whom the infec- 
 tion might have passed unobserved, then I at once resort to the 
 above verifying questioning. If such inquiry furnishes me 
 with accurate information, I continue it to the end. But 
 if it leads me back into the anamnesis, — if the history of 
 the apparent or doubtful syphilis has been intimately connected 
 for a long time with the history of other morbid processes 
 in the given case, I then postpone the inquiry until I have 
 collected complete information covering the past, until the in- 
 vestigation of the anamnesis. This observation, as to how far 
 into the anamnesis we may go while investigating the present 
 condition, not only refers to the inquiry about syphilis, but 
 to that about any other disease of the organism. 
 
— 13 — 
 
 8. Female genital organs. Former deliveries or abortions. 
 Condition of menstruation before and now. Leucorrhcea. 
 
 9. The abdomen in general. Well-marked changes in the size 
 of the abdomen, observed even when the patient is dressed, 
 impress themselves on one's memory. But the most important 
 inquiry, regarding the abdomen in general, consists in in- 
 forming oneself as to the presence or absence of pains in that 
 region ; if present, whether constant or paroxysmal, and 
 chiefly, where localized ; this last gives us important informa- 
 tion as to the source of the pams. In case the patient finds it 
 difficult to define the seat of the pain, we assist him in finding 
 an answer by asking him whether the pains are felt all over 
 the abdomen or more to the middle part of it; whether they are 
 accompanied by rumbling, and whether they are relieved by 
 the escape of gases per os or per anu7n, by vomiting or by a 
 loose stool (gastric and intestinal pains). Is there more pain 
 in the upper as compared with the lower part of the abdomen, 
 — more on its right than on its left side? With what func- 
 tional activities do they coincide (from this we infer as to their 
 connection with the liver, kidneys, ovaries, uterus and urinary 
 bladder)? Are there any pains in the posterior wall of the 
 abdomen, in the loins, and with what do they coincide : with 
 constipation, with pains along the tract of the ureters or with 
 movements of the back, as in lumbago m general (i. e. in va- 
 rious myopathies, neuropathies and affections of the vertebrae 
 and their articulations in the lumbar region) ? 
 
 10. The chest in general, and also the organs of respiration and 
 circulatio7i. If there are pains in the chest, find their localiza- 
 tion and with what they coincide : as, for instance, pain in the 
 region of the heart, of paroxysmal nature, transmitted to the 
 left arm or to both arms, accompanied by a sensation of 
 fright and anguish (as in angina pectoris) ; pains in the sides, 
 aggravated by coughing, as in pleuritis of tuberculous and 
 other nature ; pains along the tract of the intercostal nerves 
 (as in affections of the same, and in liver and kidney colics) : 
 pains in one half of the chest and simultaneously in the cor- 
 responding arm, with this also tenderness on pressure in the 
 supraclavicular cavity of the same side (neuritis of the bra- 
 
— 14 — 
 
 chial plexus) ; pains all over the chest, aggravated by pressure 
 on the sternum and ribs (as, for instance, when lying on the 
 side), coincidently occurring with rheumatic pains in the ex- 
 tremities and agg-ravated at the same time as these last on catch- 
 mg cold (usually gout or syphilis, which are easily differentiate 
 ed ; or gout and syphilis of the ribs and sternum, at times with 
 a neuritis of a similar origin) and so on. — Then inquire about 
 difficulty in breathing (dj'spnoea), joaroa^^sws of clioking (asthma), 
 paljntation of the heart, coughing, expeetoration, spitting of bloody 
 the condition of the nose and larynx (alterations in the voice). 
 Examine, the pulse and inquire about the conditifyn of the circu- 
 lation : is the patient subject to chilliness in general or in par- 
 ticular parts of the body (the extremities, feet, and particularly 
 the soles of the feet) ? Is he subject to flashes of heat in gen- 
 eral or in some certain part (particularly the head) ? 
 
 11. Is there any febrile condition (chill, heat, or only weak- 
 ness, loss of apj)etite, and thirst) ? If not, mquire if patient is 
 subject to any habitual feverish condition, and what does it 
 accompany : for instance, catarrhal conditions, most frequently 
 of the respiratory tract, less so of the intestmes and urinary 
 tract (febris cartarrhalis) ; or it may accompany rheumatic pams 
 in the extremities, in the back, chest and head (febris rheuma- 
 tica) ; i. e. most frequently it is a febrile condition accompanying 
 an exacerbation of gouty or syphilitic pains, or both of these to- 
 gether, on account of a cold or for some other reason. Is he not 
 subject to febrile states without catarrh and '^ rheumatics," of a 
 more or less clearly defined intermittent nature, coincident with 
 a residence in a malarial region, especially during autumn and 
 spring ? Is there a fever of an exhaustive character, accompan}"- 
 ing serious diseases of important organs, most frequently tuber- 
 culosis, cancer or syphilis (particularly frequent with syphilitic 
 liver), etc. ? 
 
 12. Condition of nutrition and of the hcematopjoietic system. 
 Does the patient tend to grow full and fat. or thin and pale ? 
 Does he look cachectic, etc. ? 
 
 13. Sleep, whether quiet or not ; if disturbed, why so : is there 
 cerebral hypertelnia, neurasthenia, pains, cough, dyspnoea, consti- 
 pation and an overloaded stomach and intestmes. febrile condi- 
 tion, etc. ? 
 
— 15 — 
 
 14. Mental condition: memory and the faculty of reflection; 
 state of mind, — hopeful, pleasant or oppressed, sad, etc. 
 
 15. Headache. Important questions to ask : does your head 
 ache or not? If it does ache, then, the whole or only part of it, 
 whether the temples, the back, the front, the top ; and what is 
 the character of the pain — is it constant or paroxysmal, and 
 what is the nature of the paroxysms ? Before proceeding further 
 I must make here the followmg observation : while the examina- 
 tion, as stated above, is being conducted, information must not 
 only be collected, but also made as clear to the mind as possible ; 
 it is not sufficient to learn the existence of certain morbid con- 
 ditions ; we must at the same time endeavor to find theii' cause, 
 at least the proximate one. The nearer we come to an explan- 
 ation of the latter, the clearer to one's mind become the data 
 obtained by examination, the easier and more fruitful is this 
 exammation. It is self-understood, that such a procedure is 
 more possible for an experienced physician than for a beginner: 
 but the latter will soon gain the experience, if he but acquire 
 th'e habit, instead of simply collecting facts mechanically, to 
 classify the gathered information, to look for the causes and 
 thus prepare valuable material for the erection of an organic 
 whole — the diagnosis of the whole morbid condition. It is of 
 course also necessary at the same time to acquire a certain tact 
 in such attempts at immediate elucidation of the matter, so that 
 the once established order of examination is not mterfered 
 with : if a few questions suffice to make clear the nature of the 
 morbid phenomenon, then an immediate explanation of it is 
 not only desirable, but even obligatory ; but if it become neces- 
 sary to multiply the number of questions, and enter further 
 and further into the inquiry about the condition of organs not 
 yet examined, and even into the history of the past, — then we 
 must postpone the explanation of the phenomenon until we 
 shall have collected all the information, i. e. until after our full 
 examination. Attention and exercise on the part of both the 
 student and the instructor will result in the speedy acquisition 
 of the above-named tact. 
 
 Let us now resume the question of headache. There is 
 hardly a morbid phenomenon which is so frequent and brought 
 
— 16 — 
 
 about by so many and so various causes as the unpleasant sen- 
 sations in the head: pain and heaviness. Morbid conditions of 
 the soft parts of the head and of the bones of the skull and 
 face, of the numberless nerves of the head, of the organs of the 
 higher senses, and, the most important of all, of the cerebrum 
 itself, which, outside of disturbances of its own substance, 
 reflects in itself in various ways the influence of disturbances 
 of other parts of the organism, — these are all causes of fre- 
 quent headaches and heaviness. If the picture of the morbid 
 phenomenon, as seen from the above necessary questions, points 
 directly to some certain disease (as, for instance, migraine, 
 masked malaria, syphilis, etc.), and if the completed part of our 
 examination — and this latter will have been finished, if con- 
 ducted in a certain order, by the time we reach the inquiries 
 about the headache — - contains data that may be considered as 
 the causative agents of the pain in the head, then we certainly 
 should make inquiries verifying our assumption. Otherwise we 
 must leave the explanation to the end of our investigation, al- 
 though it may happen, especially with an inexperienced practi- 
 tioner, that he will traverse almost the whole region of pathol- 
 ogy, before he will have found the causation of the pain in the 
 head. 
 
 16. Vertigo. If present, find whether accompanied by a 
 flushed or pale face, by an overloaded stomach or other dys- 
 peptic phenomena, by constipation, before hsemorrhoidal bleed- 
 ing, before menstruation or after it, by ursemic manifestations, 
 etc. 
 
 17. Paiiis in the neck., spine, and extremities. If present, 
 localize them (in the articulations, along the bones, nerves and 
 muscles), and determine their character : constant, aggravated 
 by pressure (in the arthrites, periostites and perichondrites, neu- 
 lites and myosites), or of an opposite nature (as, for instance, 
 lancinating pains in tabes) ; aggravated or not at night, etc. 
 
 18. Panxsthesice and anoesthesice. 
 
 19. The nervo-miuscular apparatus: condition of muscular 
 strength, disturbances of locomotion, condition of reflexes, 
 
 20. Sight and hearing. 
 
 21. G-eneral integument: abnormal dryness of the skin, oj' 
 sweating, itching, eruptions. 
 
— 17 — 
 
 Anamnesh (av6.fjLvr](n<i^ from dva, again and /ai/avt^o-kciv, c«ZZ fo mind 
 — a recalling to iniiicl). Tlie information obtained from the 
 patient concerning liis present condition will serve as a guide 
 in conducting the mquiry concernmg his past : we must inform 
 ourselves of the history, of the origin, course and treatment (if 
 there was an}*) of those departures from the normal health, the 
 presence of which was elicited while inquiring about his present 
 condition. We must naturally also mquire about ailments 
 which, as the patient thmks (and often wrongly so), have no 
 comiection with his present disease. We also uiform ourselves 
 at this stage of the health of the parents and relatives m 
 general. 
 
 Havmg learned the patient's past and present condition, we 
 invite him to add anything he may desire to the physician's in- 
 quiries. It is rarely that a patient will fiud it necessary to add 
 anythmg after a physician's thorough questioning. 
 
 Objective investiyation. Palpate the head (if necessary) ; in- 
 spect, palpate, percuss and auscultate the chest; mspect. 
 percuss, and, what is most important, palpate the abdomen : 
 inspect and palpate the neck, back and extremities ; examine 
 the excreta, chiefly the urme (quantity, specific gravity, color, 
 sediments, reaction, presence or absence of abnormal con- 
 stituents) and the sputum, and at times the mtestmal excreta 
 and the gastric contents ; examme, if necessary, the blood ; de- 
 termme the temperature of the body ; mstitute a special 
 examination, if necessary, of the organs of sight and hearmg ; 
 of the larjTix, of the urinary bladder, etc. 
 
 Examination of the patient serves as the basis for the diag- 
 nosis, prognosis and treatment. Followmg the method as 
 above outlmed, the physician need not fear that he may fail to 
 observe or may omit anythmg of importance for these medical 
 auns. But I must also warn you against another possible mis- 
 take — that of hunting for superfluous details, and mmecessary 
 mmuteness m mvestigatmg both the present and the past con- 
 ditions of the patient. Not everythmg by far, obtainable by 
 investigation, is necessary or important for our medical aims ; 
 we must especially distmguish the diagnostic from the semiotic 
 aims : not everythmg interestmg to the semiotician is necessary 
 
— 18 — 
 
 to the diagnostician. It is important that the begmner acquire 
 the requisite tact m his examinations, so as to avoid f atigumg 
 himself and his patient ; and to preserve the energj- which is so 
 necessary in arriving at serious, sober and therefore correct con- 
 clusions, he must leave out mmecessary and mmute details, as 
 well as everythmg that is confusmg and superficial. The full 
 possession of such a tact is, of course, only a question of time 
 and experience ; but at the same time a regular clmical teach- 
 ing, free from confusion, superficiality and excessive mmuteness 
 of detail m mvestigation, without deviating from its direct aim, 
 will midoubtedly assist, by its example, m acquuing this tactful 
 habit. — If the patient's condition be such that an examination 
 of it will be difficult or even pamful to him, — as m cases of 
 great weakness, heemoptysis, dyspnoea, cough, pams, etc., then 
 we must ask the most necessary questions, such as he himself 
 will be able to answer, and so formulate them that a word or 
 even a sign, positive or negative, will sufficiently answer them. 
 For other uiformation Ave look to the people surrounduig the 
 l^atient. They are naturally the ones to turn to m cases of loss 
 of consciousness. It is self-understood, that the objective ex- 
 ammation m such cases must be conducted with the utmost 
 care and must mclude only what is very essential. The contin- 
 uous improvement m the condition of the patient offers us the 
 opportmiity to fill in the gaps m the mvestigation. 
 
 II. Diagnosis. — It is a mistaken idea, that a diagnosis is 
 arrived at onl}^ after the investigation has been completed, as if 
 this latter were but a mechanical process of collecting uiforma- 
 tion m a certam order. On the contrary, as we have endeavored 
 to prove above, the process of investigation is a very active, 
 searching conditon of mmd : the data obtamed by mquiries and 
 objective examination are bomid to create certain suppositions 
 in the mind of the j^hysician ; these he endeavors to prove by 
 verif3"mg questions and objective investigations, observmg at the 
 same time due moderation, so as not to allow himself to be 
 carried away beyond what he has ah-eady obtamed nor change 
 the order which he decided to follow. Thus the diagnosis is 
 being continuously evolved ivhile the mvestigation is gomg 
 on, so that in the majority of cases, after the latter will have 
 
— 19 — 
 
 been concluded, we only have to sum up the total and we get a 
 complete diagnosis, i. e. that of the principal disease (^diagnods 
 morhi), as well as that of the secondary disorders and of all the 
 peculiarities of the patient (diagnosis cegri). Less frequently, 
 in cases which do not seem to be clear, or m complex cases, we 
 must resort, after the mvestigation is gone through with and its 
 sum total is made up, to another special process — to the so- 
 called differential diagnosis, or diagnosis by exclusion(i^zV<^;/!6i.s-/.s- 
 different ialis sen diagnosis per exclusionem^ ; in this we analyze 
 in turn all the suppositions that have arisen concernmg the 
 nature of the given morbid phenomena, and throwmg aside 
 the less probable ones, we retam what is most probable. 
 
 III. Prognosis. Diagnosis is a conclusion based on the 
 present ; prognosis is a presupposition of the future based on the 
 diagnosis, referrmg to the course of the disease, to the changes 
 to be expected at first and later on ; to the termination of the 
 disease : whether restoration to health, complete or partial, or 
 death ; to the nature of the effects of the j)rescribed treatment. 
 While followmg the course of the disease, we verify the sup- 
 positions, we verify the i^rognosis. It is thus evident how im- 
 portant the prognosis is for the physician ; the more correct the 
 prognosis, the stronger it is verified l)y further observations, the 
 more self-confident Ijecomes the physician, the less wavering 
 he is, and the more positive he acts ; i. e. the nearer he comes to 
 bemg a truly practical worker, a practical physician. 
 
 None the less important is the prognosis as regards the 
 patient and his immediate people and relatives. The im- 
 portance of a correct prognosis m the hospital is as nothing 
 compared to that m private practice : the reputation of and the 
 confidence m the physician depends on a prognosis which is 
 correct, faithful and m accordance with the course of the dis- 
 ease. It is hardly necessary to enlarge on the painful position 
 of the practitioner m whom the patient reposes no confidence ; 
 and worse even is the condition of the patient, if m a small com- 
 munity, m the absence of any other physician, he is compelled 
 to take treatment at the hands of such a physician. I there- 
 fore consider it my duty, and the duty of every clinical teacher, 
 to explain in each given case the prognosis not only as regards 
 
— 20 — 
 
 .the patient, but also his relatives, altliougli in the clinic, or in 
 the hospital in general, these last are absent. I will here also 
 make a few general remarks concernmg the value of the prog- 
 nosis for the patient and for his friends. 
 
 As regards the patient. You must always remember that, 
 with very few exceptions, those affected with a serious ailment 
 are, by the fact of the presence of the morbid condition itself, 
 in an oppressed mental state and look rather gloomily and with 
 but little hope into the future. For the very sake of succeed- 
 ing with his treatment the physician must infuse hope into the 
 patient, promise a complete return to, or at least, in accord with 
 the case, an improvement of his health, callmg his attention to 
 those favorable signs in the patient's condition which the latter 
 in his despair fails to see or appreciate. Quite frequently such 
 an mtentional assurance will induce the much needed sleep 
 which was absent ; and it certainly needs no explanation to 
 comprehend the importance of a quiet sleep fOr the functional 
 activity of the nervous system and through it of the whole organ- 
 ism. Nor is this the only result of the change from an oppressed 
 mental condition into a cheerful one ; if we but keep m mmd 
 the facts relatmg to the phenomena of what is known as sug- 
 gestion, we will easily perceive that here the prognosis coin- 
 cides with the treatment. But to apprise the patient of all the 
 apprehensions arismg in the physician's mmd is always a blunder 
 on the part of the latter, and sometimes even a crime : m danger- 
 ous cases, where the least significant influence may decide one 
 way or another (at times either death or a complete return to 
 health, as, for mstance, in the stage of collapse m acute pneu- 
 monia), to strengthen or to weaken the patient's courage- — 
 may bring fatal consequences. I may add that, followmg, as 
 I do, the above outlined plan as a rule, I find that it will assist 
 the physician in requiring of the patient a strict adherence to 
 the prescribed measures, disobedience being threatened with a 
 change for the worse. 
 
 But it may be asked, what will be our conduct m those cases 
 where the patient directly puts to us the questions about the 
 prognosis of the malady, desiring an answer because of the 
 necessity of arranging his worldly aifairs and of fulfilling his 
 
— 21 — 
 
 religious duties ? Let us take au extreme case : there is no 
 lioj)e for prolongiiig life, the end is approaching. In such a 
 case, our reply must be to the effect that there need be no con- 
 nection m the patient's mind between the approaching dissolu- 
 tion and the necessitj" for arrangmg the affairs and attendmg to 
 the religious rites : the performance of either does not necessarilj- 
 imply a nearmg end ; that the fulfillment of either will conduce 
 to the patient's quietude, and will therefore also strengthen 
 him, and the physician of course sees no hmdraiice to their 
 being performed. As to what regards the direct answer to the 
 question about death and its immmence, one may admit that 
 the condition of the patient is very serious (not hopeless), and 
 at the same time pomt out the possibility on the part of the 
 physician to err m regard to his suppositions m general and to 
 that of the exact time of death m particular. If those around 
 the patient desire him to attend to the requirements of religion 
 and his private affairs, then the physician must never put any 
 obstacles in their way, choosing an ojDportime moment m the 
 condition of the patient ; but the physician is not the one to re- 
 mmd the patient of it : the latter will justly consider it as his 
 sentence of death. It is the busuiess of those around the pa- 
 tient to remmd him of it, they again pleading the necessity for 
 his domg so, not because of the approachmg end, but because 
 the fulfillmg of the necessary duty will exert a quietmg and 
 strengthening effect on the patient. 
 
 If the condition of the patient is dangerous and even hopeless, 
 and neither he nor his friends approach the phj^sician with 
 regard to the questions as above, then it l^ecomes the duty of 
 the physician to opportunely remind them to settle his affairs 
 and attend to the religious rites, and through them the patient 
 is made aware of the necessity of the case. 
 
 Prognosis, as regards the patient's relatives. — The responsibility 
 that rests on the physician, and the necessity for the patient's 
 friends to be uiformed of the true condition of the patient, so 
 that measures in accord with it may be taken, make it incum- 
 bent upon the physician to apj)rise the patient's nearest relatives 
 of his condition without hiding an}i:hmg. Of the persons 
 named, only those are to be informed whose health will not 
 
— 22 — 
 
 materially suffer from the conmimiication of the expected 
 fatality. 
 
 In a general way it is necessary to be. concise and precise in 
 wordmg a prognosis. I am in the habit of employing the fol- 
 lowing formula, Avhicli may be applicable to the immense majoi- 
 ity of cases : 1. Cane (or condition) of no serious import, where 
 danger is neither present, nor to be apprehended. 2. Serious- 
 cases, m which the danger, although absent at present, is liable 
 to appear. 3. Banyerous cases, hut not hopeless ones, where 
 danger is present, but where there is a possibility of a favorable 
 termination, so that hopes for recovery may be entertamed. 4. 
 Hopeless cases. — Thus when usmg the expressions : "■ a light 
 (not serious) case," " serious," " dangerous," and '' hopeless " 
 one, I distmctly state what these expressions stand for. 
 
 IV. Treatment. — The principal rule to follow m ordering 
 treatment is the same as in other clinical exercises, namely, the 
 observance of a method and of a sj^stem of individualization. 
 The begmner, in whom clinical exercises failed to mculcate the 
 habit of strictly folio whig this rule, usually proceeds thus : he 
 diagnosticates the most striking morbid phenomenon in the 
 given case, and then, either from memory or by the aid of his 
 text-book, he selects one out of several recommended remedies, 
 the success of the choice depending' entirely on chance. Where- 
 as, by observing the rule above alluded to, we select a path 
 which is much more devoid of chance, and is more certahi ; it is 
 both methodical, not allowmg us to omit anytlihig, and mdivid- 
 ualizmg, makuig promment all the peculiarities of the case 
 and consequently pointing to the mdications and contramdica- 
 tions to treatment indicated by them. The rule is as follows : 
 keepmg m mmd the identical order of procedure which was 
 observed m diagnosis and prognosis, we must discuss consecu- 
 tively the hygienic measures, the remedial means mdicated by 
 the diagnosticated disturbances of the digestive and other 
 abdominal organs ; then the indications for the present disturb- 
 ances of the organs of respiration, circulation, etc., taldng in 
 disorders found hi all parts of the organism ; — then we must 
 see whether the measures and remedies mdicated by disorders 
 in certam organs are not contraindicated by disturbances of 
 
— 23 — . 
 
 other organs, and then after considering all the indications and 
 the contramdications, we give the preference to the most im- 
 portant ones, and out of several means recommended for the chief 
 morbid condition we select the one that is the most indicated 
 and the least con'tramdicated by the general condition of the 
 organism. 
 
 To this prmcipal rule to be observed in ordering treatment, I 
 must add a few very necessary remarks concerning the proper- 
 ties which, m my opinion, therapy must possess. 
 
 1. The history of medicine bears witness to the fact that peri- 
 ods of enthusiasm for certain remedies are succeeded hj periods 
 of therapeutic nihilism. Thhty years ago I had the opportu- 
 nity of witnessmg the decadence of such a period of nihilism 
 in Germany, — a period, the beginning of which may be traced 
 back to the time and partly to the influence of the founder of 
 the so-called homoeopathy — Hanneman ; the termination of this 
 period was due to the efforts of the best representatives of 
 German medicine — as, for instance, of Virchow — who have 
 arisen in protest against therapeutic nihilism. At the present 
 time, thanks to the discovery of a great many new and |)artly 
 very useful remedies, we observe a certain enthusiasm for 
 drugs, that is kept up by a still greater, everywhere observed 
 failing of medical practice, — namelj^, the neglect of hygienic 
 treatment. Not that the importance of hygiene is not fully ap- 
 preciated ; it is, on the contrary, appreciated better than at any 
 previous jDeriod, but the temptation to consider our medical 
 duty fulfilled after we give a prescription that costs so little 
 labor, and thus avoid a thorough hygienic mvestigation of the 
 case ajid the medical advice based thereon, this temptation is 
 frequently the cause of the above-named neglect of hygiene. 
 Steering between therapeutic nihilism and an undue enthusiasm 
 for drugs, we must conscientiously and clearly keep in mind that 
 a true, real, and not only seeming medical advice is one which is 
 based on a full recognition of the mode of livmg, as well as on 
 the history of the past and present condition of the patient ; 
 such an advice embraces not only the plan of treatment, but it 
 aquaints the patient with the causes, perpetuatmg the morbid 
 condition and found in the mode of his livmg ; it makes it clear 
 
^ 24 — 
 
 to the j)atieiit, that treatment will only assist him in returning 
 'to health; but to make this return secure the above-named 
 causes must be removed. — - in short, the patient must be taught 
 personal hygiene. I may as well add here, that as the majority 
 of patients are of weak will-power, it is the duty of the phj^sician 
 to assist them by his strength of character ; and m prescribing 
 for treatment and mode of livmg only the necessary measures, 
 he must msist upon these latter being strictly carried out. 
 
 2. The smiultaneous employment of many remedies is to be 
 avoided as much as possible, especially by the beginnmg prac- 
 titioner. When one remedy is being emploj^ed, its effect is 
 more prominent, and the beginner is sooner able to distinguish 
 it from the changes in the condition of the patient not depend- 
 ent on the employment of the drug. If it becomes necessary to 
 employ smiultaneously two or three remedies, then they must 
 not be acbiimistered m one mixture, but each must be given 
 separately, distinctly designating the time when they are to be 
 taken : at bedtime (for mstance, to quiet a cough that prevents 
 sleep, or simply as a somnifacient), or m the mornmg, or with a 
 meal, at certam attacks, etc. We thus meet the therapeutic in- 
 dication more exactly, the effect of the drugs becomes more 
 apparent and consequently the practitioner becomes more ex- 
 perienced in the application of the same. The prescriptions we 
 frequently see containing four, five and more drugs are posi- 
 tively incorrect : whoever knows that we must carefully weigh 
 all the changes in the patient's condition to be able to deter- 
 mine exactly the effect of even one drug, and that it becomes 
 more difficult to determine the effect of two and especially of 
 three simultaneously employed drugs, will understand that it 
 is impossible to determine with any degree of exactness the 
 effect of a mixture of a great number of drugs, and that there is 
 no reasonable excuse for employing such mixtures, unless it be 
 in exceptional cases and even then for a limited period of time. 
 As a matter of fact, the number of old mixtures that are pre- 
 served for employment at the present time is msignificant as 
 compared with what it formerly was. The creation anew of 
 such combinations — as for instance m the form of pills contain- 
 ing seven ingredients, ^ — with our modern legitimate and 
 
— 25 — 
 
 necessaiy tendencj for accuracy in medicinal effects, is a sad 
 anachronism indeed. 
 
 3. Hospital therapy is generally of a one-sided character, 
 dependmg upon preference m the employment of the apothe- 
 cary's means, '' drugs." Such a one-sidechiess, when m the 
 cluiic, will be transmitted to the students, if the clmician be 
 not careful enough to avoid such a defect. It is therefore the 
 duty of the mstructor, — having first of all satisfied all the re- 
 quirements of the j^atient's personal hygiene, as much as the 
 hospital conditions permit, — to apply along with the apothe- 
 cary's means also all others, and to acquaint the students 
 with the so-called special therapies : bahieotherapy (the mmeral 
 waters for dihikuig and bathmg j)urposes, hj-cbotherapy, etc.), 
 climatic therapy, the employment of compressed ah, and the 
 mhalation therapy m general, electricity, kuiesotherapy (mas- 
 sage and gymnastic exercises), treatment by a special diet, etc. : 
 either by directly applymg the named methods of treatment, or, 
 in case it be impossible to do so (as, for instance, m climatic thera- 
 py), by directmg attention to the indications for them as found 
 m the given diseased condition. If it is impossible to require of 
 ever}' physician, that he be as skilled in the various special thera- 
 pies as every specialist therapeutist is m his respective specialty, 
 we can and must at least msist, that every physician should 
 know where and when to apply tliis or that special therapy, 
 just as he knows where and when to emploj' tliis or that drug. 
 Besides, the most important methods and applications of 
 special therapies are usually acquired easily by the ordinary 
 practitioner, as soon as they have been worked out by the 
 specialists. 
 
 V/ Observation of the course of the malady. — It is self- 
 understood, that the duty of the physician is not at an end after 
 the diagnosis and the prognosis are made and a plan of treatment 
 is laid out : he must put this last uito execution. The duties 
 of the clinical uistructor run along similar Imes : he must 
 not limit himself to diagnosis, prognosis and plan of treatment, 
 but must execute the latter before his students, familiarizing them 
 with all the dithculties and peculiarities of medical practice which 
 become fully apparent only while treatment is behig carried 
 
— 26 — 
 
 out. With this in view the clinical instructor must impart to 
 the students the art of observmg the patient, the knowledge of 
 comprehending the changes taking place in the condition of the 
 latter, teach them to distmguish those of the changes which 
 depend on the course of the disease itself from those due to the 
 treatment, discuss the results of this last, and in accord with 
 them to either keep on with the once outluied plan of treat- 
 ment, or to change the latter m accord with the observation, 
 remmduig his students that the physician is but the minister 
 naturce. I can not help remarkmg here, that the clinicians do 
 not often give due consideration to the subject of observation, 
 although, without this last, clinical mstruction commenced 
 and never brought to an end always fails of its aim, without 
 bringmg the benelit that it could and should brmg. At the 
 same time it must be added that a certam amomit of experience 
 is required of the mstructor as well as due care m exploitmg 
 the time designated for clinical mstruction, which is always too 
 limited, to enable the clmician to fulfill all his duties, especially 
 m such a vast clinic as that for internal diseases ; namely, to 
 acquamt the students with the investigation, diagnosis, prog- 
 nosis and plan of treatment in typical cases in all the branches 
 of mternal faeclicine as equably and sufficiently as possible, and 
 with this to fmd time for familiarizmg them with the execution 
 of the treatment, and with the observation of the patient, and also 
 to attract the students to particij^ation m all the above-named 
 exercises and quite frequently to fill up the deficiencies in their 
 knowledge : of this we will speak presently. 
 
 VI. The making up of the deficiencies in the information 
 of the students is often very necessary, because these latter, on 
 account of the impossibility of observmg a thorough consecutive 
 ness of instruction, come to the clinic, especially at the begmning 
 of the year, without a sufficient knowledge of certain branches 
 of pathology, and more frequently of therapeutics, particularly in 
 the domam of the special therapies. Agam, it is often necessary 
 to inform the student of some particularly important changes or 
 acquisitions in the teachmg of that disease, or of that depart- 
 ment of diseases, which is under observation, — changes and 
 acquisitions which have taken place only very recently, and which 
 the student is naturally unable to follow himself. 
 
:if;l\' 
 — 27 — 
 
 VII. Autopsies have an extraorcliuary importance for tlie 
 clinic, as an instrument of progress in scientific niedicuie. 
 They give additional data to tlie ante-mortem observations, that 
 shed hght on the matter, thns furthermg diagnosis and general 
 pathology, and consecj[uently also therapeutics. The history of 
 medicme bears evidence to the fact, that it wa-s only the success 
 of pathological anatomy that made possible diagnostic progress, 
 and assists m the development of special pathology, and through 
 it of special therapeutics. From the standpomt of clmical 
 instruction, the autopsy is important as a verification of ante- 
 mortem conclusions, as a means of convincing the students — 
 the future physicians — of the jDOSsibility of a correct diagnosis, 
 and consequentl}' of a correct therapy. Still we must not forget 
 that autopsy is ]jy far not the only means for verifj-mg medical 
 conclusions ; that a constant verification is to be had while ob- 
 serving the course and termmation of the disease. It would 
 therefore be mcorrect and a shii'khig of his duty — that of 
 teachmg diagnosis and treatment of diseases — if the clmical m- 
 structor were to select by preference such cases for the students 
 as would promise an autopsy, i. e. in which treatment would be 
 230werless. 
 
 Tlie importance of the clinic in scientific medicine. — 
 We have seen from the foregomg, that in the matter of medi- 
 cal education the cluiic occupies a very important place. No 
 less important and significant is its role m medicme. as a 
 science. As at one time the necessity for assistmg the sick 
 created medical practice and later medical science, so at present 
 the clmical, that is the medico-practical activity, continues to 
 supply and stimulate medical advance, perfectmg semiotics, 
 diagnosis, general pathology and therapeutics, mducmg experi- 
 mental mvestigations aiming to determine the very nature of 
 diseases and their treatment. As regards the relation of the sci- 
 entific clmical work to the subject of clinical instruction, the 
 mstructor, without cleviatmg from his prmcipal aim, and with- 
 out loss of time, can always embrace the opportmiity of pointmg 
 out to the students the importance and the value of clmical 
 observation for • the progress of medicine, and thus acquamt 
 them also with this role of the clmic. He must, however, al- 
 
— 28 — 
 
 ways bear in mind, that his first duty consists m cHnical instruc- 
 tion, in educating scientific, practical physicians, and that a 
 considerable expenditure of time on anytliing outside of clinical 
 work will lead to a premature and therefore useless diversion 
 of the attention of the unprepared students from their most 
 necessary exercises, without satisfymg their most essential, 
 requisites. 
 
 In concluding the mtroduction to clmical exercise, I must 
 say a few words regardmg the interrelation between the work of 
 the clinical 2^'>'ofossor, that of the clinical assistants, and of the 
 students. 
 
 The professor must, first, himself follow a method and system 
 of individualization m his clmical work, and thus mculcate m 
 the students habits for the same. 
 
 Secondly,, he must carefully apportion the time allotted *for 
 clinical instruction, so that it may be possible to fulfill all the 
 duties of the clinician in an equable manner. These duties 
 have been defuied above, while discussmg the observation of the 
 patient. As regards, m particular, familiarizing the students m 
 the course of the academic year with the typical cases m all the 
 dejDartments of internal medicine as fully and as equably as 
 ■possible, I must here mark out for you the order which my ex- 
 perience, extending over many years, has taught me to consider 
 as the best. I begm the exercises m the clmic for mternal 
 diseases the first half of the academic year (seventh semester) 
 with diseases of the digestive organs (stomach, mtestmes, liver, 
 etc.), as they are the most important ones, because of their fre- 
 quency and- then- comparatively greater curability. As among the 
 very first cases presented to the students we are also sure to run 
 across some functional disturbances of the nervous system, these 
 are likewise discussed durmg the same half-year. We at the 
 same time take up the diseases of the j)eritoneum, the less im- 
 portant renal diseases (renal gravel and catarrh of the renal 
 pelvis) and gout, which are so frequently met with m diseases 
 of the digestive organs and with which they are so closely con- 
 nected genetically. The second half of the academic year (eighth 
 semester) is taken up with diseases of the organs of respiration 
 and circulation (their causation and partly their diagnosis is some- 
 
— 29 — 
 
 what familiar to the students from the propcecleutical clmic), 
 and also with the more serious renal diseases (as mflammations, 
 degenerations, etc.). Syphilis of the internal organs is preferably 
 taken up the first haK-year, because of the frequency of syphilis 
 of the liver. The acute mfectious diseases, — as typhoid, typhus, 
 relapsmg fever, malaria, pneumonia, acute articular rheumatism, 
 facial erysipelas, etc., the disturbances of nutrition (diabetes, anse- 
 mise, obesity, etc.), and the disturbances of the organs of loco- 
 motion, that we are liable to meet with m the clmic for mternal 
 diseases (as diseases of the muscles and peripheral nerves, of the 
 articulations and bones) — all these are taken up in both half- 
 years. It is impossible to strictly subdivide the contents of the 
 clinic for mternal medicme between the two half-years, princi- 
 pally because we usually meet complex cases, in which, besides 
 the principal disease under consideration, belongmg to that 
 part of pathology with which we are occupied in the given 
 half-year, there are other morbid conditions, which, although 
 belongmg to the other haK-year, must be discussed as fully as 
 the prmcipal disease, for the sake of the correct mvestigation 
 and individualization of the given case. As regards the special 
 therapies, we discuss the internal use of mmeral waters m con- 
 nection with abdominal diseases, the inhalation and climatic 
 therapy in connection with diseases of the organs of resx^iration, 
 the dietetic therapy hi abdommal diseases hi connection with 
 obesity and failure in nutrition, khiesotherapy and treatment by 
 electricity in connection with various cases ; bahieotherapy at the 
 end of the academic year, in the course of which the students 
 have had the opportmiity of observhig the various applications 
 of hydrotherapy. 
 
 Thirdly, it is the duty of clhiical mstructors to constantly at- 
 tract the student to participation hi the clhiical exercises. As 
 far as objective examination is concerned, all that can be seen and 
 partly (as percussion) heard, can usually be demonstrated be- 
 fore the whole class. But whatever needs demonstration by 
 l^alpation and auscultation would require so much time to be 
 demonstrated before the whole class, that it is impossible to do 
 it in the clinic of internal diseases, and as a subject for histruc- 
 tion, it belongs to the propaedeutic clmic ; but I nevertheless con- 
 
— 30 — 
 
 sider it necessary to always, in every case, afford an opportunity 
 to as many students as practicable, of personally convincing 
 themselves tlii-ough palpation and auscultation of the most im- 
 portant data — those on the presence of which the diagnosis is 
 based. Thus m the course of the year many acquire experience 
 in objective exammation under the supervision of the mstructor 
 (others under the supervision of the assistant, of which later) ; 
 and what is most important, the whole class gams the conviction, 
 that the diagnosis is based on data obtamable not only through 
 investigation by a skilled physician, but through that by a begm- 
 ning practitioner. In conducting the inveMigatioti, diagnosis^ 
 proi/nosis and plan of treatment, as well as m the preliminary 
 analysis of the given case and m further mvestigatuig it, be- 
 fore I pronounce my conclusion, I usually look for the opinions 
 of some of the students, and m the cases of greater difficulty I 
 turn to the whole class, requesting any one to answer the ques- 
 tion asked. Such a procedure not only attracts the students to 
 participation m clinical exercises, but soon excites in them an 
 interest toward these last. 
 
 The clinical assistants, being independent and responsible phy- 
 sicians, must fulfill theu' medical tasks, namely, to conduct the 
 investigation, diagnosis, prognosis, treatment and observation in 
 the presence and with the participation of the students m the 
 clmic, strictly folio whig the precepts of the school — that is, me- 
 thodically and individualismg — thus contmumg, as it were, the 
 work of the teacher, assistmg the students by exercises m forti- 
 fying themselves m the acquisition of a method and a habit of 
 individualization, and consequently assisting the clmical mstitute 
 m perfectmg its aims. The personal self-advancement of the 
 assistants — at times the future clmical mstructors — as well 
 as the treatment of the patients m clmic, gains not a little by this. 
 
 It is the business of the students, besides participatuig in the 
 clmical exercises of the professor and his assistants, to conduct 
 and describe the histories of diseases and to be on duty in the 
 clinic. 
 
 How to conduct the history of a disease. — The history begms 
 with the description of what was found on the patient's admis- 
 sion to the clinic : the principal complaints, the conditions and 
 
— 31 — 
 
 mode of his living, the result of the investigation into the 
 present and past condition of the patient. Then follows the 
 diary ; namely, the daily note of the treatment and of the altera- 
 tions in the patient's condition. 
 
 The description of the history of the disease^ which is presented 
 at the end of the half-year and which, with the conduct of the 
 history of the disease, serves as a certificate of the student's 
 diligence m crediting him with a semester, embraces everythmg 
 found at the prelimmary investigation, and then based on this — 
 the diagnosis, prognosis and plan of treatment, and finally the 
 diary m a connected, historical statement. In cases of autopsies 
 their results are noted down. Epicritical notices are desirable, 
 but not requisite, as not every history of a disease will present 
 a reason for them. 
 
 Service in the clinic enables the student to freely observe 
 pictures of diseases and become acquamted with the application 
 of various methods of investigation, as well as of treatment (as, 
 for mstance, hydi^o therapy, massage, electrotherapy, etc.). 
 
CLINICAL LECTURES. 
 
CLINICAL LECTURES. 
 
 FIRST CASE. 
 
 LECTURE DELIVERED SEPTEMBER I9» J889. 
 
 Gentlemen : — 
 
 We concluded last time the introduction to clinical exercises, 
 in which we explained in what order the various departments 
 of internal diseases would be taken up by us. At the beginning 
 of our clmical work I present to you the first patient. He has 
 been in the clmic smce last week (from Sept. 13th), and is 
 suffering from several diseases. It is a complex case, selected 
 by me by reason of its being more suitable for demonstration 
 than the others we ha^e in the clinic at present. 
 
 The patient, a peasant, 18 years of age, when asked as to 
 what ails him, and lioiv long he has been sick, complams, as 
 you see, of pains in the abdomen and loins, of diarrhcea and 
 vomitmg, dating his illness from Sept. 8th, inst. 
 
 Patient is so emaciated, pale and backward in stature and 
 general growth (he hardly looks to be, 15 years old), that we 
 can scarcely believe that he was completely well up to Sept. 
 8th. And indeed, when asked about it, he replies that he has 
 been ailmg for a long time, but began to feel very bad since 
 Sept. 8th. 
 
 In view of this, we must begm, as we explained in our intro- 
 duction, the investigation of the patient from his present condi- 
 tion ; after this the interrogation about his past becomes easier, 
 and the anamnestic data more intelligible. 
 
 Here is the information about the conditions and mode of 
 livmg of our patient before his admission to the clmic : he 
 lives ill a village of the Tversk Government, m a healthy local- 
 
— 36 — 
 
 it}', free from malaria ; liis dwelling is an ordinary peasant's 
 . hut ; tlie priv}^ is in the barn for the cattle, — not a very cold 
 place; he takes a hot, steaming bath once a week," does not 
 bathe in the sea during summer; does not smoke, nor drmk 
 whiskey ; drinks some four cups of hot, unsweetened tea daily ; 
 has tliree meals a day (early breakfast, midday dmner, and 
 supper), keeps all the fast-days. His food consists of rye bread, 
 cabbage soup, potatoes, occasionally buckwheat gruel, and, ex- 
 cept fast-days, meat tliree times a week. The patient is smgle, 
 has lived the past year with his parents, and does not work on 
 account of illness and weakness ; ui fact, goes out-of-doors but 
 little, exercises little, and keeps his bed most of the time. Some 
 three years before, he had been employed as an apprentice to a 
 ^village tailor, living under the same conditions as when at home ; 
 but with the exception of seven houi^s for sleep and the time 
 taken up by the three meals, he would work the whole day in the 
 close and vitiated atmosphere of the peasant's hut ; leisure for a 
 daily rest or a daily walk was not allowed : this could be had 
 only on Sundays and important holidays ; although he had at his 
 disposal seven hours for sleep wliile workmg, and as much 
 time as he wanted when livhig with his famil}^ the patient had 
 suffered for the last few years so constantly from abdommal 
 pains that he can sleep but three hours out of the twenty- 
 four ; besides, he sleeps on almost naked boards (on a bench). 
 
 Even from this collected mformation a great deal will be- 
 come clear. 
 
 It is only by the assistance of considerable muscular activity 
 out of doors that such heavy food as our patient used can 
 be readily digested ; whereas, his only bodily exercise consist- 
 ed m this : that he would sit a whole day in a close room, m 
 one position — that of a tailor at work, — with l^ent body 
 and crossed legs, his left hand holdmg the garment, while the 
 right one is engaged m monotonously plymg the needle. Not 
 to mention other possible causes, such conditions alone are 
 sufficient to give rise to a disordered digestion. The disturbed 
 sleep extending over several years has naturally tended to con- 
 tmuousl}'- undermine his health, etc. 
 
— 37 — 
 
 Now as to the conditions surrounding the patient m our clmic. 
 This latter, as you are aware, is situated m a health}^ location, 
 on a hill, and surrounded by an extensive yard and gar- 
 den. The ward where our patient is placed is satisfactory. 
 The water-closet is warm. For the six days that he has been 
 in the clmic, he got daily two soft boiled eggs, two glasses of 
 milk, two glasses of soup with chicken-meat well mmced, and 
 one-fourth of a pound of bread without the crust. This quan- 
 tity of food was given in six portions, m the following order : 
 1. At about 8 A.M., two soft-boiled eggs with some bread ; 2. 
 Two-thirds of a glass of soup and some bread ; 3. A glass of 
 milk and some bread ; 4. Two-thirds of a glass of soujd with 
 some bread ; 5. A glass of milk with bread ; and 6, at about 8 
 P.M., two-thirds of a glass of soup with a little bread. For a 
 drink, only tea which is neither strong nor hot, three to four 
 glasses (not full ones) a day, unsweetened,* for which two small 
 lumps of sugar were given durmg the whole day. 
 
 For treatment the patient drank daily two half-glassfuls (a 
 gla§s contains about 8 ounces, or about 16 tables2:)Oonfuls) of 
 natural Ems water (Kesselbrmmen), warmed to 30° R. (99.5° 
 -Fl), the first m the mornmg, one hour before the first meal, and 
 the second, one hour before the fourth meal (the second soup) ; 
 some five mmutes after the first and the fourth meals, he 
 took a tablespoonful of decoction of condurango (3 ij to 3 iij), 
 with five drops of the tmcture of nux vomica ; after each soup, 
 that is three times a day, the patient was given a tablespoonful 
 of strong white Crmiea wme ; he was given m the course of the 
 six days, for severe abdommal pains, codeine, gr. ^ -f gr. v sac- 
 chari albi per dose. His abdomen was all this time wrapped 
 m a double layer of flannel. The patient himself preferred 
 lymg, and he was also advised to avoid in any way becoming 
 fatigued, — to repose, and to walk and sit but little. Being 
 literate, the patient was allowed to read a little. 
 
 Status to-day, September 19, 1889. — Appetite, very poor on 
 l^atient's admission into the clinic, is somewhat better now ; his 
 former thirst, although not great, has disappeared. Tongue, 
 somewhat dry on admission, is now normal. Teeth healthy; 
 
 * The sugar is bitten off with each sip of tea. 
 
— 38 — 
 
 swallows freely. Before admission, he always suffered from a 
 constant feeling of heaviness and pain at the pit of the stomach, 
 which would become aggravated considerably after eatmg, when 
 there would appear bel clung of gases and of sour liquid, with a 
 f eelmg of burnmg, as well as nausea, and lately almost constant 
 vomitmg. The ejecta usually contamed a moderate quantity of 
 the gastric contents ; at one time some blood (of this latter in 
 the anamnesis)'. The pams and heavmess, as well as the belch- 
 mg and heartburn, have how considerably dimmished ; nausea is 
 rare, and there has been no vomitmg smce his sojourn m the 
 clmic. On his admission the patient had loose bowels, some 
 four to five movements a day, little at a time (about a glassful 
 for 2-i hours), watery, mixed with mucus, but of normal color 
 and without blood. For the last two days the patient had two 
 movements a day (the whole quantity for one day also about a 
 glassful), less watery and without mucus. He had, on admis- 
 sion, frequent paroxysms of severe pain in the abdomen every 
 day, also at night, accompanied often by rumbling, and 
 relieved by a movement of the bowels or by emission of gas per 
 anum. These pains are at present of rarer occurrence and much 
 less severe. We observe no icteric phenomena, nor does the. 
 patient acknowledge any m the past. Emptymg of the bladder 
 takes place regularly; quantity of urine 1400 cc. m 24 hours; 
 spec. gr. 1.014, of a strong acid reaction and pale color; when 
 fresh it is limpid, but soon becomes turbid; microscopic exami- 
 nation has shown this turbidity to consist exclusively of crys- 
 tals of oxalate of lime, with some verj- few epithelia of the 
 urmary bladder and a residue of sodium urate ; albumen and 
 sugar absent. Condition of genitatia normal; no history of 
 either coitus or masturbation. 
 
 Asked as to whether he suffers from any other pams in the 
 abdomen besides the constant pams we know of at the pit of the 
 stomach, aggravated by eatmg, and the severe paroxysms of pams 
 all over the abdomen (evidently of intestmal origm), the patient 
 informs us that there is a constant severe pam to the left of the 
 umbilicus, that is mtensified by riding m a jolting wagon (an 
 ordinary peasant's vehicle), and is radiatmg mto the left grom 
 and mto the loms ; also some pain m the chest (patient points 
 
— 39 — 
 
 with his hand to the lower lialf of the sternum and the adjacent 
 portions of the anterior surface of the chest). This pain, as it 
 appears from investigation, coincides m time exactly with the 
 pain at the pit of the stomach ; it too is aggravated by eatmg, 
 and it has also diminished smce the patient's sojourn in the 
 clinic ; it depends most likely on the same cause : disease of 
 the stomach. The pain in the left half of the abdomen is 
 evidently referable to the left kidney, but may certainly depend 
 also on disease of the descenclmg portion and sigmoid flexure 
 of the colon. 
 
 When resting, the patient's respiration is 21 to 24 per minute ; 
 pulse normal (was weak on admission, stronger now), rate 65 
 to 70 ; movements, and especially rising, mduce dyspnoea and 
 palpitation. Patient has never expectorated any blood, does not 
 cough now, and cannot recollect that he has ever suffered from 
 cough, any throat trouble, or a prolonged coryza. 
 
 As mentioned above, the patient is very pale and thin (his 
 weight on admission amounted to 91 lbs.). He is also very 
 sensitive to chills. Febrile phenomena are absent : temperature 
 lowered— 36.4 to 36.6° C. (97.5 to .97.9° F.) ; the tendency to 
 sweating, from which he suffered while at home, has disap- 
 peared ; the urine is pale, pulse not frequent, appetite is im- 
 proving. 
 
 He slept before admission not more than three hours a day ; 
 now he enjoys six or more hours of quiet sleep, thanks to the 
 diminution of the pains, partly to the wme and the more com- 
 fortable bed. 
 
 Condition of mind, much oppressed on his admission, is now 
 more spirited ; there are positively no signs of a morbidly ex- 
 aggerated mental impressiveness (" nervousness ") ; on the con- 
 trary, the patient, as you see, is ver}" quiet, reserved, and, we 
 must add, to judge from his answers, very sensible. 
 
 He suffered before admission from headaches and vertigo ; 
 these have considerably diminished and are relieved now, as 
 could be expected, by better sleep and improved circulation 
 (pulse became stronger). 
 
 Asked about the pains m the back, the patient replies that 
 the whole back aches, but particularly the loins (he puts his 
 
— 40 — 
 
 hand on tlie lumbar regions of the spme and the adjoming 
 lateral parts). As the pams are mcreased not only by ridmg 
 m a joltmg carriage, but also by any movement of the trunk, 
 they pomt not only to the kidneys, but also to the motor 
 agencies of the spine (bones, muscles and ligaments). The 
 objective exammation gives us a clearer idea of the localization 
 of the pam. There is no pain m either arms or legs, — their 
 movements are free ; Ijut the patient is very weak and easily 
 fatigued. Sight and hearing are normal. 
 
 Anamnesis. — It would be very desirable to be informed of the 
 condition of health enjoj^ed by oui* patient's parents. The pa- 
 tient, I must say agam, is so pale and emaciated, is so puny and 
 backward m his physical development, that one finds it difficult, 
 without further verification, to ascribe these ]3eculiarities solely 
 to the recent mfh-mities, to which the so numerous and so 
 promuient abdommal symptoms pomt. One can not help thmk- 
 uig that his generally weak condition and the local disorders 
 may be but an expression of a general cause (such a cause is 
 most frequently syphilis or tuberculosis) ; is the patient a vic- 
 tim of hereditary syphilis or does he come from a tuberculous 
 family? On inquiry, as you hear, we find that his parents are 
 alive and enjojmig good health; i. e. they do not ail generally 
 and particularly from any chest troubles (they suffer neither from 
 cough nor from any difiiculty m breathmg). Out of a family 
 of seven children, five died m childhood ; those remaming mclude 
 himself and his younger brother, who is not ailing. We can, 
 however, arrive at no positive conclusions from this information ; 
 the fact that out of seven children five died may lead us to sus- 
 pect syphilis, if it were not for the considerable mortalit}^ of chil- 
 dren, which is unfortunately of ordinary occurrence amidst the 
 deplorable circumstances surrounding the life of the peasant. 
 
 The patient himself has no recollection of having been sick 
 until his fourteenth year, but remembers that he was neither 
 thin nor weak. When fourteen, he was apprenticed to a vil- 
 lage tailor. Of the severe life with the latter we have already 
 spoken. After two years of such a life his health began to 
 fail : there appeared belchmg, heartburn, nausea, heaviness at 
 the pit of the stomach, and, later, pain that kept contmually m- 
 
— 41 — 
 
 creasing ; also vomiting, at first rare, tlieii more frequent ; 
 difficult stool; patient grew emaciated, became weak and. sleep- 
 less. After another year's work in such a condition, patient 
 became very thm and very weak, had to give up work altogether, 
 and over a year ago (in May, 1888) returned home, where, 
 although idle, he still lived under much the same chcumstances 
 as before, without any treatment, so that his health was not at 
 all improved for this last year. Some six weeks ago his former 
 constipation gave place to diarrhoea, — slight at the begmnmg. 
 Eleven days ago, September 8th, the patient havmg eaten some 
 mushrooms, cabbage and cucumbers, he soon experienced severe 
 pains in the region of the stomach, then there set m profuse vom- 
 iting of a dark -colored mass (the first and only time), that 
 resembled snuff dissolved in water, and somewhat later, accom- 
 panied by acute pains in the abdomen, he had some six loose 
 stools of the color of tar (indicates the possibility of the presence 
 of blood m the evacuations ijer os and per anum). Smce then, 
 and up to the time he entered the clmic, September 13th, he 
 suffered contmuously from daily vomiting, diarrhoea and aggra- 
 vatmg pains at the pit of the stomach and hi the abdomen 
 generally. He does not recollect the exact time when he first 
 felt pams generally in the back and particularly m the loms, as 
 well as m the abdomen to the left of the umbilicus, but thinks 
 it must be long ago. 
 
 It were now time to enter upon the fuial objective examination 
 of the patient ; but the lecture is at end, and without finishmg 
 this exammation and establishing a final diagnosis, I must take 
 up the treatment of the patient ; I must also explain the neces- 
 sity for such a procedure m certain cases in clinical teaching. 
 The case before you is the first that we examine jomtly, and 
 besides, as far as can be seen already, it is a complex one. To 
 judge by the mformation obtained we must expect disturbances 
 of various parts and functions of the organism : of the stomach, 
 intestmes, kidneys, of nutrition. Either of these two circum- 
 stances (the more so when both together) necessitates a lengthy 
 prelimmary analysis that would require many lectures ; and as 
 we have but three lectures a week, it would take us too long 
 to complete our prelimmary analysis. The patient, meanwhile. 
 
— 42 — 
 
 cannot be left without treatment : this last begins from the 
 time he enters the hospital, so that considerable changes may 
 have taken place in the condition of our patient by the time we fin- 
 ish our extensive examinaition. Let us assume, that he will im- 
 prove, will regain his health, will be cured ; what profit can you 
 derive from the fact that /was able to cure the patient, if you 
 yourselves will not acquire the skill to do it, if you will not be 
 constantly informed as to how such a desirable consummation 
 was attained, and if you will not follow with me the treatment 
 and learn why we use certain remedies, and why we replace 
 them with or add others to them, as the changes in the condi- 
 tion of the patient may demand? I therefore, in such cases, 
 conduct simultaneously the analysis of the patient and the 
 course of treatment, and devote one part of each lecture to a 
 contmuation or conclusion of the primary analysis, and the other 
 to observation, that is, to the discussion of the changes that 
 take place and to the direction of a further course of treatment. 
 It is true that without arriving at a positive diagnosis it is 
 impossible to fully explain just why a certain course of treatment 
 is to be adopted. But, as you know from my introduction to 
 clinical work, and as you see it verified in this case, a diagnosis 
 is arrived at, not immediately at the end of the mvestigation, 
 but gradually while this is being conducted ; if we have not as 
 yet established a positive diagnosis, we nevertheless can not say 
 that nothing in the condition of the patient is clear to us. 
 This enables me, with the aid of the information obtamed by 
 you from the systematic study of internal diseases, to gradually 
 acquamt you, although at first not fully so, with the treatment 
 adopted even before the conclusion of the primary analysis, and 
 thus to attract your participation from the very beginning in 
 such an important matter for you as conducting treatment and 
 investigation. The farther we advance in our primary analysis 
 and generally in our familiarity with the case, the easier will 
 such a method of teaching become ; some such method, however, 
 is mevitable. From my long experience, I will add here, that 
 such a method is not only free from inconvenience, but is indeed 
 useful ; the teacher must at times repeat himself — repeat the 
 same subject twice ; but first, such a repetition is usually a 
 
— 43 — 
 
 more lucid explanation of the subject, and forms an addition to 
 one's knowledge ; and secondly, a repetition of those impressions 
 and mformation most important for the practical physician — 
 that should always be fresh m his mind — will result in this, 
 that all the impressions and information will not be superficial 
 and ephemeral, but will implant themselves lastmgly in the 
 memory of the students. It is well understood that, when in 
 analyzmg the patient's condition the plan of treatment will have 
 been discussed, all the gaps will be filled, and whatever could 
 not be clearly understood m the begmning will be explamed 
 then. 
 
 When beginnmg the discussion of the treatment, as well as the 
 hygiene of the patient, we must first explain to you what has 
 already been done for him smce his admission into the clinic, and 
 what has already produced, as you have heard, a perceptible 
 improvement m the patient's condition. It is hardly necessary 
 to explam the importance of a satisfactory habitation, a warm 
 water-closet, and of flannel around the abdomen of a patient 
 subject to acute abdominal pams and diarrhcjea ; also that he was 
 given food often and a little at a time, — almost exclusively of a 
 semi-liquid nature, and, I may add, lukewarm (tea, milk, soups, 
 everything at the temperature of freshly drawn milk). I shall 
 speak however, more fully later on of such an important subject 
 in any disease, — and especially for our patient, — as diet. You 
 understand the indication for codeine for pain. The chief indi- 
 cation for the wme was the feebleness of the heart's action as 
 evidenced by the weak pulse and by dizzmess ; besides, the wme 
 he got was strong and not sour, such being useful m diarrhoea. 
 I will also remmd you that the rapid combustion of the alcohol 
 of the wme in the blood protects from combustion the tissues 
 of the body, thus checkmg the tendency to exhaustion. To be 
 sure, such effect is inconsiderable, in view of the small quantity 
 of wme the patient gets ; but taking into consideration his ex- 
 treme emaciation and the impossibility, on account of disease 
 of the alimentary organs, of rapid improvement in nutrition, 
 even such a trifling advantage is not to be neglected. 
 
 I will not stop at this moment to explam the indication for 
 the Ems-Kesselbrunnen mineral water. I know, from years 
 
— 44 — 
 
 of experience, that the students attending the clinic are in- 
 formed theoretically, by their text-books, that such and such 
 waters are used in such and such diseases ; while the systema- 
 tic study of mternal pathology teaches them that for such and 
 such diseases such and such waters are ordered; but I also 
 know that they are completely at sea as regards the clinical, that 
 is, the practical, part of balneotherapy — lacking as they do the 
 ability to select^ for a given case, from several, often many, waters 
 recommended for a certain disease, the one most suitable for 
 the case, as well as the technical skill in the use of such mineral 
 waters (how much and at what times to be taken, etc.). But then 
 I consider it the duty of the clinician to familiarize the stu- 
 dents with this subject ; and therefore, from almost the very 
 beginning of my clinical practice, appreciating highly the great 
 importance of mineral waters as an agent of gastric therapy, — 
 and not of that alone either — I have considered it my duty to see 
 to it that the students acquire skill in selecting mineral waters, 
 and that they become accustomed to their practical use. With 
 this in view I utilize the first case, which presents an indication 
 for the use of mmeral waters ; but such a case must be clear 
 in all its peculiarities, and must be fully diagnosticated. Thus 
 only after having established a positive diagnosis and plan of treat- 
 ment will I be able to show you the indication, in our present 
 case, for mineral waters, — for Ems-Kesselbrunnen m particu- 
 lar, — its quantity and the time of its admmistration (one hour 
 before meals, etc.). Once this elucidation is made and some- 
 what extended by suitable examples, no difficulty will present 
 itself in explaining the indication for mineral waters m other 
 cases that we may come across. 
 
 The decoction of condurango and the tincture of nux vomica 
 are not to be compared with the mineral waters in their impor- 
 tance ; but their use will be fully explained in the complete 
 course of treatment later on. 
 
 It remains for us to designate the treatment for to-day. The 
 undoubted and equable improvement of all the symptoms m the 
 condition of the patient pomts to a correct course of treatment, 
 and it will, therefore, be adhered to without alteration ; but in 
 order the sooner to put an end to the abdommal pains and the 
 
— 45 -- 
 
 diarrlicBa, ^yllicll produce a depressing and weakening effect on 
 the patient, I shall replace the codeine with a stronger prepara- 
 tion, — namely, the tincture of opium (tine, opii simplex, 5 
 di'ops in case of more or less severe pains) and a warm bath ; — 
 not quite a warm one, a lukewarm bath will rather tend to 
 aggravate the diarrhoea, consequently also the pams ; a hot 
 bath may weaken the patient, whose heart is abead}' weak. 
 As we aim to relieve the pams and the diarrhoea without weak- 
 enmg the patient, he will be given a bath that will produce m 
 liim a feeling of agreeable warmth. In the determination of 
 the temperature of such a bath we are guided by the foUowmg : 
 the more exhausted and the more sensitive to chills the patient 
 is, the higher must be the temperature of the bath to produce 
 the sensation of agreeable warmth ; if this sensation is mduced 
 in a healthy man by a bath of the temperature of 27 to 28° R. 
 (92.7 to 95° ^.), then a sensitive patient will requne one of 
 29 to 30° R. (97.2 to 99.5° F.) and higher. AVe Avill order for 
 our patient a bath of 29° R. (97.2° F.^ so that, m case he feels 
 chilly, we may be able to at once raise it to a higher tempera- 
 tui-e by addmg some hot water. 
 
 LECTURE OF SEPTEMBER 20, 1889. 
 
 The jjatienfs condition. The gastric and mtestmal pains 
 were relieved (opium was needed onlj* once), but he had one 
 loose stool; there is also less pain in the back. The bath at 
 29° R. (97.2° F.) did not seem comfortably warm to the 
 patient, but when its temperature was raised to 30° R. (99.5° F.^ 
 he felt well and remamed m it for ten mmutes. Was some- 
 what weak after the bath, but slept well — longer (seven 
 hours) and sounder than before. Feels himself generally 
 better to-day. 
 
 Let us now turn to the unfinished part of our joint mvesti- 
 gation of the patient, to the objective exammation. The re- 
 sults of this are as follows : 
 
 Inspectio7i of the whole body. — On the back we find the charac- 
 teristic scaly eruption of pityriasis versicolor, the microscope 
 
- — 46 — 
 
 shows the presence of the parasite m the scales causing the 
 eruption (microsporon furfur), so generally met with in ema- 
 ciated persons, and particularly m those suffermg from or pre- 
 disposed to tuberculosis. Extreme emaciation ; skin thm, with 
 almost no subcutaneous fat. Cervical, axillary and inguinal 
 glands normal. 
 
 Qhest — fiat and generally poorly developed ; scapula3 stand 
 out. Percussion and auscultation elicit nothmg abnormal in 
 the respiratory organs, the heart and the great thoracic arteries. 
 
 Abdomen^ on inspection^ seems to be sunken, and equallj^ so 
 on all sides, also m the region of the stomach (at the pit of the 
 stomach and ui the left hypochondrium). 
 
 Palpation of the abdomen. — I must first make a few remarks 
 concernmg the method of palpating the abdomen, as I practised 
 it before you, and as I usually do it, without gomg into a par- 
 ticular discussion of this method of investigation, which is 
 the busmess of the propaedeutic clmic, i. e. of practical semio- 
 tics. Palpation of the abdomen must be conducted with the 
 utmost care, so as not to cause harm to the patient nor obtain 
 misleading data, and not to mduce, by roug'h manipulation, 
 pam in localities where there is none. I will also add that 
 abdomuial palpation should be practised as uifrequently as 
 possible, as even the most careful examuiation may react un- 
 favorably on the patient; and moreover, the less frequent the 
 palpation, the more appreciable become any changes ui the data 
 obtamed by this method of mvestigation. I first determine the 
 presence or absence of cutaneous hyperaesthesia. I then proceed 
 to palpate the patient as he is usually seen, ui the lymg position, 
 on the back, at first on the median part of the abdomen, from the 
 ensiform cartilage down to the os pubis, then laterally from the 
 hypochondrium to the ingumal region. I always make a double 
 palpation — first superficially, and afterwards a deep one down 
 to the posterior wall of the abdomen if possible. From the data 
 obtamed by such a method of examination (always obligatory, if 
 the inquuy as to the condition of the abdomen demands it) 
 it may be learned whether it is necessary to resort to other 
 means, such as palpation of the abdomen with the patient in 
 the lateral or in any other position, or to some special method 
 
— 47 — 
 
 of palpation. I would also remark that in the case of a doubt- 
 ful, not clearly defined tenderness to pressure in some part of 
 the abdomen, I palpate, for comparison's sake, the correspond- 
 mg locality on the opposite side, so as to avoid a possible error 
 that may be caused by an unequal pressure. I palpate the 
 diseased side somewhat more lightly and the healthy side 
 somewhat stronger. If this should indicate a greater tender- 
 ness on the former, there is, of course, no doubt of its presence 
 there. 
 
 I will now recapitulate the data obtained by palpation : 
 cutaneous h}'percesthesia absent ; quite strong compression of 
 the folds of the skin m various parts of the abdomen do not 
 cause any pain; patient says he feels the forcible squeezing, but 
 experiences no pam. From the upper edge of the liver and 
 spleen, located while percussmg the chest and by the palpation 
 of both hypochondria, it becomes apparent that the dimensions 
 of these organs are normal. The kidneys are inaccessible to 
 palpation, either with the patient in the lying or in any other 
 position. The region of the spleen is not sensitive to pressiu-e 
 (pressure under the left margm of the ribs causes no pain). 
 There is considerable tenderness in the region of the stomach 
 (it was stronger on his admission) and some tenderness on the 
 side of the liver, sharply defined by the region of the gall- 
 bladder ; the remaining portions of the right hypochondrium 
 are not tender. Takmg mto account all these data, together 
 with the dyspeptic symptoms learned by interrogating the pa- 
 tient, and the simultaneous relief of these symptoms and of the 
 pain in the region of the stomach, we must accept the stomach 
 as the seat of this pain, and not the left lobe of the liver. As 
 you will recollect, we found on inquiry, that the patient had 
 severe intestmal pams, which have now diminished. Palpation 
 has shown the region of the descending colon and of the sigmoid 
 flexure to be sensitive, while that of the caecum and of the 
 ascending colon were not sensitive — a good sign, indicating, in 
 the presence of diarrhoea, of a frequent desire to defecate, and 
 of mucus m the evacuations, a simple catarrh of the large m- 
 testine. Tuberculous ulcerations of the intestmes, which one 
 might suspect in view of the extreme emaciation of the patient, 
 
— 48 — 
 
 his weak constitution and the eruption already mentioned, are 
 usuall}^ located at the termmation of the small and the begin- 
 nmg- of the large mtestuies, thus causing tenderness in the right, 
 and not, as m our patient, in the left, iliac region. In the 
 other portions of the abdomen, that correspond to the position 
 of the intestines, there is no sensitiveness on palpation. There 
 is, to be sure, some very slight tenderness along the median 
 line of the abdomen, but it must evidently be referred to the 
 abdommal aorta, which is surrounded by a network of nerves, 
 as the paui is felt by the patient only along the course of that 
 artery, and only when its pulsation is perceptible through pal- 
 pation. This sensitiveness to palpation in the vicinity of the 
 abdominal aorta is of conunon occurrence m exhausted and 
 irritable subjects, as our patient had become from long-contm- 
 ued insomnia. Thus also the considerable pamfulness on the 
 left side of the abdomen, which is sharply defined by the locality 
 of the left kichiey and its ureter, is evidently referable to these 
 two organs, and not to the mtestines, the more so because, while 
 palpatmg the left kidney from the front the patient com- 
 plams of pam simultaneously m the left lorn. Sensitiveness on 
 palpation, although m a lesser degree, is also felt m the region 
 of the right kidney and ureter. We must exclude the partici- 
 pation of the peritoneum, tliat is, the presence of peritonitis, m 
 the production of the abdomuial pams : the character of the pains 
 (which are neither as severe nor as sharp as in peritonitis), the 
 freedom of motion, and the absence of febrile conditions, render 
 it improbable. 
 
 You may see, therefore, that a circumstantial uiquiiy and an 
 exact objective mvestigation make it possible, notwithstanding 
 the existence of many causes for pams and the great variety of 
 them dependent thereon, not to be confused by this variety, but to 
 exactly determme the sources of the pams, the affected organs. 
 As such we fuid, in this case, the stomach, part of the mtestinal 
 canal, both kidneys — particularly the left one — and the gall- 
 bladder. 
 
 Back. — On his admission the patient complained of pains all 
 over the back, particularly m the loins, aggravated by move- 
 ments of the spine. Objective investigation has sho'svn then 
 
— 49 — 
 
 the absence of liypersestliesia cutis, but on pressure tliere was 
 tenderness in the promment bony portions (the spmous pro- 
 cesses of the vertebrae and scapulae), and some in the muscles 
 of the spme and a few intercostal nerves ; directly and acutel}^ 
 pamful was the region of the left kidney, that of the right one 
 less so. At present the patient does not complain of pain all 
 over the back, but only in the region of the loins, especially on 
 the left side. By objective examination we find absence of 
 cutaneous hypersesthesia, the tenderness in the bones, muscles 
 and nerves of the back disappeared, with the exception of some 
 m the lumbar region of the spine, the motions of the spine 
 became freer, but the sensitiveness m the kidneys, especially 
 the left one, has diminished but little. Considermg the fact 
 that while at home the patient slept on almost naked boards, so 
 that his back was subjected to almost continuous trauma- 
 tism, and that with the removal of these latter (the patient 
 reposing on a soft bed while in the clmic) and with the im- 
 provement m his nervous condition, thanks to a more quiet 
 sleep, relief of the abdominal pams, w^arm bath and the like, 
 the pains over the whole back have rapidly dimmished and 
 almost disappeared, — we must refer these pains to the above- 
 named external parts of the back which suffered from trauma- 
 tism. We must, of course, exclude any affections of the spmal 
 cord or it membranes owmg to the absence of any symptoms of 
 such affections. The pains in the back m the region of the 
 kidneys are unquestionably to be referred to the kidneys, as is 
 evident from the data obtamed through inquiry and objective 
 exammation of the abdomen. 
 
 The tendon, knee and other reflexes are normal. 
 
 I have already had occasion to observe that the weak con- 
 stitution and extreme emaciation of the patient, m conjmiction 
 with the pityriasis versicolor, excite a suspicion of the possi- 
 bility of his suffering from tuberculosis. Of the organs affected 
 in our patient, we would in all probability expect the intestines 
 and the kidneys to be the seats of tuberculosis ; we therefore 
 had the faeces and urme exammed for tuberculous bacilli; but 
 m neither of them was their presence demonstrated. 
 
 Having finished our investigation, we should now pass over 
 
— 50 — 
 
 to the positive diagnostication of the case; but m accordance 
 with the method of teaching adopted by me for cases requiring 
 a lengthy discussion, as I explained last time, I must devote 
 the rest of the lecture to the treatment required by the condi- 
 tion of the patient to-day. 
 
 We will certainly not change the hygienic conditions. Pa- 
 tient's appetite is improvmg ; he would fain eat more than 
 he is allowed ; but for the sake of caution we will wait another 
 day or two before mcreasmg his quantit}^ of food. The Ems 
 water, the bitters and the wine we will continue in view of their 
 favorable action. 
 
 In the treatment of the diarrhoea one addition is to be made : 
 notwithstanding the improvement of other symptoms, the evac- 
 uations contmue fluid; this is naturally detrimental to the 
 condition of our emaciated patient and hinders his improve- 
 ment. 
 
 What are we to add to our treatment m order to overcome 
 this difficulty ? If the evacuations up to now had been not only 
 fluid, but also frequent and contamed mucus, — which would 
 pomt to a contmumg catarrhal condition of the large mtestine, — 
 then it were better to mtroduce some therapeutic means per 
 rectum — as tamim suppositories. But the frequent tenesmus 
 has ceased, and there is no mucus m the faeces ; so that the 
 contmuous fluid evacuations point rather to a poor absorptive 
 power of the small mtestine, dependmg, perhaps, on a catarrhal 
 condition of the same. 
 
 The mtroduction of remedies i^er anum in diseases of the 
 small mtestine is recommended as yet only for special condi- 
 tions (as, to destroy microbes, to render ptomames harmless, and 
 to remove accumulated contents), m cholera, typhoid fever and 
 other diseases ; it remains yet for practice to prove the useful- 
 ness of such a procedure ; but in such cases, as m that of our 
 patient, of an evidently simple catarrh, practice speaks for the 
 mtroduction of remedies per os. 
 
 What then shall we prescribe for our patient per os ? Shall 
 we increase the dosage of opium ? No. Opium is mdicated (al- 
 ways after a preliminary emptying of the bowels) m more acute 
 cases of catarrh ; the chief indication for its use is uitestinal 
 
— 51 — 
 
 pain. In chronic cases, where the uitestmal pams have al- 
 ready disappeared, opium seldom cures the diarrhoea, and more- 
 over, it is harmful, masmuch as it tends to derange the appetite 
 and "weaken the musculo-nervous apparatus of the intestmes. 
 The mtestmal pams in our patient are very slight, and the 
 appetite is just beginnmg to improve, while the nervo-muscular 
 apparatus of the intestines is very weak, as is evident from the 
 poorly developed muscular system generally and the constant 
 constipation during the whole course of the disease, mitil the 
 present diarrhrBa. We will, therefore, give him the tmcture of 
 opium as heretofore only in the case of more or less acute 
 mtestinal pams which disturb the patient : five di'ops per dose, 
 while for the diarrhfjea proper we shall prescribe tincture of coto, 
 at first m ten-drop doses in a spoonful of warm water, 
 three times a day, m the intervals between meals, and mcrease 
 the dose if necessary. Why do we give just this, and no other 
 remedy? Fnst, in cases Kke the present one, tinct. coto has 
 proved to be useful, and I can testify to this from my own ex- 
 perience ; and secondly, because in this case tmct. coto seems to 
 be more suitable than the other remedies recommended for 
 diarrhoea, as, for mstance, to mention the prmcipal ones, 
 tannin, lead acetate, silver nitrate, and bismuth. Tannm and lead 
 acetate derange the appetite, while silver nitrate and bismuth 
 subnitrate are less reliable, m my experience, than is tmct. coto. 
 Besides, the simultaneous use of mmeral waters, which is 
 necessar}" for our patient, as you see by the success attendmg 
 the treatment, and as you will find later from the detailed ex- 
 planation of our therapy, makes it easier to bear tinct. coto than 
 tannm and the above enumerated metallic salts. 
 
 Shall we continue the warm baths ? Patient slept particularly 
 well last night after a warm bath — a quiet, soijnd sleep. As 
 a patient's sleejD is better the less the pain he suffers from, and 
 vice versa, we ma}^ assume that the warm bath has tended to 
 relieve the pains and at the same time to diminish the pathological 
 processes that cause these pams. But experience teaches us 
 that a warm bath may also brmg about better sleep m another 
 way, — by changmg the distribution of blood m the periphery 
 of the body and in the internal organs, — m this case m the 
 
— 52 — 
 
 cerebrum : our patient is alwa3^s chilly, and particularly so on 
 sleepless nights ; but last night he was not chilly. The favorable 
 action of the warm bath on the pains and on the sleep is of the 
 greatest importance to our patient, who has so long suffered with 
 insomnia. Without improving the sleep it is impossible to bruig 
 the nervous system, and consequently the whole organism, to a 
 normal condition. The good effects of a warm bath are the more 
 to be appreciated, as it does away with the necessity for the in- 
 ternal admmistration of hypnotics, which, besides inducing sleep, 
 exert other and even harmful mfluences either on the alimen- 
 tary or other organs or on the nervous system itself. 
 
 But the warm bath has also its di^awbacks. The patient felt 
 weak some time before and after leavmg the bath ; it was at the 
 same time evident, from the feebleness of the pulse, that the 
 general debility was a result of weakened hear1>action, which 
 was manifested quite clearly m the cerebral circulation. To re- 
 sort to frequent warm baths, subjectmg the patient repeatedlj^ 
 to such weakenmg of the heart's action, temporary and evanes- 
 cent though it be, is certainly hardly desirable. Besides, the 
 frequent use of the warm bath may establish a predisposition to 
 colds, which must especially be taken mto consideration m view 
 of the approaching winter and the severe conditions of life sur- 
 rounclmg our patient. We will therefore order for him baths not 
 daily, but, as circumstances may require, one every second or 
 third day ; we shall contmue usmg them as long as we obtain 
 favorable results. We may expect that, with his improvement, 
 the patient will be able to bear baths of a lower temperature, 
 29°!'. (97.2°i^.) or even 28° E. (95°^.) ; m case of his complete 
 recovery, he will have lukewarm baths, and later cool rubbings 
 to diminish the susceptibility to cold. 
 
 Finally, I consider it .necessary and, in the present condition 
 of the patient, possible, to give him a general massage ; I say 
 possible in his present condition, because on his admission, a 
 week ago, the numerous pains were so severe, so aggravated by 
 active and passive movements (as, for instance, even when 
 turned over very carefully) , his sensitiveness on account of the 
 insomnia was so great, that he could hardly have borne the 
 slightest massage. Now, as you know, all the pains have dimin- 
 
— 53 — 
 
 islied, the motions are freer, and there is a feeling of comfort, 
 thanks to the qniet sleep for the past week; the application of 
 general massage is therefore timely. But why and for what 
 purpose ? 
 
 General massage for cases not exactly like ours, but simi- 
 lar, was recommended by the American physician S. Weir 
 Mitchell, and gave excellent results. His observations were 
 soon verified and his method of treatment was accepted every- 
 where. I personally can attest to its undoubted usefulness, 
 and in certam cases, I thmk, it cannot be replaced by an}- other 
 method. The idea occurred to Dr. Mitchell m connection with 
 a case like the following : a woman, the mother of a numerous 
 family, exhausted by pregnancies, births, and sometimes b}' 
 lactation, Ijegms verj- decidedly to lose her health ; the appetite 
 and nutrition are impaired, she loses sleep, grows very thin and 
 weak ; with these there are usually associated disturbances of 
 the sexual and nervous functions : too frequent and weakenmg 
 losses of blood durmg menstruation, excruciating pams m the 
 head and back, palpitation, dj'spntjea, etc. The usual remedies 
 such as arsenic, iron, the Iwomides, forced feedmg and others 
 — have no effect, ]3i'uicipally because the household cares and 
 the chikben require mtense physical and mental activity and 
 do not leave sufficient time for sleep, poor though it be, but 
 tend to keep up the disturbance of the health. It is in such 
 cases, that Dr. Weir Mitchell, leaving medicines aside (later, 
 when there is improvement in the jDatient's condition he admin- 
 isters iron, and m very large doses at that), attacks directly 
 the cause of the disturbed health, the muiatural physical and 
 mental exertion and the fatigue resulting therefrom; he pre- 
 scribes 'for the patient absolute rest — physical (remauiing in 
 bed six weeks at first without gettmg up at all) and mental (com- 
 plete abstmence from household duties for the same length of 
 time, and even, as far as jDossible, to be kept free from all dis- 
 turbing impressions ; when not bemg given massage, rubbing 
 and frequent nourishment, the patient is allowed to listen to 
 some light readhig, but is not permitted to read herself). In the 
 absence of physical activity, the only means of mducing a con- 
 stantly good appetite and sleep — the first requisites in the 
 
— 54 — 
 
 improvement of nutrition and of the nervous system — she is 
 ordered general massage. 
 
 The general idea of Mitchell's method of treatment being 
 clear, without gomg mto particulars, for which this is not the 
 time, let us turn to the use of massage in the case of our pa- 
 tient. We were to prescribe for him bodilj^ rest — to rest in a 
 lying position, not only because any movement would produce 
 pam, and does so to some extent even now, but also on account 
 of his extreme weakness and fatigue. I may as well add here, 
 that mental rest is also secured for the patient : his youthful- 
 ness, particularly m connection with his sojourn m the clinic, 
 preclude any care ; his only anxiety — about his health — we 
 succeeded in allaying by promising a complete restoration of 
 health. In the absence of physical exercise we will give him 
 general massage over the whole body except the head, the con- 
 dition of which presents no mdication for massage, and the abdo- 
 men, in which there are so many tender and painful org-ans, that 
 even very careful massage may cause harm. Besides seciu^mg a 
 good appetite and sleep, massage Avill be useful, fu'stly, in di- 
 mmishing the chillmess of the patient's body, by mducing an 
 equable distribution of the peripheral circulation, and through 
 this of the circulation of the rest of the body ; secondly, by re- 
 moving the remainmg pams in the muscles and other parts of 
 the back, it will chiefly tend to better nutrition and to develop 
 the muscles and the other organs of locomotion, which circum- 
 stances, m connection with the general improvement m his 
 health, can not but exert a favorable influence on the future of 
 the whole organism : thirdly, by becoming the means of remov- 
 ing the important disturbance of nutrition, as evidenced by the 
 oxaluria (the constantly abundant urmary sediment consists 
 almost entirely of oxalate of lime). The exact nature of ox- 
 aluria is not known, but its close relation to diabetes mellitus is 
 probable ; the therapy of both has very much m common, and 
 we are therefore led to think that general massage, so useful m 
 diabetes, will also be so in oxaluria. 
 
 The application of massage in our patient we shall alternate 
 with the use of baths : two or three days massage and then a 
 bath. 
 
55 — 
 
 We treat the pityriasis versicolor by rubbing the affected 
 parts with cotton-wool saturated in a solution of corrosive sub- 
 limate (1 to 1000). 
 
 LECTURE OF SEPTEMBER 22, 1889. 
 
 Condition of the patient. — Appetite better, patient begs in- 
 sistently for more food ; the dyspeptic gastric phenomena, with 
 the former quantity of food, consist only of a slight eructation 
 devoid of pain ; stool once a day and of thicker consistency ; 
 intestmal pains very slight ; the pams in the left kidney are 
 dimmishing, but not to an equal extent. Respiration less fre- 
 quent (20 agamst 23 to 25 as previously), evidently on account 
 of the diminished abdommal pain, and partly also because of a 
 sounder sleep. Pulse, 60, stronger than formerly ; patient's 
 weight 92 lbs. (one pound more than before) ; sleep better — 
 always seven hours and quietly ; pains in the back diminished. 
 He bears massage very well ; feels better than usual at the time 
 of, and a few hours after the massage, — at times he sleeps for 
 about one-half hour after it. There seems to be no call for a 
 change in the treatment, while the quantity of food must be 
 increased. 
 
 Diagnosis. — Let us now turn to positive diagnostic conclu- 
 sions, while we follow the same method as we have already 
 explamecl in our mtroduction to the clinical work — as we did 
 in our mvestigation. 
 
 I have already had occasion to observe that the patient's 
 weak constitution and extreme emaciation, as well as the 
 presence^ of pityriasis versicolor, excite a suspicion of tuber- 
 culosis or syphilis. From the data obtained in regard to his 
 parents, we could not, as you will recollect, decide as to his 
 coming from a tuberculous family, nor was there foundation 
 enough for suspecting hereditary S}q3hilis. As far as the 
 patient himself is concerned, everythmg contradicts his suffer- 
 ing from either sypliilis or tuberculosis. As regards the mtes- 
 tines and the kidneys, those organs in which we would suspect 
 the existence of tubercles the soonest, the careful examination 
 
— 56 — 
 
 of the ffeces and urine for the nine clays of his sojourn in the 
 clinic failed to elicit anything to justify the suspicion, while the 
 continuous and comparatively rapid general improvement, as well 
 as the improvement of these organs, speaks decidedly agamst 
 their being uivaded by tuberculosis. Nothing mdicates the 
 existence of syphilis : the hair on the head, quite thick, al- 
 though falluig out a little m the course of the ailment, does so 
 on account of the patient's lack of nutrition, but there never 
 was a decided falling of the hair ; teeth healthy ; outside of the 
 pitj-Tiasis versicolor there is no other eruption, nor is there any 
 scar from any previous ulcerations ; there are no evident traces 
 of any former affection of the mucous membranes ; lymphatic 
 glands are normal, no history of any obstuiate chronic catari-h 
 in the past, nor is there one at present ; no pronounced noctur- 
 nal pains m the tract of the tibiae or other bones, no weakenuig 
 of the memory. 
 
 We must therefore conclude, that the patient has neither 
 syphilis nor tuberculosis, but tlmt, m his present condition, he 
 is predisposed to this latter, or m fact to any other severe 
 disease, as for instance, chronic nephritis (m view of the 
 decided oxaluria and the evident renal colic) and others. 
 
 The Stomach. — This organ, wliich seems from the anamnesis 
 to have been affected the first of all, presents a complete 
 picture of a chronic catan4i : there developed consecutively 
 anorexia, heaviness m the stomach, gaseous eructation, sour 
 eructation with heartburn, pain m the stomach, nausea and 
 vomiting, constipation ; all these symptoms were aggravated by 
 eatmg. But will the coincidence of the gastric symptoms in 
 our patient with the type of a chronic gastric catarrh be suffi- 
 cient proof for us to establish a final diagnosis of the latter 
 without further discussion ? Certamly not ; first, because the 
 disease is of such duration and has so weakened our patient, 
 that we are led to think of somethmg more serious than a 
 chronic gastric catarrh, especially as there was some bloody Voni- 
 itmg, which does not occur in the latter; and secondly, because, 
 this being your first and withal complex case, it must be gone 
 mto as particularly as possible, so that there may be a complete 
 explanation of all pomts, not hindered by any doubts (the more 
 
— 57 — 
 
 so, as all the gastric diseases present many similar symptoms). 
 With, this object in Adew we will call m the aid of differential 
 diagnosis. 
 
 Does not the patient suffer from nervous gastric dyspepsia? 
 This may call mto existence the same symptons as a gastric 
 catarrh : heavmess and pains in the region of the stomach, eruc- 
 tation and heartburn, nausea and vomiting. It chiefly differs 
 from catarrh ui that in the latter all the above enumerated 
 symptoms are constant ; whereas m nervous dyspepsia, in uncom- 
 plicated cases, they are liable to sharp changes m accord with 
 the changes m the nervous condition generally (uncomplicated 
 nervous dyspepsia is rarely seen without a general disturbance 
 of the nervous system) ; if the nervous condition is not normal, 
 then even small quantities of very light food will tend to produce 
 the dyspeptic phenomena ; but so long as the condition of the 
 jiervous system is good, then even abundant quantities of heav- 
 ier food will be digested without any inconvenience ; besides, 
 these changes may occur rapidly, daily. The gastric contents m 
 cases of catarrh contain mucus and, accordmg to the investiga- 
 tions of our clmical assistant, Dr. Popoff, conducted m the lab- 
 oratory of Prof. Babuchin, also leucocytes, whereas neither is 
 present in nervous dyspepsia. But all this refers to j9wre 
 nervous dyspepsia, which is not seen quite often ; if contmued 
 for a long period, it will become associated with a catarrhal condi- 
 tion, which is partly caused by it. Pure gastric catarrh without 
 simultaneous symptoms of nervous dyspepsia is observed more 
 frequently ; but the most frequent cases are probably the com- 
 plicated ones ; viz., catarrh, and at the same time, to a greater 
 or lesser extent, nervous dyspepsia. The presence therefore of 
 mucus 'and leucocytes in the gastric contents mdicates only a 
 catarrh, but at the same time does not exclude the possibility of 
 a simultaneous nervous dyspejDsia. Turnuig now to our patient, 
 the total absence of the above-mentioned sudden changeabil- 
 ity in the gastric symptoms, previously (as I learned in my 
 inquiry) and before us m the clinic, refutes the idea of liis 
 suffering from nervous dyspepsia. Later, when we come to ex- 
 amme the general condition of his nervous system, we will find 
 proofs to justify such a conclusion. 
 
— 58 — 
 
 Does the patient have an atrophic gastric catarrh ? Did not 
 the long continued gastric catarrh induce an atrophy of the 
 gastric glands, which would result in a diminution, or even in a 
 suspension, of the secretion of hydrochloric acid and pepsin, i. e. 
 in the impossibility to digest albuminous bodies ? The rapid dim- 
 inution of the gastric sym]3toms in our patient since his admission 
 to the clinic and their total absence at present while digesting a 
 goodly quantity of largely nitrogenous food (as eggs, soup with 
 bro ken-up meat, milk), speak decidedly against it. 
 
 Does our patient suffer from gastric cancer ? The patient's 
 age and the long continuance of his trouble certainly contradict 
 this supposition, but still not unconditionally. Cancer is possi- 
 ble even at his age ; and as far as the long duration of the 
 disease is concerned, there might at first be a chronic catarrh, 
 while the cancer could appear later. But against cancer sjDcak 
 positively the same data as against atrophy of the gastric 
 glands : rapid improvement of the gastric symptoms and the 
 unimpeded digestion of a tolerable quantity of food. 
 
 We can not be so positive with regard to idcer of the stomach. 
 The apparently bloody vomiting and the frequently occurring 
 (especially before admission to the clinic) attacks of severe 
 pains in the abdomen, accompanied by vomiting, speak for it. 
 The fact that this bloody vomit happened only once m the long 
 run of the disease, and even then only after he had eaten a con- 
 siderable quantity of mushrooms, speaks against ulcer. There 
 are known cases where the use of mushrooms, as a food, was 
 followed by a bloody vomit. The attacks of acute pain in the 
 abdomen accompanied by vomiting might be ascribed to an 
 exacerbation of the gastric catarrh, and also to symptoms of 
 liver and kidney colic (of which I will speak later). Although 
 the rapid improvement in the gastric symptoms and their absence 
 during the digestion of a goodly quantity of food do not speak 
 as decidedly against ulcer as against cancer and atrophy of the 
 glands of the stomach, still they make the existence of an 
 ulcer in our present case hardly probable, because even if im- 
 provement and return to health is j)ossible in gastric ulcer, it 
 could not be so decided in such a short time. 
 
 It is beyond doubt, then, that our patient suffers from a 
 chronic gastric catarrh. 
 
— 59 — 
 
 In a clironic gastric catarrli the mucous membrane of tlie 
 stomach is fomicl to be hypersemic, thickened and covered with 
 mucus. As regards the microscopic appearances, Dr. Popoff's 
 investigations * give the following results : there is observed 
 everywhere a hyperplasia of the tissues of the mucous mem- 
 brane, particularly of the connective tissue, a mass of leucocytes 
 and mast-cells ; the epithelium is not only not detached, but 
 is in a condition of active karyokinesis, while its cells are en- 
 larged and full of mucus : the number of parietal cells is 
 mcreased and the process of karyokinesis is observed m some : 
 then there are a great many chief cells and also a numl^er of 
 cells which it is difficult to clistmguish as belonging to either 
 one or the other (Nussbaum's cells). 
 
 As regards the hydrochloric acid and pepsm, the mvestigations 
 of Dr. Popoff, both from experiments on animals and from obser- 
 vations on patients, show that m the condition of chronic gastric 
 catarrh these substances are secreted in quantities sufficient for 
 digestion, so that the peptic (digestive) power of the stomach re- 
 mams unimpaired, except at the period when fatty degeneration 
 and atrophy of the gastric glands have already begmi. AVhere, 
 then, one may ask, do the dyspeptic symptoms in catarrh come 
 from ? The causes of these are : 1. weakened gastric move- 
 ments, (as evidenced by the msufficient emptymg of the stom- 
 ach, that usually occurs in gastric catarrh) which prevent the food 
 from bemg ultimately mixed with the gastric juice (this may 
 also be caused by the mucus). 2. As Dr. Popoff assumes, the 
 numerous microbes of the stomach, which remain m it. when 
 the latter is in a catarrhal condition, for a longer time on ac- 
 count of bemg surrounded by the mucus covering the wall of 
 this organ, and also because of the sluggishness of the gastric 
 movements. The classification and study of these microbes m 
 the future will surely shed some light on their possible role in 
 causmg the dyspeptic j)benomena m gastric catarrh, as well as 
 their part m the origm of the catarrh itself. 3. Finally, the 
 addition to the catarrh of a nervous dyspepsia, — of possible 
 changes of nervous origin, in the secretion of the gastric juice. 
 
 However that may be, the contents of the stomach in a catar- 
 
 *In liis doctoral thesis, " Catarrli of the Stomach." 
 
— '60 — 
 
 rlial condition contain an abnormal quantity of gases and 
 acids ; then there is besides, as already observed, an insufficient 
 emptying of, and at times even a stretching of the stomach by 
 the accumulated contents, and as a result of the retarded pas- 
 sage of the gastric contents into the intestines, there is consti- 
 23ation. This stretching of the stomach, quite often met with, 
 but usually yieldmg readil}" to correct treatment, must not be 
 confounded, as is often done, with another, a much less frequent 
 but more obstinate and difficultly removable condition of the 
 stomach, viz., dilatation of the stomach, as it is observed, for 
 mstance, m diseases of the gastric pjdorus, that prevent the 
 passage of the gastric contents into the mtestines. 
 
 Does our patient suffer, besides the gastric catarrh, also from 
 stretching of the stomach? The data obtained so far fail to 
 verify this, at least for the later period of the disease : neither on 
 his admission nor at present can we notice the least distention 
 in the left hypochondrium ; the attacks of vomitmg, before his 
 admission, with the catarrh m a condition of exacerbation, were of 
 daily occurrence and the vomitmg non-abundant ; whereas m the 
 condition of gastric distention, vomitmg is abundant m quantity, 
 but of rarer occurrence. But it is principally the rapid improve- 
 ment m the appetite that speaks against gastric distention, because 
 in the latter condition, as long as this distention is not removed, as 
 long as the stomach is not enij^tied (for this, lavage is best), 
 there is anorexia. You will observe, that in discussing the ques- 
 tion as to whether our patient suffers from a distended stomach 
 or not, I do not mention the so-called gastric splash, as I do not 
 consider this a reliable symj)tom of distention of the stomach ; 
 it is true that it usually accompanies distention, but may be 
 found to take place also in the absence of this condition, even in 
 perfectly healthy people ; it is even probable that it may occur also 
 in the mtestmes, at least m the large one. It were unreasonable, 
 in view of the unreliability of such a symptom, to attempt to 
 cause it m our patient, whose abdomen, including the stomach 
 itself and the neighboring very tender left kidney, is so highly 
 sensitive. In the discussion of cases which will present a thera- 
 peutic indication for lavage, and which will later probably be 
 brought before you, I shall touch also on the gastric splash. 
 
— 61 — 
 
 Particular attention has been drawn latel}^ to the stomach and 
 its diseases, to the mvestigation of the walls of the stomach, to 
 the condition of its glands at the time of digestion, to the obser- 
 vations of the fiTst stages of gastric catarrh, to the investiga- 
 tion of alterations m the secretions of the gastric juice in 
 diseases of the stomach and m other ailments. As might be 
 expected, the results obtained are taken advantage of m perfect- 
 mg diagnosis : not only is the matter vomited or that oljtamed 
 by gastric lavage (where this last is used therapeutically) ex- 
 ammed, — all this was certamlj" also done before ; but the gastric 
 contents are directly obtained with a view of examinmg them and 
 the introduction of sample food is resorted to (^' trial breakfast," 
 '' trial dinner "). This consists in introducmg mto the previously 
 emptied and washed-out stomach food of a certain quantity and 
 quality, and later, at certain intervals, the gastric contents are 
 withdi'a'mi and examined : by the results of this mvestigation 
 we judge of the peptic power of the stomach, of the quality of 
 the gastric juice (whether or not it contains a sufficiency of 
 hydrochloric acid and pepsm) and of the strength of the gastric 
 movements (whether or not the stomach is emptymg its contents 
 regularly). Some msistently recommend such procedures m prac- 
 tice, and require their application almost m everj'^ case of gastric 
 disease, claiming that diagnosis, without these, is either impos- 
 sible, or at least msufficient. 
 
 Without drawing at present any general conclusions as to the 
 importance of the above-mentioned methods of investigation, and 
 the judiciousness of their being msisted upon in practice, let us 
 see what data we might obtain, were we to apply these methods 
 to our present case, whose seriousness warrants the use" of any 
 method that would give any special results. If our patient vom- 
 ited or if there were any necessity for washmg out his stomach, 
 then it would certamly be singular not to examme the vomited 
 matter or that obtamed by lavage. But while m the clhiic our 
 patient did not vomit, and lavage was not mdicated (why it 
 was not, is partly ajpparent to you from what I said of the com- 
 plete absence in the patient of any signs of a distended stomach, 
 and will later, in discussing the treatment, be made clear). 
 We consequently would have to resort to obtaining the contents 
 
— 62 — 
 
 of the stomacli and to the expenmental mtroduction of food, 
 that is, to the frequent introduction of the gastric sound. And 
 what woukl we learn by tliis ? We would learn, whether the 
 food is well digested or not, whether or not the hydrochloric 
 acid and pepsin are secreted m sufficient quantity. But we have 
 learned this without the introduction of a sound, and moreover 
 with greater certamty and without any mconvenience or harm 
 to the patient. By mtroducmg easily digestible food m small 
 quantities, we observed that the dyspeptic phenomena began to 
 dimmish rapidly and in a few days disappeared altogether : at the 
 present time our patient, having six meals a day, not onlj- does 
 not observe any dj'speptic symptoms after each meal, but on the 
 contrary soon has a desii^e to eat agam — also a sure indication 
 of a previousl}^ completed digestive act. Consequently, we also 
 mtroduced " trial " meals, and several times a day at that, and we 
 not only learned that the secreted gastric juice ls of normal quality, 
 and that normal digestion can take place, but we also constantly 
 keep under observation the condition of the digestion and its im- 
 provement, not b}' resortmg to the contmual mtroduction of the 
 sound and to the investigation of the gastric contents, — and how 
 mconvenient this would be for both the physician and patient ! 
 — but by being guided by the most reliable criterion, namely, the 
 absence of dyspeptic phenomena and the improvement in the ap- 
 petite, with which the data obtamed by the gastric somid will stand 
 comparison, these bemg frequently misleaduig and.cjuestionable. 
 Besides, these last data can only pomt to the condition of the 
 gastric digestion, and it would therefore be one-sided and erro- 
 neous to judge by them — as one is often tempted to do — of 
 the condition of digestion in general, because dig-estion takes 
 place not m the stomach alone, but to an equal, if not to a 
 greater, extent also in the small mtestine. 
 
 But this is only one side of the question ; let us look at the 
 other. Does not the introduction of the stomach-tube entail 
 hardships on the patient, — may it not even harm him ? It is 
 only after persistent persuasion on the part of the physician, 
 that patients overcome the feelmg of extrelne disgust towards 
 this procedure. As far as harm is concerned, not to speak of 
 the unfortunate accidents m the past that were due partly to 
 
— 63 — 
 
 tlie imperfectiiess of the metliod and partly on account of the 
 physcian's negligence, even now, with the most perfect method and 
 extreme care, the introduction of the sound is often not devoid of 
 harm to the patient. Thus, in our patient, in the presence of the 
 exacerbation of the gastric catarrh, wdth which he was admitted 
 to the cluiic (daily vomiting with acute pam), the introduction 
 of the sound might have caused a fresh attack of nausea and pain, 
 that is, it might have aggravated the condition of the stomach, 
 that was just beginnmg to improve when the patient m general 
 and his stomach m jjarticular were surrounded as far as pos- 
 sible by favorable conditions. This would take place m a catar- 
 rhal condition of the stomach ; the risk of mjuring the patient 
 would l3e greater still m gastric ulcer or cancer. The introduc- 
 tion of the sound, in cases of nervous dyspepsia, may also 
 considerably aggravate the condition of the patient. More than 
 once, at medical consultations, have I seen severe cases of ner- 
 vous dyspepsia and general nervous disturbance, m which the 
 proposition to introduce the sound was under discussion, — a 
 proposition that in the majority of cases had to be set aside, and 
 the patient improved despite or rather on account of its non-intro- 
 duction. It can not be denied, that the thoughtless mtroduc- 
 tion of the somid, without sufficient reasons, unfortunately quite 
 frequent with practitioners who are carried away by novelty 
 and fashion, deserves strong condenmation. 
 
 From the foregoing it becomes clear which method would be 
 the more reliable m determinmg the condition of our patient's 
 stomach and its peptic power, — the one that we have chosen, 
 creatmg for the patient and his stomach jDossible favorable con- 
 ditions, and removmg whatever aggravated the condition of the 
 stomach and made digestion difficult, or the other, in which we 
 would add to the above the introduction of a gastric sound, that 
 might exert a contrarj^ influence. 
 
 Let us now consider the importance of the gastric sound in 
 the differential diagnosis of our case. In regard to the atrophic 
 condition of the gastric glands, the rapid decrease of the dyspep- 
 tic phenomena and the improvement in the appetite speak so 
 strongl}^ against it, as to obviate the necessity for using the 
 so mid. While its use with a diagnostic j) expose in the case of 
 
— 64 — 
 
 cancer would not only fail to give as good results as were ob- 
 tained by observation, but would even lead to vacillations in 
 the diagnosis. In fact, the rapid decrease of tbe dyspeptic 
 phenomena and the improvement in the appetite, which are not 
 to be thought of m a case of a fully developed cancer (the pa- 
 tient has been ailmg for a long tune), enabled us to positively 
 exclude cancer; whereas the examination of the gastric con- 
 tents obtauied by the aid of the sound, b}^ showing the presence 
 of hydrocliloric acid, would lead us to doubt as to whether the 
 case was that of a simple chronic catarrh or whether cancer 
 might not also be present ; for, although m the majority of cases 
 of cancer the contents of the stomach contam no free hydi-ochloric 
 acid, appreciable under certam color reactions, still there are 
 frequent exceptional cases, hi which the free acid is found. In 
 ulcer of the stomach the mtroduction of the sound, not to speak 
 of special risk of injurmg the patient, would give notion g of po- 
 sitive value m the way of a differential diagnosis between thLs 
 condition and chronic catarrh. As regards nervous dyspej)sia, 
 we have said before, that the complete absence of sudden 
 changes in the local (dyspeptic) phenomena, and as we shall see 
 later, the general nervous condition of the patient, permitted us 
 to j)Ositively exclude it without necessitatuig a supplementary 
 investigation. 
 
 But some will say, this is all clear to me now ; but how was 
 it at the begmnmg ? In the beginning it was only probable, that 
 the patient had a clironic gastric catarrh, and no other disease 
 of the stomach ; but the pi-obability became stronger every day, 
 so that in a few days the probabilit}' became a eertaijity. To be 
 sure we had to wait a few days ; but washing of the stomach, 
 the introduction of a " trial " meal and, subsequent to this, the 
 frequent introduction of the somid, as well as the repetition of 
 this procedure (which would be necessary m such a serious, 
 complicated case of long duration), would also require rather 
 more than less time, because, as was explamed above, observa- 
 tion of the patient when surrounded by favorable conditions 
 only would clear up the matter sooner than if he were surroun- 
 ded by both favorable and unfavorable (the mtroduction of the 
 sound) conditions. The ^possibility of keepmg the patient mider 
 
— 65 — 
 
 observation after he had been placed among favorable circum- 
 stances, the causes keeping up the diseased condition having been 
 removed, while strong medical agents are not resorted to before 
 the matter is clear, — this possibility is of great value m arriv- 
 ing at a correct diagnosis, and consequently, also, correct thera- 
 peutics, especially in chronic cases. 
 
 Now that we have considered the value that the gastric sound 
 and the mtroduction of a " trial " meal would have in our case, I 
 can express my opmion concerning the importance of this method 
 of investigation in its present state for the diagnosis of gastric 
 diseases in general ; only rare cases present a judicious reason 
 for the application of this method; it may be otherwise when m 
 the course of time the reliability of the data obtained by this 
 method will be increased. 
 
 To avoid misunderstandings, I will add that we must not con- 
 found two different matters : it is one thmg to work out a new 
 method, which is always a matter worthy of respect, but is only a 
 question of the personal mvestigations of the clinician, and not a 
 subject of uistruction for his students ; to these he must communi- 
 cate only tried methods, that deserve to be applied m practice 
 on account of then valuable results ; nor must they be Ijurden- 
 some to either patient or physician. It is another thing to pre- 
 sent to the students methods that are mcomplete and may 
 burden them with procedures that offer nothing new or valuable, 
 at the same time inconveniencing the patient and leadhig to waste 
 of time and energy on the part of the physician, besides distractmg 
 his attention from facts that are important and yet easily obtain- 
 able. Many a time have I seen the fruitlessness of the labors of 
 physicians brought up under such influences : such a physician 
 would collect a mass of minute and worthless data (not to speak 
 of the present time, let me recall the " titration " ej^idemic of 
 sad memor}^, the exhaustive exammation of the ui'me, useless for 
 practical purjDOses, etc.), without knowmg what to do with them : 
 he would spend time and energy in collecting these and, not 
 havmg passed thi'ough a regular clmical course, he fails to ob- 
 serve the simple, patent and nevertheless very important facts : 
 and even if he does observe, he does not take advantage of them, 
 and thu.s remams, until taught by bitter experience, if not for- 
 
— 66 — 
 
 • ever, a fiiiical seniiotician, a ]30or diagnostician, and consequent- 
 ly an inefficient therapeutist. Such a physician prides himself 
 on his " scientific " method of practice in that he applies the 
 minutest and latest results of mvestigations, not comprehending 
 that science — the highest common-sense — can not be contra- 
 dictory to the orduiary reasonmg, according to which we must 
 select from a great mass of data only what is of utility, and 
 must resort to methods of investigation that are really necessary. 
 I must remind you that whatever has been said of the gastric 
 sound refers to its use for diagnostic purposes ; its application 
 in therapeutics, where it constitutes a useful, unreplaceable 
 method of treatment, is a totally different matter, of which we 
 shall speak later. 
 
 LECTURES OF SEPTEMBER 27 AND 29 AND OF 
 OCTOBER 4, 1889. 
 
 Patient^ s condition Septemher 27. — Former treatment con- 
 tinued ; the quantity of food increased : up to the 2 2d the 
 patient got two glasses of milk, two glasses of soup with finely 
 broken up meat, two eggs, and about one-quarter pound of white 
 bread; but now he gets besides these two glasses of milk- 
 soitp with manna, one-fourth of a chicken, and another one- 
 quarter pound of bread. This quantity of food the patient takes 
 m seven portions. The appetite contmues improvmg and the 
 patient craves for more food. The only dyspeptic symptom is 
 slight retchmg. The pains m the stomach and on the side of 
 the gall-bladder have disappeared entirely : pressure m these 
 regions elicits very little tenderness. Stool — once a day, pain- 
 less (smce the 22d he has been given the opium drops only 
 twice) ; evacuations thicker, not liquid, but soft and somewhat 
 formed, without mucus. The urine is less pale, with a smaller 
 sediment of oxalate of calcium. The pains in the kidneys, and 
 especially m the left one, persist as yet and become aggravated 
 on movmg and walkmg, if the abdomen be not suffiently sup- 
 ported by the flannel bandage ; the left kidney is still verj- 
 sensitive to pressure. The pains in the back are limited to the 
 region of the kidneys, the others have disappeared after mas- 
 
— 67 — 
 
 sage. Tlie organs of tlie chest are normal, as before. For five 
 clays tlie patient gained another pound in weight (his weight is 
 now 93 pounds). Sleeps quietly, some seven and one-half 
 houi'S at night and one-half hour m the day-time ; mental con- 
 dition better, physical weakaess less. The former headaches 
 and dizziness absent. 
 
 There is evidently no need of changing the treatment; we 
 must only increase the dose of the tmcture of coto, as the evac- 
 uations are as yet changeable, at times formed, at others not : 
 besides, the patient might become habituated to the previous 
 dose : we will give him now fifteen drops thi^ee times a day (in- 
 stead of the former ten). We will also add some cognac to 
 the milk — a teaspoonful to a glass. The quantity of food will 
 be carefully mcreased. 
 
 We will turn now to the diagnosis : 
 
 The diagnosis of the condition of the stomach was finished 
 last time. We will only add to-day, that the mcrease of the 
 appetite and the contmually improvmg digestion tend more and 
 more to verify our diagnostic conclusions concerning the con- 
 dition of this organ. 
 
 The intestinal tract. — Until last August the patient suffered 
 with a constant constipation. The causes of this might be : 
 first, the retarded passage of the gastric contents mto the intes- 
 tmes because of the weakened movements which usually 
 accompany gastric catarrh (the patient on admission had no 
 signs of dilatation of the stomach, probably on account of tlie 
 constant vomitmg before admission, which emptied this or- 
 gan) ; and second, a weakening of the nervo-muscular activity of 
 the stomach and mtestmes, due to the weakness of the nervo- 
 muscular apparatus m general and to his sedentary life. Since 
 Augnst the constipation has been replaced by a diarrh(jea — a 
 sign of a superadded intestinal catarrh. Both the large mtes- 
 tme (frequent painful strammg, mucus m the evacuations. 
 P-tms in the region of the sigmoid flexure) and probably the 
 small one (as was exp lamed when ordering tincture of coto) are 
 effected by the catarrh. The patient's weak constitution and 
 poor nutrition, as well as his pityriasis versicolor, excited a sus- 
 picion of tuberculosis m general, and of that of the intestines 
 
— 68 — 
 
 in particular, although the absence of fever and pams in the 
 ileo-coecal region spoke against it. Repeated exammation of 
 the fseces failed to prove the presence of intestmal tuberculosis, 
 while the rapid improvement in the general condition as well 
 as in the condition of the mtestines also positively exclude 
 it. 
 
 The liver mid the hiliary j^assages. — The liver presents noth- 
 ing abnormal : the pam elicited by pressure at the pit of the 
 stomach was referable, as explamed during the objective exam- 
 ination, not to the left lobe of the liver, but to the stomach, 
 There is slight but constant tenderness on pressure m the region 
 of the gall-bladder, pomtmg to some, diseased condition of the 
 bladder. Which is it? From the data at hand it points only 
 to biliary calculi m the bladder ; the slight intensity of the pains 
 spealts against pericystitis, while the entire absence of swelling 
 excludes any new formation. Catarrh of the gall-bladder, as 
 part of the general catarrh of the biliary passages, must also be 
 elimmated, on account of the absence in the past and at the 
 present time of any symptom of this condition, namely jaundice, 
 as a result of the obstruction of the biliarj^ passages, due to their 
 catarrhal condition. There remain then biliary calculi. Whe- 
 ther or not our patient had attacks of biliary colic brought on, 
 under accidental circumstances (as by traumatism, b}- riding 
 in a jolting carriage, by faulty diet, mental excitement, cold), 
 by the presence of calculi in the bladder, we can neither deny 
 nor affirm. We have not observed them m the clmic ; but then 
 every exacerbation and every attack of pam ceased in the clinic. 
 Concernmg the past history of the patient it is impossible to de- 
 cide as to what extent'the attacks of pain eventuating in vomit- 
 mg depended on the exacerbation of the gastric catarrh and to 
 what extent they were due to liver and kidney colics. As re- 
 gards the last two diseases, we may mfer, judging by the present 
 condition of the patient, that the principal colic was of renal 
 origm. 
 
 Kidneys. — The left kidney is very tender on pressure ; the 
 right one much less so. Besides, at home, after a jolting ride, 
 and, to a very slight extent, in the clinic after walking, there 
 appeared typical attacks of renal colic, viz., pains in the re- 
 
— 69 — 
 
 gion of the left kidney, radiating upward and into the left lorn, 
 as well as downward into the left groin and left testicle. The 
 cause of this is evidently ascribable to concretions of oxalate of 
 lime m the pelves of the kidneys (nephrolithiasis), especially in 
 the left one. We say of oxalate of linie, because our patient has a 
 typical oxaluria : urine pale, but strongly acid ; on his admission 
 it gave an abundant sediment of crystals of oxalate of liine, with 
 scarcely any uric-acid deposit. Further than this the kidneys are 
 not affected : there is neither hsematuria nor any catarrh of the 
 renal pelves, (the urine contams no mucus, no leucocytes, no 
 epithelium from the renal pelvis, nothing but a small quantity of 
 bladder epithelium), nor nephritis (albumen and cylmders are 
 also absent m the urine). The patient himself presents a typical 
 oxaluric aspect, as described by the well-known neapolitan clini- 
 cian, Cantani : mental and nervous oppression (oppressed mental 
 condition and bodily weakness on his admission), emaciation in 
 general and of that the muscular system in particular, and severe 
 pams m the loins. I will add that, with the improvement m general 
 and with that of nutrition in particular (as seen by the gain in 
 weight), there was also observed a turn for the better in the course 
 of the oxaluria : the urme is now less pale, and gives a less abun- 
 dant sediment of oxalate of lime crystals, but, instead, more of the 
 uric-acid deposits (amorphous sodium-urate and even crystals of 
 uric acid). Physicians resident at the mmeral springs, such as 
 Contrexeville, where so many suiferers with oxalic acid 
 nephrolithiasis congregate, have observed that, with the im- 
 provement in health m these patients, a dimmution in the 
 oxalic acid sediments in the urine takes place, while the uric-acid 
 sediments mcrease proj)ortionately.* However, the improve- 
 ment in our patient is only noticed in the oxaluria as yet ; the 
 kidney pains decrease very slowly. Experience has shown that 
 the concretions of oxalate of lime, formed m the pelvis of the 
 kidney, are the most difficult of all to treat, and require a long 
 time before they disappear. 
 
 Does not our patient suffer from movable kidnej^s, es^Decially 
 the left one, which is so sensitive on motion (although this symp- 
 
 * Debout d'Estrees: Des iudications des eaux de Coutrexdville, Paris, 
 1889, p. 8. 
 
— 70 — 
 
 torn is also found with renal calculi) ? Notwithstanding the 
 patient's extreme emaciation and his sunken abdomen, we were 
 unable, while examming him, to even once feel the left (or the 
 right) kidney ; however, this fact would speak agamst a ma- 
 terial displacement, but would not exclude limited mobility of 
 the kidney, for the existence of even this latter condition is suffi- 
 cient to account for severe renal pains while in motion or while 
 bemg jolted. Considering the extreme failure of nutrition, the 
 weakening of all the tissues of the body and the number of 
 traumata, to which our patient was subjected (riduig m a 
 wagon), mobility, especially of the left, painful kidney, is very 
 probable. 
 
 Patient's chesty as we said before, is poorly developed. The 
 lungs and the respiratory tract present notlihig abnormal ; the 
 heart is normal except for the weakness of its contractions. 
 The weakness of the pulse, which is now decreasing, depends 
 partly on the anaemia, partly on the weakened heart-action, that 
 accompanies failure of nutrition m general and of the muscular 
 system in particular. 
 
 Nutriti07i and JTcematopoiesis. We have pomted more than 
 once to the extreme failure of nutrition and to the poor develop- 
 ment of the patient, as well as to the causes of these conditions ; 
 we have also called j^our attention to another important symptom 
 of a greatl}^ disturbed nutrition, namely, oxaluria. As regards 
 hsematopoiesis, the patient certainly presents ansemic symptoms 
 — a weak pulse, paleness, dizziness with a pale face, chilliness, 
 etc. ; but his ansemia is only a part of the general failure of nutri- 
 tion, and not an mdependent affection, as chlorosis, pernicious 
 anaemia, leukcemia. We draw this conclusion, first, from the 
 complete absence of any sjmiptoms of the above-named diseases, 
 and secondly, from the fact that neither the spleen nor the lym- 
 phatic glands present anything abnormal. 
 
 His nervous system^ when he was admitted to the clinic, pre- 
 sented, as you will recollect, the following abnormal phenomena : 
 poor sleep, dizziness, pains in the head, back and abdomen, 
 oppressed mental condition and bodily weakness — an aggrega- 
 tion of symptoms which is usually observed hi persons suffering 
 from nervous debility, — neurasthenia. Must we conclude from 
 
— 71 — 
 
 this that our patient has neurasthenia ? We constantly hear in 
 our practice nowadays of cases diagnosed as " neurasthenia," 
 and we find that under this name entirely different cases are 
 mcluded, which are similar only in their nervous manifestations, 
 and not even m all of these. Such a custom will eventuate in 
 the term neurasthenia losing its distmctive significance and be- 
 commg a name only for a group of symptoms, and this not 
 always the same ; whereas m reality it defines a certam disease. 
 
 Here are the characteristic features presented by persons suf- 
 fering from a typical, pure, uncomplicated neurasthenia : ofttimes 
 they are men sturdilj^ built, long-lived, with perfectly healthy 
 pectoral and abdominal organs of a normal (up to a certam 
 period) functional activity, and an excellent nutrition ; and still 
 they are complammg of nervous disturbances, that at times 
 they sleep well, at other times poorly, without being able to as- 
 sign any reason for it ; of a rapid changeability of the mental 
 condition — now oppressed, now excited ; both their mental 
 energ}^ and physical strength quickly give way to weakness. 
 To all this there is superadded pain in different parts of the 
 body, for which there would, at the painful spots, seem to be 
 no apparent local cause ; also hj^pertesthesia cutis and an in- 
 crease in the tendon reflexes ; later on disturbances appear in 
 the functions of different organs, usually first of all constipa- 
 tion, later (occasionally a long time after) nervous dyspepsia, 
 palpitation of the heart, and other symptoms. Investigation of 
 the causes of such a diseased condition usually brmgs to light 
 hereditary predisposition, — weakness and susceptibility of the 
 nervous system from their very birth, and also affections of the 
 latter acquired through the agency of noxious influences. 
 
 Is it thus with our patient ? The poor sleep in his case was 
 not the result of unknowai causes, but was due to the pams, up- 
 on the relief of which it soon became normal ; with better sleep 
 and with the improvement of the pulse (of the heart-action) 
 the headaches and dizziness also soon disappeared; the other 
 pains were very clearly traceable to various diseased conditions 
 in parts where they were felt; our joatient has neither skin- 
 hypersesthesia and mcreased tendon reflexes, nor any apparent 
 signs of nervous dyspepsia, nor palpitation of the heart; nor is 
 
— 72 — 
 
 his mental condition changeable ; on the contrary, he is very 
 reserved ; the oppressed mental state m which he was when ad- 
 mitted soon passed away with the relief of the; pams, improvement 
 in the sleep and with the revival of hope in our patient ; the 
 considerable and slowly disappearing physical weakness is 
 easily explamable by the extreme emaciation of the muscles and 
 the unsatisfactory development of the skeleton. Considering 
 the general failure of nutrition m our patient, which would nat- 
 urally reflect itself in the nutrition of liis nervous system, then 
 the poor sleep for a prolonged period of time, and the acute pams 
 in the many affected organs for a similar period, which m its turn 
 would affect the nervous system injuriously, and observmg at 
 the same time, how rapidly the latter improves simultaneuosly 
 with the general improvement in the patient's health, with the 
 relief of local pains and better sleep, we must conclude, fu"st, 
 that our patient's nervous system presents not only a particu^ 
 larly weakened condition, but that, on the contrary, it appears 
 to be the strongest part of his whole organism ; and secondly, 
 that our patient has no real, primar}" neurasthenia; that his 
 nervous symptoms were developed m consequence of and 
 owmg to diseases of other organs (witness the anamnesis), 
 and they pass away so quickly with the removal of the causes, 
 that they evidently disprove the existence of obstinate neuras- 
 thenia, even of secondary origin. 
 
 As is evident from the preceduig, the summary of our diag- 
 nostic conclusions is as follows : our patient has a clu'onic gastro- 
 mtestmal catarrh, that assumed an acute form before he entered 
 our clmic ; also biliary calculi, renal colic, very probably a mov- 
 able left kidney, serious failure in nutrition, with oxaluria', pity- 
 riasis versicolor, a series of secondary nervous disturbances of a 
 passing nature, extreme emaciation of the muscles, and a poorly 
 developed skeleton. We can not state the degree of depen- 
 dence of the last two conditions on heredity, as we know but 
 very little of the constitution and health of the patient's parents ; 
 but it is beyond doubt that at first the contmuous sitting in the 
 position of a tailor at work, and later on the uninterrupted lying- 
 posture, on account of the pams and weakness, which means a 
 contmuous lack of regular phj^sical exercise and fresh air in the 
 
— 73 — 
 
 course of the last four years, in the period of adolescent growth 
 of the organism, could not but play an important part in the 
 development of the diseased conditions above mentioned. 
 
 Progyiosis. — The patient's condition is serious, that is, such 
 (vide Introduction to Clinical Exercises) as not to present any 
 immediate danger to life, but such a danger may arise either 
 because the various affections of our patient, becoming aggra- 
 vated on the return to his former surroundmgs of life, may 
 bring him into a condition beyond remedial action, or, rather, 
 because of the possible development in the exhausted organism of 
 tuberculosis, chronic nephritis, etc. ; or finally, some accidental 
 cause, such as a severe cold, may bring about a rapidly develop- 
 mg affection that may prove fatal to the weakened organism. 
 The diseased conditions of the patient are not of a fatal character 
 ■per se, and are curable. Whether or not they are easily 
 curable is another question : it must be apparent even to you, 
 beginners though you be, that they are difficultly curable 
 conditions, — particularly so, if we are to apply treatment as 
 thoroughly as our science demands it ; i. e. not only to effect 
 the removal of local affections, but also to improve the patient's 
 nutrition and constitution, without which treatment will be far 
 from thorough ; nor would the improvement m health be lasting. 
 But the chief difficulty lies m this, that if we even succeed in 
 removmg the local disturbances while he is in the clmic, m im- 
 proving his nutrition and in directmg into a healthy path the 
 future well-being of the patient, we must teach him to live, as 
 as far as possible, under such conditions of life, that he may, 
 after leavmg the clinic and returnmg to the former unfavorable 
 surroundings of life, remam m the possession of what he gamed 
 and thuS strengthen his health the more. 
 
 Such is, in the given case, the physician's view of the future. 
 Of this the patient must be informed only so far as will enable 
 liim to appreciate his own condition and his individual hygiene, 
 in order to combat noxious mfluences, and by avoidmg them to 
 preserve his health ; but not so much of it as would discourage 
 liim, depriving him of the energy so essential in the struggle. 
 
 Treatment. — To meet all the requirements of hygiene is the 
 essential condition of every successful treatment. You know 
 
— 74 — 
 
 by this time the nature of and the reasons for the hygienic con- 
 ditions under which we placed our patient ; you also know that, 
 partly with a hygienic purpose in view (to make up for the lack 
 of exercise) and partly on account of certam therapeutic objects, 
 as already explamed, massage was ordered for our patient. It 
 remains now, while we occupy ourselves with the hygiene, to 
 speak of the diet. 
 
 As a drmk, the patient was given only tea, lukewarm, neither 
 hot nor strong. Water, especially if not warmed, would only 
 tend to prolong the diarrhoea. Lukewarm tea, as a slightly 
 astringent drink, is more suitable for diarrhoea. But tea is not 
 only slightly astringent, it is chiefly a stimulant and the patient is 
 habituated to its use ; this is to be taken into account. I will not 
 enter now into a detailed discussion of the important question, as 
 to the limits to be permitted by the physician m the use of stimu- 
 lants, as our case does not j)resent a sufficient reason for such a 
 discussion : our patient not only does not abuse the most impor- 
 tant of these, — wme, brandy and tobacco, — but does not use 
 them at all. I will only observe that, as the normal course of the 
 nervous and consequently of the other functions of the body 
 does not, strictly speaking, require the aid of coffee or tea, and as 
 a resort to such beverages will therefore oidy throw out of 
 balance the regular operation of these functions, the physician can 
 certainly not advise those not accustomed to the use of such stim- 
 ulants to become habituated to them, but, on the contrary, he 
 must dissuade them from acquiring such a habit. It is a differ- 
 ent matter when one is already habituated to the use of tea or 
 coffee. If these have been used for a long time m moderate 
 quantities without exerting any particularly noticeable unfavor- 
 able mfluence, then there is no reason for msisting on absti- 
 nence from them, because their discontinuance (not to mention 
 the fact that m the majority of cases the physician's prohibition 
 will be like unto the voice clamoring in the wilderness) is often 
 accompanied by important and, in the case of an active life of 
 the habitue, very distressing disturbances to his health. To be 
 sure, cases of abuse of these beverages with evident bad conse- 
 quences therefrom, require either limitation in their use or even 
 total abstinence ; the latter, as is evident from what was just said 
 
— 75 — 
 
 concerning their moderate use, is to be accomplished very care- 
 fully. The use of wine, brandy, and to a certain extent of tobacco 
 must certainly be regarded much more seriously, and their limited 
 use or their discontmuance must be urged more msistently ; but 
 I must say agam, their total discontinuance is in certain cases to 
 be undertaken with great caution, after weighing all the cir- 
 cumstances pro and contra. 
 
 To cause our patient to discontinue the use of tea and to com- 
 pel him, in his present condition, to give up an accustomed and 
 a most permissible stimulating beverage, would be not only m- 
 expedient, but positively erroneous. Our patient needs the tea 
 not only as a drink suitable for diarrhoea, but also as a gentle 
 stimulant. The indications for stimulants are so strong in this 
 case that we have even prescribed wme for him, the indications 
 for which have been pointed out above. 
 
 " We will now take up the question oifood. The patient was 
 admitted with a chronic gastric catarrh, and in a state of exacer- 
 bation at that. We first of all took care to see to it, that the 
 food did not irritate the stomach, and with this m view we 
 ordered it preferably in a liquid form (particularly on account of 
 the possible, although hardly probable presence of ulcer of the 
 stomach), viz., such as would not irritate mechanically ; and warm, 
 so as not to produce any thermic irritation — neither hot nor 
 cold (especially in view of the diarrhea) ; and finally such as 
 not to irritate the stomach chemically (the patient, of course, 
 gets no vinegar, mustard, or pepper, etc.). 
 
 Now come the most important questions concerning the 
 quantity and quality of food and the time for taking it. 
 You know that we mstructed our patient to eat little at a time 
 and often ; you also know the nature of the food. The general 
 success of the treatment stands witness to the fact that it also 
 has been administered correctly. You are, doubtless, desirous of 
 knowing why such an apportionment of food was successful and 
 what guided us m prescribing it. We will take it up in order. 
 
 The quantity and the apportionment of the food. — If a patient 
 with a catarrhal condition of his stomach is given, at his usual 
 meal-times, for breakfast or dmner, one-haK or even one-third 
 of his ordinary quantity of food, he will, on taking it, fail to ob- 
 
— re- 
 serve any dyspeptic symptoms at all or lie will have them in a 
 much lesser degree ; but he would usually complain of either 
 being hungry or at least of not experencing a feeling of satiety, 
 that is, a sufficient filling of the stomach. This fact is the basis 
 of the commonly accepted and very useful method of adminis- 
 tering food to such sick — little at a time and at frequent 
 intervals. How is this to be ordered? 
 
 A sensible, careful patient, with a strong will-power, is ad- 
 vised thus : Eat little at a time, — enough to still the hunger, 
 but never gorge yourself, not even to complete satiety ; but as 
 soon as you feel not merely hungry, but a lively appetite, eat 
 again the same quantity, that is, without complete satiation. 
 It is usually necessary to add : eat as slowly as possible ; do 
 not hurry (a besetting sin) ; you will thus be able to better 
 chew the food and will observe that your hunger is the sooner 
 satisfied : you finish eating before being over-sated. To be sure, 
 even with such patients and with such instructions we do not al- 
 ways at once get good results ; but we at once establish the proper 
 quantity of food to be taken at one time. Patients are liable 
 to either overeat, or to eat too little at a time, if frightened by 
 too energetic instructions from the physician, particularly if 
 they be over-scrupulous : they will not repeat the meal often 
 enough, and by going hungry interfere with the success of the 
 treatment. But if the physician follows attentively the course 
 of treatment and repeatedly offers additional explanations, then 
 the patient will acquire the habit of taking his meals regularly, 
 thus guaranteeing a healthy condition of the stomach also for 
 the future. 
 
 On the other hand, in some cases — as, for instance, m our pa- 
 tient — such instructions are not sufficient. He was habituated 
 to poorly nutritious, bulky and difficultly digestible food ; here 
 he gets food that is nourishing, of small bulk, easily digested, 
 and besides more palatable and more appetizing. It is, there- 
 fore, rather dilhcult for him to observe the principal require- 
 ment in eating, namely to eat till hunger is satisfied, and not to 
 satiety. If the quantity of food be not clearly limited, he will 
 always overeat. In such cases the physician must do as we 
 have done : havmg explained to the patient the above-mentioned 
 
— 77 — 
 
 requirement, define exactly the quantity of food and the fre- 
 quency of the meals, and then verify their correctness by 
 observation, increasing or diminishing the quantity of and the 
 intervals between the meals in accordance with the degree of 
 the dyspeptic phenomena and the condition of the appetite. 
 The gradual increase in the general quantity of food runs par- 
 allel to the improvement m the condition of the stomach, as 
 you see clearly from the j)resent case. 
 
 It is even more difficult to properly prescribe the quality of 
 the food. To be guided only by general hygienic and phj'sio- 
 logical data will not bring the desired results, as even little 
 experience will prove : isolated cases are too often met with 
 presenting too great idiosjmcrasies. In consideration of this it 
 only remams to thoroughly study the given case. Our patient 
 had a gastric catarrh while mgesting poorly nourishing food, 
 that was Imlky and not frequently taken ; we proved success- 
 ful with him while givmg him food of an exactly opposite 
 nature. In other cases, as for instance, in those of pure ner- 
 vous dyspejDsia, uncomplicated by catarrh, nourishmg but too 
 delicate food is often successfully replaced by a coarser food. 
 To be sure, we may run across some verj- difficult cases ; but a 
 careful investigation of every given case, of the habits and 
 peculiarities of the patient as regards his food (as to which kind 
 of food agrees with him and which not) will always enable us 
 to prescribe, in accord with the hygienic and physiological data, 
 the first, so to speak, trial food, and later, guided by the results 
 obtamed, to gradually formulate a correct selection, thus at the 
 same time teachmg the patient how to preserve the stomach m a 
 healthy condition. I must here enter my protest against the 
 use of the stomach sound for verifymg the correctness of the 
 prescribed food still more forcibly than I did while we discussed 
 its use for diagnostic purposes hi gastric diseases : iu'st, because 
 the results of verification obtained by the sound, with the 
 methods at present m use, are less reliable than those obtained 
 by ordinary observation ; and then, the introduction of the 
 somid, especially if frequent, may undoubtedly hinder digestion 
 and become prejudicial to the favorable course of the disease. 
 
 The food must be varied within limits admissible for the pa- 
 
— 78 — 
 
 tient, but it must be prepared plainly, without suspicious sauces 
 and dressings, but palatable withal. 
 
 In prescribing a diet for our patient, it was not only the con- 
 dition of the stomach that was taken into consideration. The 
 intestinal catarrh, as apparent from the diarrhoea, required cer- 
 tain peculiarities in the prescription, as has been noted above ; 
 the prescription would be different in the case of constipation, 
 which is seen oftener than diarrhcjea in gastric catarrh. The 
 disturbances m the patient's nutrition also require a different 
 diet. We have been able to a certain extent to conform our 
 treatment to these, especially as regards the oxaluria, having 
 prescribed for him preferably a nitrogenized food with a prohi- 
 bition of sweets (excepting a very trifling quantity of sugar 
 with his tea) ; this, as has been proved, was not only permis- 
 sible, but even requisite in the condition of his stomach and 
 intestines. The present condition of his digestive organs cer- 
 tamly does not permit the use of a fattening diet, which is 
 indicated by his extreme leanness, as for mstance, cod-liver oil 
 or large quantities of milk or its preparations. Time will show 
 how far such a diet may be necessary and when its use is pos- 
 sible. It will also be our task to gradually change his present 
 food, in accordance with the rapidity of his convalescence, to 
 his habitual coarser diet, which he will return to after leavmg 
 our clinic. 
 
 Taking up the treatment proper, we will follow the same or- 
 der as laid down m our Introduction to Clinical Work, and which 
 has been followed in our investigation and diagnosis. 
 
 The stomach. — The indication for Ems water will be spoken 
 of separately, for reasons we have already explamed. Why did 
 we prescribe for our patient decoction of condurango and tincture 
 of nux- vomica ? The so-called hitters are useful m chronic catarrh 
 of the stomach. Without discussing the pharmacological reason 
 for their action, I will say that clinically their use is of un- 
 doubted utility : when taken at meal-times they alleviate the 
 dyspeptic symptoms. Condurango, notwithstanding its slightly 
 bitter taste, acts like the bitters (by diminishing the dyspeptic 
 phenomena) even better than those formerly used. Besides, 
 condurango is very useful in diarrhoea, which will sometimes 
 
— 79 — 
 
 pass off by the use of this drug alone. The nux-vomica 
 drops are added, — first, because they are strongly bitter (the 
 slightly bitter, insipid taste of condurango is even somewhat 
 unpleasant to patients, who usually prefer the addition of nux- 
 vomica), and secondly, this drug, because of the strychnine, will 
 act as a tonic to the weakened nervo-muscular apparatus of the 
 intestines, and our patient, as you will recollect, suffered from 
 almost constant constipation until last August. It is also con- 
 venient to admmister condurango and nux-vomica in the follow- 
 ing formula : ]^ — Extracti fluidi condurango 3 j, tmcturse 
 nucis-vomicse 3 ij. M. D. S. 20 - 25 drops in one-half wuie- 
 giass of warm water twice a day after meals. 
 
 Intestines. — The measures to combat the diarrhoea, the intes- 
 tinal catarrh, are as follows : rest m recumbent position, warmth 
 (warm food, a warm abdominal supporter, warm baths), improv- 
 ment m the condition of the stomach, of the gastric digestion, 
 and, as mentioned above, condurango. We have already 
 explained why we prescribed codeine and the tincture of opium, 
 (for pain), why we give coto drops and not tannin or other 
 astringents, — and why we did not resort to tannm or any other 
 clysters. 
 
 The gall-bladder. — Ems water was prescribed agamst biliary 
 calculi, because clmical and partly pharmacological data lead to 
 the conclusion that the alkalme mmeral waters, to which class, 
 as you know, the Ems water belongs, have the tendency to re- 
 duce the size of and break up the calculi, thus facilitating their 
 expulsion. This will also be expedited in our patient by the 
 improvement in the gastro-intestinal digestion and in the nutri- 
 tion. The correction of faults in diet, rest, the avoidance of 
 traumatic mfluences, warmth (warm abdominal bandages and 
 warm baths), and the strengthening of the nervous system 
 brought about by the relief of the various pains and the im- 
 provement in sleep — all these will tend to dimmish the con- 
 stant tenderness of the gall-bladder and to avert attacks of 
 biliary colic. 
 
 The Kidneys. — For the oxalic acid gravel we prescribed the ■ 
 Ems water, although alkaline mineral waters are properl}^ more 
 suitable for renal gravel of another nature — namely, the uric 
 
acid gravel, which is usually found not with pale urine, as that of 
 our patient and of oxaluria in general, but in urine that is more 
 strongly colored than normal, namel}^, orange-yellow or even 
 orange-red. Against oxalic-acid gravel are particularly indica- 
 ted the earthy (containmg lime) mineral waters, as, for instance, 
 Contrexeville ; but we could not prescribe these waters, as they 
 would act, especially in our patient, as laxatives, thus prolong- 
 ing the exhaustmg diarrhoea. It is the meat diet, the improve- 
 ment in nutrition and in digestion, general massage, and the 
 improvement in the condition of the nervous system, that will 
 diminish the production of the oxalic-acid gravel and stop the 
 oxaluiia. The diminution in the tenderness of the kidneys, and 
 the cessation of attacks of renal colic, will be effected by the same 
 measures, as were recommended for the gall-bladder symptoms, 
 namely, rest, warmth and a strengthened nervous system. As 
 it is quite probable that the patient's left kidney is somewhat 
 movable, it will become necessary for him, later on, when he 
 moves about more freely, to wear a special kidney bandage, in 
 place of the msufficient simple abdominal band. 
 
 The heart. — The weak cardiac activity required stimulation ; 
 we have spoken above of the mdication for wme m connection 
 with this. 
 
 Nutrition. — We just now mentioned the measures for com- 
 batmg the oxaluria. While discussmg the diet we spoke of 
 what could be done for the patient in his present condition for 
 the extreme emaciation. 
 
 The nervous system in general, the musculo^nervous apparatus, 
 the constitution of the patient. — We first of all attempted to im- 
 prove the patient's sleep, for as long as there is sleeplessness 
 we cannot expect any improvement either in the nervous sys- 
 tem or in the condition of the whole organism. We succeeded 
 in gaining a considerable improvement m this direction by re- 
 lieving the various pams and by the use of warm baths and of 
 general massage ; all this has already been spoken of. Besides, 
 the special object m the use of massage lies m the improvement 
 of nutrition and in the development of the nervo-muscular ap- 
 paratus, in the mcrease of muscular strength, which, after the 
 local ailments shall have been removed and improvement in the 
 
— 81 — 
 
 general nutrition having been attained, will become the startmg- 
 point for the possible improvement in the constitution of the 
 patient. 
 
 It now remains for us to explain why we prescribed Ems 
 water for our patient, and coincidently we shall speak of mmeral 
 waters in general. 
 
 LECTURE OF OCTOBER 6, 1889. 
 
 The patient's condition is improving constantly; the pre- 
 scribed treatment is justified by the obtamed results and requires 
 almost no alterations ; there is therefore no necessity for bring- 
 ing the patient before you as frequently as before. The patient 
 was given, as you remember, at the begmnmg, daily, two glasses 
 of milk, two glasses of soup with broken-up meat, two eggs, less 
 than one-fourth pound of white bread and three spoonfuls of 
 wine. He still gets two glasses of milk with cognac, two glasses of 
 soup with meat, two eggs, more than one-half pound of white 
 bread, two glasses of milk soup with manna, one-fourth of 
 a chicken, two meat cutlets, and the wine as before ; but the ap- 
 petite is constantly mcreasing and the patient begs for more 
 food. This quantity of food is well digested, without anj- dys- 
 peptic phenomena, unless it be some belching at times, which is 
 easy, pamless, odorless and non-acid. Very rarely, when the 
 patient feels strong hunger, there appears a slight pain m the 
 region of the stomach, but this ceases at once on taking some 
 food. This pain is but an indication of a greater necessitj' for 
 nourishment, a necessity that appeared simultaneously with the 
 improvement in the condition of the stomach. Considering the 
 patient's extreme emaciation and the fact that he is as yet grow- 
 mg (he is but eighteen years old), this necessity is certainly not 
 to be wondered at. The evacuations, once a day, are normal, 
 more frequentl}^ of a solid consistence (we have given no 
 oj)ium since September 27th). The abdomen is not distended, 
 notwithstanding the abmidant quantity of food and the not very 
 copious excretions, which fact points to a normal intestmal ab- 
 sorption ; this is also apparent from the cessation of the for- 
 merly frequent rumblmg. The spontaneous abdommal pams are 
 
— 82 — 
 
 . insignificant, appeariag only on walking — in the region of the 
 left kiclnej. Examination of the abdomen elicits a marked tender- 
 ness in the same region, and a trifling sensitiveness ui the region 
 of the sigmoid flexure and in that of the gall-bladder. The urine 
 is not pale, but of normal color, does not become turbid so readily 
 as it did formerly : the oxalate of lime sediment is contmually 
 decreasing, while that of sodium urate has increased a little, but 
 ceased to increase further. The pulse is contmuously improv- 
 ing. Patient's appearance is better than before ; he has gained 
 three pounds smce admission (he weighs ninety-four pounds). 
 The pit}'Tiasis versicolor is passing away — is less scaly and 
 paler. The sleep is better ; the mmd is clear, the strength 
 mcreases little by little : the patient is able to stand up longer 
 (this used to produce dizziness) and to walk more. 
 
 How shall we continue the treatment ? We will add another 
 half glass of Ems water (so that the patient will be taking 
 half a glass three times a day, each time about one hour be- 
 fore a meal) with a view to more effectively diminish the kidney 
 pains, which may be due to the oxalic-acid gravel. To use the 
 Contrexeville water for this would be rather risky, because, as 
 we explained before, it might cause a return of the diarrhoea. 
 Even a somewhat larger dose of Ems water, though it be luke- 
 warm, would tend to prolong an existing diarrhoea. We have 
 therefore limited the dose until now to two half-glassfuls of this 
 water ; but now, with the improved condition of the intestines, 
 we can give some more of the Ems for the above-mentioned 
 purpose. The condurango and the nux vomica will be contin- 
 ued for a long time ; experience has proven the utility of such 
 a procedure in cases similar to ours, in a gastric catarrh of such 
 duration and with a simultaneous mtestinal catarrh. Guided by 
 experience, we will continue the coto drops some time even after 
 the cessation of the diarrhoea, and then leave them off gradually. 
 As is apparent from what was said, we must continue the wine, 
 massage, and at times the baths. 
 
 May we recommend for our patient walkuig out-of-doors ? He 
 has grown somewhat stronger, the weather is pleasant, and the 
 fresh ail' would certainly be very beneficial for him. But it is bet- 
 ter to abstam, as yet, from recommendmg such walks. Although 
 
— 83 — 
 
 surely better than before, the patient's strength is still not very 
 great ; besides, he still takes at times the warm baths so necessary 
 for him. There is therefore a risk of jeopardizmg the patient's 
 condition through fatigue from walking and a possible cold ; this 
 might bring on a return of the diarrhcea, or it might increase the 
 renal pains. Besides, the walks are not necessary for him as yet : 
 the patient's appetite is excellent and his sleep satisfactory. 
 
 Before passing on to the mineral waters, I consider it neces- 
 sary to say a few words about those methods of treatmg gastric dis- 
 ease to which I have not resorted in the present case. A review, if 
 not of all, then at least of the most generally used methods of 
 treatment of gastric diseases in connection with our first case, 
 will be advantageous in explaining the relative usefulness of the 
 various methods of this therapy, and will make still clearer the 
 reason why we have treated our patient as we did and not 
 otherwise. 
 
 'Hydrochloric acid was proposed for facilitatmg gastric diges- 
 tion some thirty years ago ; and smce it has been shown 
 experimentally that the secretion of this acid by the stomach 
 diminishes at times, or is even entirely suspended, its therapeu- 
 tic application seemed to become even more judicious. During 
 the first year of my clinical practice (also some thirty years 
 ago) I made use of this acid ; but the results obtained compelled 
 me to dismiss it, so that since then I do not resort to it (I 
 shall mention later the only exception where I use it still). At 
 consultations, however, I have had, and have now, opportunities 
 to see it employed in diseases of the stomacli. As before, so at 
 the present time, with the condition of the stomach so carefully 
 investigated by the modern methods, the results of its use are 
 identical. First, they are very inconstant, the acid benefiting 
 the patient at times, but oftener not, on the contrary impairing 
 the appetite, causing pains in the region of the stomach, — in 
 short, tending to hmder digestion ; second, even when it does bene- 
 fit the patient, the relief is only temporary, i. e., it assists in promot- 
 ing the digestion of the meal with which it was taken, but does not 
 cure the disease that causes the dj'spepsia. If this latter disease 
 
— 84 — 
 
 be a catarrh of the stomach, then it will be necessary to cure it 
 with alkalines, bitters, lavage ; if the dyspepsia be of nervous 
 origin, then we must resort to a radical treatment of the gen- 
 eral nervous disturbance. At the same time, hydrochloric acid, 
 being but a palliative remedy, while helping (which it rarely 
 does), will disguise the results of the radical treatment, and will 
 prevent the formation of a correct idea as to the success of the 
 latter ; while in case it does not relieve, it may become harmful, 
 causing, as we said above, a disturbance of digestion and even 
 of nutrition, if used for a long time. 
 
 We alluded above to the employment of hydrochloric acid in 
 diseases, in which the secretion of this fluid by the stomach, or 
 rather, in which the action of the acid secreted by the stomach on 
 food, is made difhcult, in catarrhal conditions by the presence of 
 mucus, in gastric dilatation by the accumulated contents. (Dr. 
 Popoff, whose work I have already mentioned, found the secre- 
 tion proper of hydrochloric acid by the stomach in these diseases 
 to be normal in a very great number of both experimental and 
 clmical cases investigated by him.) While in cases where the 
 secretion of this acid is entirely absent and cannot be made to 
 reappear, that is, in atrophy of the stomach, when its glands are 
 destroyed, the palliative results obtamed through the employ- 
 ment of the acid are trifling and not to be relied on as tending to 
 prolong to any extent the life of the patient. At all events, as 
 you may know, hydrochloric acid is neither employed nor valued 
 in diseases of the stomach as much at present as it was formerly. 
 
 Of the employment of pepsm and trypsin, in the form of an ex- 
 tract of the pancreas, I must say the same that I said of the 
 employment of hydrochloric acid, and again with the same 
 exception. 
 
 Such a conclusion concerning these three remedial agents re- 
 fers to the condition of things at present only, without, of course, 
 making any predictions in regard to their future application. 
 
 The exception, which was spoken of before, refers to cases of 
 gastric dyspepsia in chlorosis and other anaemic conditions, m 
 which the secretion of the gastric juice is very much decreased, 
 and where hydrochloric acid administered after meals sometimes 
 gives good results. The complete cessation of dyspeptic phe- 
 
— 85 — 
 
 nomena even in these cases can only be obtained however by a 
 radical cure of the above-named diseases. 
 
 Here I must also mention the various food-compounds, pre- 
 pared so as to make them very suitable for digestion, as meat- 
 juice, (beef-juice), meat powder, peptonized albuminates and the 
 like. I personally do not employ them, but as a consultant have 
 seen them used in quite a number of cases. I could never per- 
 suade myself as to the necessity for their employment. In the 
 majority of cases their use is not followed by any particular 
 results ; while in those rare cases where the patients bore them 
 well — when unable to bear ordinary food — and even improved 
 on their use, investigation has shown that either the " orclmary " 
 food was unsuitable, or that the treatment followed at the time 
 of its administration was wrong, and the food could not there- 
 fore be borne. I will also add that, through the careless prepa- 
 ration and preservation of these so-called " especially digestible " 
 foods, which are unfortunately much more frequent than their 
 conscientious manufacture, they, bemg generally unpalatable, be- 
 come repugnant to, and may even harm, the patient, probably on 
 account of the ptomaines developed in them. The relatively 
 high price of these food preparations must also be taken into 
 account. 
 
 We employed no lavage of the stomach m the present case, 
 as there was no uidication for it, viz., distention of the stomach 
 by the accumulated contents (as we pomted out m our diagnosis), 
 — not to speak of the exacerbation of the catarrhal condition, 
 just before he was admitted (pains m the stomach and daily vom- 
 iting), which was a strong coutra-indication for gastric lavage. 
 The success of our treatment is a sufficient proof that there was 
 in reality no necessity for the employment of this method of 
 treatment. I hope to present to you at my next lecture a case 
 with indications for gastric lavage, and I will then discuss 
 thoroughly the necessity for its employment in its correct appli- 
 cation, in which it is a most useful method of treatment. 
 
86 — 
 
 LECTURES OF OCTOBER 10 AND II, 1889. 
 
 It remains to be explained why we prescribed for our patient 
 a mineral water ; why particularly the Ems ; why in the 
 quantity designated ; and why at certain times (one hour before 
 the meal), etc. 
 
 Of all known remedies for catarrh of the stomach, and also 
 of the upper portion of the mtestines, of the biliary, urinary and 
 respiratory tracts, for biliary calculi, renal gravel and gout, sodi- 
 um in the form of the bicarbonate and the chloride is considered 
 the best. What is the most convenient form for administering 
 these combinations of sodium in gastric catarrh ? At the begin- 
 ning of my medical practice I occasionally saw sodium bicarbon- 
 ate admmistered even in pills, — the least suitable form: for 
 along with the medicament itself, the bicarbonate, there was in- 
 troduced into the stomach m large quantities a pillular mass 
 (extr. taraxaci, etc.) that uselessly burdened the organ and 
 only served as an obstacle to the efficiency of the sodium. The 
 best form is without doubt a solution, m which the above named 
 compounds of sodium come in contact with the mucous membrane 
 of the stomach in the easiest and most equable manner. 
 
 Sodium bicarbonate and sodium chloride are often given, with 
 the addition of laxative salts, if necessary, in powders, the pa- 
 tient being directed to dissolve them in a certam quantity of 
 water. The chief recommendation for such a form is its cheap- 
 ness ; but it has, unfortunately, numerous drawbacks : the patient 
 may not always take of the supply prepared by the druggist a 
 uniform quantity, nor does he always dissolve it m a like quan- 
 tity of water (the degree of concentration of the solution is quite 
 important) ; and, what is most important, he dissolves the 
 powders m w^ater of an uncertam composition. This water may 
 contam substances either directly harmful to the stomach (usu- 
 ally an abmidance of lime compounds), or such as will change 
 the composition and through this the effectiveness of the 
 powder dissolved in it. To have powders prepared in a drug- 
 store, weighed out for each dose (often several times daily), 
 would destroy the princi]3al advantage of this method — its 
 
cheapness — considering the value of the apothecary's labor ; 
 while to have an exactly prepared solution made with carefully 
 selected soft water (containing but few hard particles ; not to 
 speak of distilled water) for daily use, would make such treat- 
 ment very expensive. It thus remains to prepare exact solutions 
 iu great quantities in factories, which is certainly much cheaper, 
 and which we see in establishments for artificial mineral waters. 
 
 Can artificial mineral waters replace the natural ones ? My 
 long experience teaches me to prefer the natural ones, used 
 either at the places they are formd, or in the patient's house 
 when imported. We certainly can not deny the efficiency of 
 the artificial waters, which may, m the absence of the natural 
 ones, suffice, if they are carefully prepared. Unfortunately this 
 latter circumstance is rather a rarity. The difference in the 
 prices of the natural and artificial waters is very small, owing to 
 their mutual competition. Besides, the mineral waters are 
 bemg employed now m much smaller doses than they were 
 formerly, (of this later), and treatment by them can by no 
 manner of means be designated as more expensive and less 
 accessible than treatment by other drugs, — rather the contrary. 
 As regards the efficiency of the natural mmeral waters as com- 
 pared with the above described powders, for the composition of 
 which they usuall}^ serve as specimens, the superiorit}^ of the 
 former is so immense as not to admit of any comparison. 
 Many a time have I seen a complete cure by the regular employ- 
 ment of mmeral waters m cases of gastric catarrh, constipation, 
 renal and biliary colic, in which the long contmued use of the 
 powders was productive only of failure. 
 
 At the beginnmg of my medical practice the customar}^ course 
 was as follows : during the summer, patients were either sent 
 directly to the mmeral springs, or, if not sent there, they were 
 ordered to take artificial waters and at times natural imported 
 ones. At the other seasons of the year the above-named powders 
 and pills were prescribed. The difference m the results of the 
 treatment, made more prominent by the dissimilar conditions of 
 life during the warm and cold seasons of the year, at the place 
 of the patient's regular residence, or, in case of his having gone 
 to the waters, amid completely changed surroundings, was very 
 
striking indeed. I therefore, from the very beginning of my 
 clinical and independent medical practice began to use the 
 mineral waters, mostly natural ones, all the year round, exercis- 
 ing due caution, of course; — the routme habit was so strong, and 
 the possible dangers from the use of mineral waters, especially 
 warm ones, m the cold season, were so great. Physicians who 
 quietly looked on while their patients imbibed, both in winter 
 and summer, some five to ten cups and more of hot tea daily, 
 felt anxious lest these patients should catch cold by di-mking 
 three times a day half a glass of Ems or Karlsbad water, which, 
 although somewhat warmed, was still of a lower temperature 
 than the customary beverages. But the force of circumstances, 
 aided by my practice and that of my assistants and former 
 students at the clinic, has triumphed at last, so that now in 
 Moscow, as well as in Russia generally, the use of mineral 
 waters at every season of the year has replaced the pills and to 
 some extent the powders ; although even at the present time in 
 some university cities with clinics, and partly within the circles 
 of their medical mfluence, the improved practice is either alto- 
 gether absent or is only slowly being mtroduced. 
 
 Appreciatmg highly, for reasons just explained, the import- 
 ance of mmeral waters, I lecture on them every year to my 
 students. 
 
 I consider it the business of the clmic to impart to the future 
 physicians the skill m selecting and the technique of using the 
 mineral waters ; and the personal experience of my former stu- 
 dents, testifymg to the benefit derived from these lectures, 
 impels me to continue m the same Ime. 
 
 It becomes apparent from the above why we prescribed for 
 our patient the best remedies agamst gastric catarrh — bicarbo- 
 nate of soda and sodium chloride — in the form of a mineral 
 water. The question arises now, why have we selected the 
 Ems water and no other? To answer this and at the same 
 time to show by what we are guided m selecting a mineral 
 water, we will compare the Ems water with others containing 
 the above-named combinations of sodium. But I must before- 
 hand say a few words in explanation of the difficulties en- 
 countered by the young physician in selecting a mineral water 
 
— 89 — 
 
 in any given case, and thus explain to you the duty of the in- 
 structor m impressing upon you the acquisition of the ability to 
 make this selection. Our physician opens his text-book of 
 pathology and therapeutics and looks for the indications for the 
 employment of the mineral waters in the given case — say 
 catarrh of the stomach : the text-book recommends Ems, Vichy, 
 Yessentucki, Karlsbad, etc. ; for biliary calculi, Karlsbad, Vichy, 
 Yessentucki, etc ; for renal gravel, Vichy, Yessentucki, Karls- 
 bad, etc ; but which water is he to order? No answer. He 
 then looks in his text-book of balneotherapy for advice, and 
 finds that Ems is recommended for gastric catarrh, biliary calculi 
 and renal gravel ; Vichy and Yessentucki for gastric catarrh, 
 biliary calculi and renal gravel ; and Karlsbad for gastric catarrh, 
 biliary calculi and renal gravel. The text-books evidently do 
 not help one. It is only m the clinic, that is, m presence of the 
 given cases, that we can show in a correct way, in the very best- 
 manner, how the choice of a mmeral water is to be made. The 
 clinic certainly does not exclude the text-books on balneotherapy, 
 nor, those on special pathology and therapeutics, — they are 
 surely necessary ; but the clinic supplies the kej- to them, and 
 teaches how to make use of the material therein contamed. 
 
 Let us take for comparison the mineral waters of Ems, Ober- 
 salzbrunnen, Vichy, Yessentucki, Karlsbad, Franzensbad, Ma- 
 rienbad and Kissingen. We will also have to discuss the 
 so-called bitter waters, which contain principally laxative salts 
 (such as Fiedrichshall, Piillna, and our Caucasian spring " Maria 
 Theresia " ) as well as the earthy waters (as Contrexeville), — 
 since the first named, although of course employed separately, 
 are sometimes used in conjunction with the latter ones ; while 
 the indications for the others are at times not clearly distin- 
 guishable from those we have mentioned. We will thus 
 speak of the most important mineral waters employed for inter- 
 nal use, except those containing iron and arsenic, which we will 
 have occasion to discuss in the treatment of chlorosis and aneemia. 
 I have selected the above enumerated waters because they are 
 the best known and the most studied from a chemical, clinical 
 and to some extent physiological standpoint, and because, if 
 correctly employed, they are undoubtedly efficacious. 
 
— 90 — 
 
 Experience of many years — for some of them, of centuries — 
 has proved that they contain a happy combination of curative 
 agencies, which are very beneficial in many frequently occurring 
 and important diseases ; besides, they present tyjyes for compar- 
 ison with many other mmeral waters, so that m discussing these 
 we discuss not the individual waters, but whole classes of them. 
 I have just said that the mineral waters selected by me for 
 comparison contam a happ}^ combmation of curative agencies. 
 "What are these agencies ? Water, carbonic acid, bicarbonate 
 of soda, sodium chloride, and laxative salts (sulphate of soda 
 and sulphate of magnesia). The constituents of the mineral 
 waters enumerated are found in a comparatively large quantity ; 
 they contain besides some other solid components m a small, 
 even infinitesimal quantity, as compared with those mentioned. 
 The importance of the latter is not absolutel}- known. In se- 
 lecting a mineral water we generally take into account the 
 constituents found in a com]3aratively large quantity ; although 
 we should not, nor is there any reason to, deny the importance 
 of the components found merely m minimal proportion. It is 
 quite likely that some differences in the action of the various 
 waters depend on these latter, though there may be similar com- 
 position as to the quantity and quality of their chief mgredients. 
 
 You have been taught by pharmacology the pharmaco-dyna- 
 mics of these chief mgredients. I will only remind you of 
 what is most important for an understanding of the therapeu- 
 tic action of mmeral water. 
 
 Water increases all the secretions ; if warm, it particularly in- 
 creases perspiration ; if of lower temperature, then the urine, bile, 
 etc : b}' mcreasmg secretion it influences the animal metabolism. 
 Cold water causes increased peristalsis in the gastro-intestinal 
 canal, removes constipation, but may tend to cause diarrhoea and 
 pams, mtestinal and gastric, whereas warm water, on the con- 
 trary, soothes the pains and diminishes the diarrlirea. 
 
 The action of carbonic acid. Avhether free or liberated from the 
 -carbonates, in the stomach, is similar to that of cold water in the 
 gastro-mtestinal canal : it increases peristalsis, removes constipa- 
 tion, but may also cause diarrhcea, pains and, at times, vomiting. 
 
 It is the hicarhonate of soda and the sodium chloride which are 
 
— 91 — 
 
 the principal curative ingredients of the alkalme mineral waters, 
 as proven by the experience of centuries. The mechanism of 
 their action is not wholly known. We know this much : first, 
 they assist m dissolving and removmg the mucus ui catarrhal 
 conditions, an effect which is of very great importance. In 
 gastric catarrh the mucus prevents the access of food to the 
 mucous membrane, so that this is stimulated to a lesser degree 
 by the food, and consequently secretes the gastric juice less 
 actively, which in its turn reaches the food less readih' on ac- 
 count of the mucus ; on removuig this, the normal condition is 
 reestablished. In catarrhal conditions of the respiratory tract 
 the accumulated mucus causes difficulty in breathing, coughmg, 
 etc. The excellent action of the combmations of sodium men- 
 tioned is not limited to the removal of mucus only, but we 
 know nothing more of an exact nature. Secondly, they uicrease 
 the secretion of the gastric and other alimentary juices, of the 
 urine, etc. They alter secretions ; for mstance, they convert 
 a strongly acid urine, with uric acid sediments, into a slightly 
 acid,' neutral or even alkalme one, and thus they j^revent the 
 formation of fresh gravel and assist m dissolving and removing 
 that already formed. They very likely act m a similar manner 
 on the bile. Thirdly, in small quantities they act favorably on 
 nutrition (contrariwise m large quantities, — of this later), di- 
 mmishmg the quantity of the excreted nitrogen. To both bicar- 
 bonate of soda and sodium chloride a similar action is ascribed, 
 especially as the bicarbonate, on reaching the stomach, must be 
 converted mto sodium chloride in the presence of the free 
 hj'drochloric acid of the gastric juice. But bicarlx)nate of soda 
 is particularly valuable m practice, as principally those waters 
 are used mternally — in catarrhal conditions, l3iliary calculi, 
 renal gravel, gout, diabetes mellitus, etc., — which contain the 
 bicarbonate, usually also the sodium chloride ; and not the ones 
 containmg any sodium chloride without the bicarbjnate of soda. 
 The laxative salts increase peristalsis and may cause a trans- 
 udation from the mucous membrane of the intestines. By 
 emptyhig the mtestmes, m cases of constipation, they cause a 
 dimmution in the size of the abdomen, facilitate breathing and 
 circulation, which is very beneficial in difficult circuktion of 
 
— 92 — 
 
 the head, and chest. Decreasing, by the aid of laxation, the 
 absorption by the intestines, and invitmg a transudation from 
 their mucous membrane, they diminish the fulhiess of the portal 
 venous system (which action may be very serviceable in certain 
 liver troubles), and of the venous system in general ; they also 
 influence nutrition and reduce obesity. 
 
 The following table, compiled by me from the most reliable 
 analyses obtainable, so kindly placed at my disposal by Dr. A. 
 I. Tsherbakoff, shows the total amomit of the solid components, 
 and, separately, the amount of those that are found in large (m 
 heavy type) and medium (in ordinary type) proportions (the 
 very small components are omitted so as not to impair the gen- 
 eral aspect of the table) in the mineral waters which we have 
 selected for comparison, as well as in the bitter ones. The table 
 also shows the quantity of carbonic acid contained in the various 
 mineral waters, and their temperature in degrees of both Reau- 
 mur and Fahrenheit. The carbonic acid, whether free or com- 
 bined, is shown in its total amount, because when in the stomach, 
 if combined, it will be liberated under the influence of the 
 hydrochloric acid of the gastric juice. 
 
 As regards the temperature of the water, I will say this : 
 some of you will probably practice at the places where mineral 
 springs are located, but the majority will doubtless employ 
 imported waters (patients are not very frequently sent to the 
 watering places). The imported waters have not, of course, 
 their natural temperature, but that of the surroundings m which 
 the vessel containing them is placed. Nevertheless, the table 
 shows the natural temperature of the waters, that long years of 
 observation have shown to be so very important a part of their 
 efificacy. What shall be the exact temperature of the water we 
 are employing in the given case will be explamed later on. 
 I will only state now, that even while employing the waters at 
 their source the extremes of their natural temperatures are to be 
 avoided ; as, for mstance, in case of a too low temperature, like 
 that of the Marienbad Kreuzbrunnen (53.1°i^.), the water re- 
 quires to be warmed ; in case of too high a temperature, as that 
 of the hot Karlsbad spring, the water is allowed to cool. But 
 at the same time, the Marienbad water is used and prescribed 
 

 
 
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— 94 — 
 
 because of its being comparatively cold, and tlie Karlsbad for 
 its being a comparatively warm water, and the benefit obtained 
 by the use of these waters, as shown by experience, depends on 
 their being used at the above temperatures. In prescribing 
 the temperature of the imported waters we must also be guided 
 by these experiences, 
 
 Havmg become familiar with the composition of the mmeral 
 waters selected by us for comparison, let us see why we ordered 
 for our patient the Ems water and why we consider it more 
 suitable for our case than any other water. 
 
 The diagnosis has showni our patient to be suffering from a 
 chronic gastro-intestinal catarrh, m a state of exacerbation just 
 before he was admitted to our clinic, from biliary calculi, renal 
 colic, oxaluria, extreme failure of nutrition and of physical de- 
 velopment, and from consequent nervous disturbances of a 
 temporary nature. He chiefly comj)lained, on admission, of gen- 
 eral weakness, of pains m the abdomen and of a diarrhcBa. 
 
 As can be judged by the table, the advantages of Ems water 
 for such a patient are at once apparent : the warm temperature 
 of the water is very beneficial in pains and in diarrhoea ; the 
 moderate quantity of bicarbonate of soda and of sodium chloride 
 is much more suitable for pams, diarrhoea and failure m nutri- 
 tion, than a large amount, as. for instance, that amount of the 
 bicarbonate in Vichy and Yessentucki, and of the chloride in 
 Kissingen ; then the trifling amount of other component parts 
 besides the principal ones (the Kesselbrunnen spring contains, 
 out of the total amount of 35.5 of solid parts per 10,000, 30.2 
 parts of bicarbonate of soda and sodium chloride, so that on the 
 rest fall but 5.3 parts) is always of great importance, and espe- 
 cially so in a case like ours, where the stomach and the intestmes 
 are so severel}^ affected, because such " pure " mineral watei"S 
 are much easier borne than waters of an opposite composition. 
 
 The course of the illness has proved, as you know, that we 
 were not m error in prescribing Ems for our patient. Let us 
 consider now what would have been the action of other mineral 
 waters m the present case. 
 
 Marienbad is evidently contra-indicated, — first, because, being 
 a cold water (53.1°i^.), it would aggravate the diarrhciea and 
 
— 95 — 
 
 all the pains ; and secondh^, containing, as it does, great quan- 
 tities of sodium sulphate (49.5 per 10,000), it would act as a 
 strong laxative. 
 
 The same must be said of Franzenshad, which is also a cold 
 (51.8°i^.) water, and which also contains, although in a smaller 
 amount, sodium sulphate (28.0 per 10,000). 
 
 Kissingen is contra-indicated in our patient for many reasons : 
 it is also a cold water (51.8°^.), but, although the sodium sul- 
 phate is absent, it contains such a quantity of the sodium chloride 
 (58.8 per 10,000) that it acts as a laxative, the more so as it 
 also contains, small though the quantity be, some magnesium 
 sulphate, a strongly laxative salt ; finally, it contains no bicar- 
 bonate of soda, but on the contrary a great deal of lime salts 
 (15.3 per 10,000). 
 
 Karlsbad^ with one important exception, is very similar to 
 Ems: it, too, is a warm (135.8°i^.) water, containing the same 
 amount of sodium bicarbonate (18.1 per 10,000) and sodium 
 chloride (10.3 per 10,000) as Ems. It is also a very pure 
 water ; but among the chief component parts it contams a con- 
 siderable quantity of sodium sulphate (23.9 per 10,000) — a 
 laxative salt. Some physicians employ Karlsbad, as a warm, 
 or hot, water, and in diarrhoea. 
 
 In cases where the constipation is alternated often by diar- 
 rhoea, but where the first usually iDredominates, I have had 
 opportunity to see some successful results with the Karlsbad ; 
 but for cases similar to that of our patient I positively prefer 
 the Ems. 
 
 Vichy. — The Celestins spring is cold (53.6°JP.) and con- 
 sequently unsuitable for our patient. The Grande Grille sprhig 
 is very similar to Ems : the water is also warm (105. 8°i^.), does 
 not contain any laxative salts (except a trifling quantity of 
 sodium sulphate), is also very pure, but has a greater quantity 
 of sodium carbonate (48.8 per 10,000), and is therefore contra- 
 indicated in our patient, or is at least less suitable for him than 
 Ems, partly because of his diarrhoea, but principally on account 
 of the extreme failure in his nutrition. The long-continued 
 use of great quantities of bicarbonate of soda has been shown 
 by clinical investigations and experimental data to injuriously 
 
— 96 — 
 
 affect the nutrition, especially in patients as emaciated as ours 
 is. 
 
 The Yessentucki springs are cold, contain even more bicar- 
 bonate of soda than the Vichy springs, and also a great deal of 
 sodium chloride, and are therefore even more contra-indicated in 
 our patient than those last, on account of the diarrhoea and of 
 the failure in nutrition. 
 
 Obersahbrunnen (" Silesia water" ) approaches Ems in the 
 quantity of the bicarbonate of soda (21.6 per 10,000), but is 
 unsuitable for our patient because it is a cold water (47.3°i''.), 
 containing a great deal of carbonic acid (38.1 per 10,000), and, 
 although in a small quantity, also sodium sulphate (4.6 per 
 10,000), and is consequently liable to aggravate the diarrhoea 
 and the pains. I will take occasion to say a few words con- 
 cernmg the employment of Ems and Obersalzbrunnen in diseases 
 of the respiratory tract, in which these waters are used more 
 frequently than any others ; I will do so now, so that I may not 
 have to touch upon this subject later on when we come across 
 patients suffering from these diseases. The Ems waters, from 
 the Kranchen and Kesselbrunnen springs, are employed at 
 their location in the following manner : Kranchen for diseases of 
 the organs situated above the diaphragm, and Kesselbrunnen in 
 diseases of parts below the diaphragm. The reason for this is 
 evident : in the diseases of organs below the diaphragm, as we 
 see it so well exemplified m our patient, with his (on admission) 
 torturing pains and diarrhoea, the warmer Kesselbrunnen (37.3° 
 i2., 116°^.) is more suitable than the cooler Kranchen (28.7°-R., 
 87.8°i''.) ; on the contrary, in diseases of " parts above the dia- 
 phragm," namely, of the respiratory organs, Kranchen is more 
 suitable, because the much warmer water of the Kesselbrunnen 
 might rather tend to call out haemoptysis. In the imported 
 Ems water there is certainly no such difference in the temper- 
 ature of Kranchen and Kesselbrunnen, and they can therefore 
 both be used indifferently, in view of the similarity of their com- 
 position, heating them up to the temperature required by the 
 presenting case. 
 
 Sms and Obersalzbrunnen. — Ems is usually prescribed in ca- 
 tarrhal conditions of the respiratory tract, Obersalzbrunnen in 
 
— 97 — 
 
 tuberculous affections of the same : thus in the ordmary most 
 frequent form of tuberculosis of the lungs, that is, in chronic 
 tuberculous broncho-pneumonia. Ems is not prescribed for 
 tuberculosis pulmonum for fear of causing h^emoptj^sis. The 
 cause of hsemoi^tysis when brought on by the employment of 
 Ems in patients suffering with pulmonary tuberculosis, is to some 
 extent found in the very locality of Ems, which is reij .warm 
 during summer ; while the locality where Obersalzbrunnen is sit- 
 uated is much cooler. Another cause lies m the fact, that Ems, 
 bemg warm and containing less of carbonic acid, rather tends to 
 constipate, and constipation creates a predisposition to heemop- 
 tysis ; whereas Obersalzbrunnen, being cold and contaming a great 
 deal of carbonic acid and also little of a laxative salt (sodium 
 sulphate), is rather of a laxative nature. When using the im- 
 ported Ems and Obersalzbrunnen waters, the differences of 
 locality and temperature are of coui'se not taken mto account, 
 and both waters may be employed mdifferently for catarrh and 
 tuberculosis of the respu-atory organs, Obersalzbrunnen being 
 prescribed for cases mclmed to constipation, and Ems for those 
 with a tendency to diarrhoea. 
 
 As has been explamed above, the Contrexeville water, contain- 
 ing lime, would be the most suitable for the oxaluria and renal 
 colic in our patient, but as it would tend to prolong the 
 diarrhoea we were compelled to abstain from employmg it and 
 had to resort, m combating the above-named diseased conditions, 
 to the use of the alkalme Ems waters. 
 
 It becomes apparent from the above, why we preferred above 
 others the Ems water for our patient; but to make still 
 clearer the matter of selecting mineral waters and at the same 
 time to characterize, even to a slight extent, the most important 
 of those selected by us for comparison, I shall again return to 
 this subject m the next lecture. 
 
 LECTURE OF OCTOBER 13, 1889. 
 
 Condition of the patient. — A week has passed since we saw 
 the patient last time. Durmg this week he continued takino- 
 the warm Ems water (one and one-half glasses per day), the 
 
— 98 — 
 
 decoction of condurango with drops of nux-vomica, drops of 
 coto, and wine ; continued taldng baths at times and had mas- 
 sage constantly. The patient's condition is steadily improving. 
 The quantity of food is slightly increased by the addition of a 
 glass of milk and of about one-fourth of a pound of white 
 bread, and the food itself is somewhat changed; on account of 
 the difficulty in obtainmg . fresh eggs, they were discontinued 
 and replaced by an additional quantity of chicken meat. The 
 patient gets now per diem the following : about one poruid of 
 white bread (the whole bread with the crust is eaten), one-half 
 chicken, two meat cutlets, two glasses of soup with broken up 
 meat, two glasses of milk soup with manna, and three glasses of 
 milk with cognac. This quantity of food is digested by the 
 stomach without any dyspeptic phenomena. The intestinal 
 evacuations once a day, the first days after the third half-glass 
 of Ems was added, were formless and even somewhat liquid, 
 however without pams on defecation, but these last few days 
 they again became quite solid, although the patient contmues, 
 as I said, drinkmg three half-glasses of the water. The abdo- 
 men is not distended. The spontaneous pains appear only at 
 the side of the left kidney, more frequently on motion, and are 
 weaker than formerly. Examination of the abdomen also 
 elicits tenderness only on the side of the left kidney ; at the 
 other places, among them m the region of the gall-bladder and 
 sigmoid flexure, where a week ago pressui-e elicited tenderness, 
 there is at present neither sensitiveness nor tenderness to be 
 noted. The urine became normal, — it is neither pale nor turbid, 
 outside of the usual and normal slight cloudiness due to mu- 
 cus, and gives absolutely no sediment of calcium oxalate crys- 
 tals. The pulse continues strong. Patient keeps gainmg m 
 weight, the latter being no\v ninety-eight pounds (seven pounds 
 more than he weighed on admission). His sleep is satisfactory, 
 his strength grows steadily. 
 
 After what was said of the plan of treatment and in view of 
 the just enumerated results of this last, it is evident that noth- 
 ing is to be changed as yet in the treatment. The di'ops of 
 coto must be continued till the mtestinal evacuations become 
 normal — steadily, without oscillations ; the dose of these drops 
 
99 — 
 
 must be slightly increased, as the patient could become habitu- 
 ated to them ; instead of fifteen drops as heretofore he will be 
 given twenty drops three times a day. 
 
 I return to the mineral waters. 
 
 In what cases is Marienhad to be prescribed ? This water in 
 the quantity of bicarbonate of soda (16 per 10,000) and of 
 sodium chloride (17 per 10,000) approaches Ems water, but con- 
 tains a great quantity of a laxative salt, sodium sulphate 
 (49.5 per 10,000) and besides it is a cold water (53.1°!'.). 
 I will attempt to give you a description of typical patients who 
 require treatment by Marienbad. They are usually people of 
 good constitution, over forty years of age, well-to-do, leading 
 generally an mdoor life, brain-workers ; their amusements 
 (readmg, cards, theatre, society) also of a mental character, 
 with little out-door exercise, — mostly city inhabitants. The 
 followmg collection of diseased phenomena is usually to be 
 found with them : 1st, considerable dyspeptic phenomena — 
 prmcipally constant or frequently occurrmg symptoms of an 
 over-loaded stomach (due usually to a temporary overdistention 
 of the organ, and not to an established dilatation of the same) : 
 a feeling of fulness and heavmess m the epigastrium, belch- 
 ing, often pamful, with a sensation of burning, of gases, liquids, 
 or of mostly undigested food ; but constant and severe pains, 
 as well as vomiting, are usually absent. Investigation ordmarily 
 finds the causes of this condition to be m the majority of cases 
 as follows : the patient over-eats constantly ; being well-to-do, 
 he usually has very palatable food, often also wine, and he there- 
 fore eats much more than is plainly necessary for satisfying 
 hunger ; added to this is a nervous dyspepsia, as the patient 
 is either a neurasthenic, or, as we shall see later, becomes such; 
 oftentimes there is also associated with this a gastric catarrh, 
 but such is usually trifling, without pain or vomiting. Then 
 such patients usually suffer from a constant constipation (or at 
 least from an insufficient emptying of their bowels), partly on 
 account of their neurasthenia, partly because of the distended 
 stomach, that is on account of the retarded passage of the 
 
— 100 — 
 
 gastric contents into the intestines. The abdomen is distended, 
 the cliaphi'agm is pushed upward. The urme is more colored 
 than normally, and gives frequently some uric acid sediments. 
 There appear at times slight symptoms of renal colic, and some 
 gout}- pains in the small articulations. The liver is usuUy 
 enlarged and sensitive on account of hypersemia. Tliis latter 
 is due either to the fact that the patient is addicted at the 
 same time to alcoholic drinks, or because the passage of the 
 food-stuffs from the intestmal canal into the vente portee is 
 more abundant than normally, or, as some suppose, also because 
 these stuffs contain a great number of ptomames (which are 
 also supposed to cause a h}^jer?emia of the liver), which in 
 such a condition of digestion are produced in abundance by the 
 usual microbes of the stomach and of the intestmes. There are 
 at times also produced slight symptoms of liver colic. The 
 organs of resphation are either normal or there is a slight 
 catarrhal condition of the upper respirator}^ organs ; the organs 
 of circulation are either healthy or present some slight signs of 
 a chi'onic arteritis. The patients, however, usually complain of 
 dyspnoea and palpitation, which may in part be due to purely 
 mechanical causes, as the high position of the diaphragm, or 
 partly to reflex action, through the nervous system, by the 
 abdommal disturbances, and perhaps on account of the above 
 mentioned ptomaines. The patients are usually not lean, but 
 stout, and sometimes even obese ; they usually complain of 
 " influxes of blood to the head," or of the followmg morbid 
 symptoms (partly simply of a vasomotor origm, partly probably 
 of ptomaine origin) : a feeling of heat in the head, flushed 
 face, a general heavmess in the head, at times pam at the 
 nape of the neck, clizzmess, troublesome sleep, fatigue while 
 employed mentally, and an irritable and somewhat gloomy men- 
 tal state. Such patients, if they were not neurasthenic before, 
 become such now to a greater or lesser extent, on account of 
 the above-mentioned abdominal and mental disturljances, es- 
 pecially under the influence of the above-described mode of 
 living. If this morbid condition is not clearly defined as yet, 
 being only in the begmning of its development, then it is, of 
 course, possible to bruig the patieiit to his normal healtii by the 
 
— 101 — 
 
 aid only of a strictly regulated diet. But if this condition be 
 completely, even if not extremel}- developed, then it would be 
 erroneous to attempt to improve the patient's condition hy hy- 
 giene only, without a resort to treatment : it is doubtful whether 
 such an improvement could ever be reached; at any rate only 
 after a considerable length of time, in the course of which the 
 patient would remain needlessly in a very unsatisfactory or even 
 painful condition. It is here that we must prescribe Marien- 
 bad in connection, of course, with hygiene. 
 
 Before we speak of the action of Marienbad, let us consider 
 what would be the action of Ems in such a case. Being a 
 warm water and not containing any laxative salts, Ems would 
 tend to costiveness, thus aggravating the constipation, and, on 
 being absorbed, would increase the overloading of the vena 
 portffi and the hyperfemia of the liver ; as a consequence both 
 the chest and chiefly the head sjaiiptoras would become aggra- 
 vated. Whereas Marienbad, bemg a cold water and contaming a 
 laxative salt, if used correctly in quantities sufficient to cause 
 abundant, gruel-like evacuations (but not watery, of which 
 later ^, would sufficiently empty the gastro-mtestinal canal and 
 would thus remove the above-named consequential disturbances. 
 If the Marienbad water be administered correctly, that is, so as 
 to produce abundant, gruel-like evacuations, but not always 
 watery, then it is likely that its bicarbonate of soda and its 
 sodium chloride are absorbed either completely or j)aTtially, 
 because with the general improvement of the patient the former 
 slight sjanptoms of liver and kidney colic, as well as the gouty 
 symptoms, are seen to disappear. Patients, especially if obese, 
 grow thin by the use of Marienbad. 
 
 If ni addition to the use of Marienbad, there is also a radical 
 change instituted, even for a short time, in the mode of living 
 and in the surrounding circumstances ; as, for mstance, a trip 
 to Marienbad itself, and later, to combat the neurasthenia, a 
 trip to the sea-bathmg places (for those who are younger, to the 
 more northern ones, as Lamanche or the Baltic Sea ; for the 
 older ones — to Biarritz or the Black Sea), or, without leaving 
 the immediate localit}'-, a removal from the citj^ to the country 
 (m connection with this, Marienbad is taken in May, while the 
 
— 102 — 
 
 • younger patients bathe in the river during June and July, and 
 the older ones take salt-baths at a temperature of 27°R. and 
 lower), then the result of such a treatment may be a complete 
 return to health ; — the patients feel rejuvenated. If, besides, 
 the physician be careful and strict in his requirements and make 
 it clear that the obtamed result can be lastmg only m case the 
 hygienic rules are strictly adhered to, and the former careless 
 mode of life is avoided, then the issue will be perfectly satis- 
 factory, especially if the patient possess a strong will and be 
 careful of his health. In the contrary, unfortmiately more 
 frequent, cases, when the patient falls back to his irregular 
 hygienic habits, a repetition of the Marienbad or of some other 
 similar water becomes necessary. These repetitions do not, of 
 course, give the same satisfactory results, as when the water 
 was used the first time, and besides a repeated and, particularly 
 frequent, employment of mineral water is not without its un- 
 doubted harm, for it deranges digestion and nutrition. 
 
 What would be the action of the Vichy sprmgs on a case, as 
 described above, so suitable for Marienbad? Grande Grille, 
 being a warm water and containing almost no laxative salts, 
 would aggravate the constipation and with this also the con- 
 dition of the patient. The cold Celestms would be less consti- 
 pating ; but not contamuig any laxative salts, it would not act 
 upon the bowels sufficiently and would consequently be inferior 
 to Marienbad. In such cases it is the degree of costiveness 
 that decides the choice ; if the tendency to constipation is not 
 great, then even the cold Celestms will act as a laxative, if 
 assisted by a temporary or a frequent use of a small quantity of 
 some bitter, so that together they will exert an effect approxi- 
 mating the action of Marienbad ; (the other diseased conditions, 
 outside of constipation and its consequences, found in a 
 patient described above, as the dyspeptic, liver and kidney 
 symptoms, will be certainly favorably acted upon by the Celes- 
 tms, so rich in bicarbonate of soda). This latter is then evident- 
 ly better mdicated for such patients than Vichy. 
 
 What would be the action of the Karlsbad spruigs on such a 
 patient? They contam sodium sulphate, but in half the 
 quantity, contained by Marienbad, and besides they are partly 
 
— 103 — 
 
 warm and partly hot : the warmth of the water may, especially 
 m conditions of constipation, inhibit the laxative action of the 
 moderate quantity of the sodium sulphate and consequently, by 
 aggravating the costiveness or its effects (particularly the head 
 symptoms), will aggravate the patient's condition or at least by 
 not inducing a sufficient evacuation of the bowels, it will not 
 produce the necessary curative effect. 
 
 A few words regarding the indication for Kissingen. It has 
 much ui common with that for Marienbad, because, although 
 Kissmgen does not contain any sodium sulphate and but a little 
 (5.9 of the 10,000 parts) of magnesium sulphate, it still is a laxa- 
 tive, thanks to its low temperature (51.8°i^.), the great amount 
 of carbonic acid (30.4 per 10,000) and the enormous quantity of 
 sodium chloride (58.8 per 10,000). But the laxative action of 
 Kissingen is not as strong as that of Marienbad, and it is there- 
 fore suitable for such patients as were described in discussing 
 Marienbad, but somewhat older and not m the best of nutrition ; 
 besides, also for such patients as do not present any clearly ex- 
 pressed indications for the use of bicarbonate if soda (as uric 
 acid gravel, etc.), as this last is absent in the Kissingen water. 
 
 For what cases is Karlsbad prescribed ? Principally for severe 
 gastric catarrh, accompanied by pains and vomitmg, and for 
 severe liver colic, depending on biliary calculi; m both such 
 cases there is, to a greater or lesser extent, constipation, or con- 
 stipation mtermittent with diarrhoea of short duration ; but this 
 latter is neither constant nor considerable (for such a case, as 
 was explained above, we would employ Ems). The warm or 
 even the hot water of the Karlsbad springs, contaming a moder- 
 ate amount of sodium bicarbonate, of sodium chloride and of 
 sodium sulphate, and as little of the remainmg mgredients as the 
 water of the Ems springs, and being just as "|?w,re," acts splen- 
 didly in the above mentioned cases. Marienbad would evident- 
 ly be unsuitable for such cases, because, being a cold water, it 
 would tend to aggravate the gastric pains, the vomiting and even 
 the attacks of the liver colic, or because it would purge the pa- 
 tient strongly ; whereas in these cases severe purgmg is posi- 
 tively undesirable, as it hmders the treatment, while our aim is 
 to empty the bowels regularly ; this would not prevent absorption 
 
— 104 — 
 
 and consequently the further action of the mmeral alkaline 
 water on bile, biliary calculi and also on the urine and urinary 
 gravel, if such is to be found at that time. On the contrary, 
 Vichy, namely, the warm Grande Grille, which would be suitable 
 in such cases because of its warmth and of the abundance of its 
 sodium bicarbonate, is contra-indicated by the constipation, that 
 particularly aggravates the head symptoms, because, not contam- 
 ing any laxative salts, the water would aggravate the constipa- 
 tion and its consequences. The same must be said of Ems. In 
 the above described cases where Karlsbad is indicated, if the con- 
 stipation be severe and the head symptoms considerable, then a 
 laxative salt (usually the " Karlsbad " salt itself, obtamed from 
 Karlsbad water and containing sodium sulphate) is added to the 
 water ; while m old persons, in whom there may be any apprehen- 
 sion of apoplexy, derivative bloodlettmg is to be resorted to, 
 leeches applied to the region of the coccyx, before Karlsbad is 
 employed. 
 
 A few words concerning the indications for the Fraiizensbad 
 Salzquelle (lit. salt-spring). Franzensbad is famous for its min- 
 eral-mud baths (Moorbader). Thither flock in great numbers 
 women suffermg from diseases of the genital organs and from 
 failure in nutrition and strength, and also exhausted and neuras- 
 thenic men. Such persons often, almost always, suffer with 
 dyspeptic symptoms, gastric and mtestmal, due to a slight 
 catarrh or to nervous dyspepsia, — usually with constipation, — 
 who require the use of slightly alkalme and laxative waters. 
 Salzquelle, as you may see by the table, is just such a water, and 
 is in addition very pure, containmg, outside of the prmcipal 
 ingredients, very little of other component parts. Marienbad 
 would be too strong for such patients. Ems is also unsuitable, 
 as it would not remove the constipation. Finally the cold Salz- 
 quelle is preferred to the hot Karlsbad for women with diseases 
 of the generative organs, because of the liability of the latter to 
 either cause or to aggravate internal hemorrhage. 
 
 The chief indication for the Vichy springs is gout (arthritis 
 urica) and renal gravel (in the form of urates) with or without 
 dyspeptic symptoms, but ^vithout obstinate constipation, and 
 besides in patients with a florid, or at least a good nutrition. 
 
— 105 — 
 
 Marienbad would be unsuitable for such patients, for acting 
 as a laxative, it would hinder absorption and consequently also 
 any further action of the alkalies ; while Karlsbad, because of 
 the warmer temperature of its water, would have a weaker 
 diuretic effect, and besides would act as a laxative, which again 
 would counteract its diuretic effect. Finally, Vichy contains 
 bicarbonate of soda — the prmcipal active agent for the above- 
 named cases — in a much larger amount than either Karlsbad 
 or Marienbad. However, Karlsbad is prescribed for renal 
 gravel, as well as Vichy is for biliary calculi, we bemg guided, 
 besides other considerations, usually by the fact that if, in the 
 presence of both the liver and the renal colics, the fu\st predomi- 
 nates, then Karlsbad is given, if the latter — then Vichy. 
 
 Yessentucki. — There is a generally prevalent opinion to the 
 effect that the Yessentucki sprmgs are equivalent to those of 
 Vichy. This opinion is wrong; the number of indications em- 
 braced by the Yessentucki springs is much greater and much 
 more varied than the number of mdications for Vichy sprmgs. 
 They are alike m the quantity of the predominant bicarbonate of 
 soda, although the Y^essentucki springs Nos. 17 and 18 are richer 
 m it than the A^ichy sprmgs. But the chief difference between 
 the springs of both groups consists in the quantity of sodium 
 chloride, of which there is little in Vichy and much in the Yes- 
 sentucki. The considerable quantity of the sodium chloride 
 imparts to the Y^essentucki sprmgs a laxative action, which is 
 lacking in the Vichy sprmgs ; although this laxative action is 
 not as strong as that of the waters contamiug sodium sulphate 
 or magnesium sulphate. We shall see later that m this quality 
 of the Y^'essentucki sprmgs lies their chief preference. Finally 
 the three Yessentucki springs, Nos. 17, 18 and 4 (the ascending 
 stream), so very similar in their composition C|ualitatively. pre- 
 sent a considerable quantitative difference, which again forms a 
 great advantage, enabling us to order this or that spring, accord- 
 ing as to Avhether the case requires a stronger or weaker action, 
 taking into accomit the degree of development of the diseased 
 conditions, the constitution and nutrition of the patient. 
 
 In all the cases for which the Vichj- sprmgs are prescribed (vide 
 above), we also prescribe the Yessentucki with even greater 
 
— 106 — 
 
 .success, if there be, as there is liable to be in the majority of 
 cases, a tendency to constipation; if there be an inclination 
 toward diarrhoea, which is rather of rarer occurrence, then the 
 Vichy, as is apparent from what was stated above, would be 
 more preferable. In view of their low temperature and the 
 considerable quantity of the contained sodium chloride and 
 carbonic acid, i. e. because of their laxative effect, the Yessen- 
 tucki springs are successfully prescribed for the same cases, in 
 which Kissmgen-Rakoczy is indicated (vide above), if there 
 is simultaneously an indication for the introduction into the 
 organism of bicarbonate of soda, which is lacking in the Kis- 
 singen spring. With the aid of the simultaneous use of a 
 small quantity of some bitter water, as, for instance, of the 
 Maria Theresia spring (near Pyatigosk), the water of the Yes- 
 sen tucki sprmgs Nos. 17 and 18 can in many cases fully re- 
 place Marienbad, and, when warmed sufficiently, also Karlsbad. 
 For urinary gravel, composed not of urates, but of phos- 
 phates and oxalates, as also for gouty patients with failure 
 in nutrition, in the so-called atypical gout, the earthy mineral 
 waters are indicated ; the best of these, as far as is known now, 
 is ContrexeviHe, which I have already mentioned above. 
 
 LECTURE OF OCTOBER 18, 1889. 
 
 While comparing the mineral waters of which I spoke above, 
 I presented typical examples where they are to be employed, 
 but I certamly did not mtend to exhaust the whole variety of 
 cases which may present some preeminent indication for the 
 use of this or that water. This comparison of the most impor- 
 tant mineral waters has made clear to you their chief individual 
 characteristics, the knowledge of which will enable you to 
 correctly prescribe these waters ; I repeat, the most impor- 
 tant waters, because they have been the most investigated, the 
 most useful, and because in the great majority of the occurring 
 cases we see them meet all the indications ; not to mention the 
 fact, that they, as I said once already, present types of whole 
 classes of mineral waters. This comparison has also made it 
 
— 107 — 
 
 clear to you as to how the selection of a mineral water for a 
 given case is made, which knowledge will aid you in prescrib- 
 ing also other mineral waters not discussed by us. 
 
 When speaking of treatment (in the Introduction to Clmical 
 Exercises) I pointed out the mistake of employmg complicated 
 medication. You might ask whether it would be correct to use 
 such combinations of drugs as presented by a mmeral water. 
 You might also ask why I selected for comparison only the 
 foreign waters, except the Yessentucki. 
 
 The knowledge of the effectiveness of the mineral waters has 
 been obtained in a purely empirical way, at a remote period, 
 when medicine and balneology were far from their present per- 
 fected condition. To reach this perfection there were required 
 centuries of labor, gigantic progress in diagnostication, general 
 pathology and therapeutics, as well as in the chemical and clin- 
 ical (and partly physiological) knowledge of the mineral waters. 
 These tests of centuries the waters stood nobly : the more 
 they were studied, the greater and not lesser, became their 
 importance, until it is now enormous as compared with what it 
 was before. They stand above comparison with the various com- 
 plex decoctions, powders, pills, drops, etc., — fruits of experience, 
 but oftener of the fancy of the physician, — fruits of but ephe- 
 meral existence, as time shows, burymg them into oblivion. 
 
 For comparison we took only foreign waters, except Yessen- 
 tucki. We must first of all remember that these foreign waters 
 are the very useful ones, and that a familiarity with these and 
 the knowledge of their employment is just as necessary as the 
 knowledge of the employment of opium, quinine and others, and 
 these also are foreign drugs. We have selected these waters 
 because they present the best examples known to us of a happy 
 natural combination of curative agencies, and because the indi- 
 cations for their use are best known to us (it is for the same 
 reason that we chose Yessentucki from among our own waters ) . 
 However, I do not in the least doubt, but that the considerable 
 employment with us of the foreign mineral waters is but a 
 matter of temporary duration. I am perfectly certam, that our 
 great land is very rich in various mineral waters possessing just 
 as happy, and even much happier, combinations of curative 
 
— 108 — 
 
 forces. Time will bring it about, that we will become acquainted 
 with these waters and that we will investigate their composition. 
 Knowing this last and the various combinations which cen- 
 turies of experience in foreign waters, and some experience in 
 our o\vai, has shown to be effective, we shall soon learn for 
 what cases these our waters will be beneficial, and we will em- 
 ploy them on the spot as well as export them, mstead of the 
 foreign ones, as we do now. 
 
 I pass now to the very important subject of the mode of 
 employ mg the mineral waters : what shall be the daily quantity, 
 at what time of the day admmistered, and for how long a 
 period. 
 
 At the beginning of my medical practice the mineral waters 
 were employed only during summer and the patient usually de- 
 parted, with the purpose of di'mkmg them, for the places where 
 the springs were located. Imported mineral waters were pre- 
 scribed but seldom. Artificial mmeral waters were used also 
 during summer in those few places, so rare then, where such 
 waters were prepared. But for the principal object, I will 
 repeat, of drinking the water, summer excursions were under- 
 taken to the mineral water resorts. 
 
 The general character of practice at that time was such that 
 waters were used then in much larger quantities than they are 
 used now. Dr. Debout d'Estrees (" Les indications aux eaux de 
 Contrexeville," Paris, 1889) mentions the fact that the famous 
 writer Madame Sevigne (he refers, as you see, to a long gone- 
 by past) was ordered daily at Yichy 12 glasses of the water of 
 the Grande Grille spring, she being previously bled and given 
 a laxative. We now generally give less. Dr. Debout d'Estrees 
 is rather inclined to ascribe this to the fact that, a« he expresses 
 it, the struggle for existence has made our generation anaemic 
 and nervous.* 
 
 Without denying, but on the contrarj^ considering it quite 
 probable, that the percentage of men of strong constitution and 
 health in certain social strata is now smaller than it was form- 
 erl}^ I still think that there was another reason for the former 
 
 * 'Sos cerveaux, surmenes par le striiggle for life, nous out donue I'ane- 
 mie et les nevroses, que ne connaissaient pas nos peres (page 11). 
 
— 109 — 
 
 use of water iii greater quantities, namely, this : that the arrivals 
 at the springs, never having the necessary time at their dispo- 
 sal, the physician attempted to obtain the desired effects sooner, 
 and therefore administered the water m great quantities. But 
 at present, when the waters are much more used, while remain- 
 ing at one's own constant residence, this lack of time, and with 
 it the necessity for haste, are absent. It is well miclerstood that 
 the progress in diagnosis, general pathology and therapeutics 
 could not but have a certain influence on the diminution of the 
 prescribed quantity of the water for cMnking purposes. 
 
 However, even now the routme method of drinking the water 
 at the resorts in summer differs greatly from the manner in which 
 they are used at the other seasons of the year, and even now pre- 
 serves a great many of the former procedures. The water is 
 usually drunk m the early morning, when it is not yet hot, so 
 that the prescribed walk to be taken after the water is made less 
 burdensome ; the water is taken on an empty stomach and m 
 lesser quantity than formerly, but always in a greater quantity 
 than when the water is prescribed not in summer, but at other 
 seasons of the year and at the place of the patient's residence. 
 Such a routine treatment often gives excellent results. Picture 
 to yourselves a city mhabitant of strong constitution, who is habi- 
 tuated to late rismg and of course to retirmg late to bed, who com- 
 mits errors in his diet, lives a mental life, has almost no exercise, 
 and but seldom goes out into fresh air, — imagme such a person lead- 
 ing a totally different life at the w^atering place : he rises early and 
 therefore goes to bed early, observes a correct diet, spends consider- 
 able time out-doors, does a great deal of moving around, rests from 
 his mental labor, and frequently, in addition to all this, removed 
 from the place of his permanent residence and free from the many 
 constant and unpleasant impressions, he drinks the correctly pre- 
 scribed water and usually takes his baths regularlj^ We certainly 
 get in such cases strikingly good results. But unfortunately such 
 is not always the case. Routine, that has always something of 
 good with it, — namely, that which created it, remams but routine, 
 that is, it is at times beneficial, at other times harmful. Not to 
 speak of the cases, when the physician's advice concerning a trip 
 to the watering place is incorrect, when without individualizing 
 
— 110 — 
 
 the given case, without considering all its peculiarities, he orders 
 a trip not for the one for whom it may be convenient and bene- 
 ficial, but for a person who can only with difficulty tear himself 
 from his near relatives and wonted surromidings of life, and for 
 whom, besides, such a trip is beyond his means. Not to speak 
 of such a wrong and useless advice to midertake a trip, I will 
 only point to the impracticability of the above alluded to routine 
 even for many such cases, where the trip is both indicated and 
 possible. Here is one of the cases that occur quite frequently. 
 A woman, somewhat exhausted and ansemic, subject to chills, 
 nervous, and a poor sleeper, comes to the watering place in ac- 
 cord with the advice of tlie physician, begins the above described 
 routine method of living and of drinking the waters. She cannot 
 fall asleep early m the evening but sleeps quite somidly in the 
 morning hours. She is waked up to go to the spring, to take a 
 walk, and to listen to the inevitable music. Without having 
 a good night's sleep she starts out, soon becomes chilled, owing 
 to the coolness of the morning air, experiences a sharp sensation 
 of hunger and is soon fatigued ; and in such a condition — hun- 
 gry, chilled through and tired out, she must drink a cold water 
 and walk for a long time. Her condition has, of course, become 
 even worse than it was before, and the water was of no benefit. 
 The patient then consulted one of my former students, who 
 lived at the watering-place and who was acquainted, tlirough my 
 clinic, with the use of mineral waters. He first of all advised 
 her to sleep in the morning as long as she felt sleepy, not to 
 interrupt the sleep, not to drink the water on an empty stomach, 
 but after the morning coffee, before breakfast and before dinner, 
 and m a lesser quantity ; to be out in the fresh, open ah, for a 
 longer time, but at the same time to walk only as long as her 
 strength permits it, and by no manner of means until she be- 
 comes fatigued. After this the patient began to improve. 
 
 I alluded to the trips to the watering places with the 
 purpose of acquainting you, at least to some extent, with this 
 medicinal agency, and to present examples in which this agency 
 is suitable and where not, and finall}^ to point out the necessity, 
 while employing this remedy, for individualizing your cases, so 
 that you may not fall mto routine habits and that you may 
 
— Ill — 
 
 change the routine order of living and of drinking the waters in 
 accord with the peculiarities of the given case. I cannot discuss 
 the subject much longer, the more so, as you will all undoubtedly 
 have to prescribe the mineral water much of tener for the patients m 
 their places of residence, without sending them to the watering 
 places. We will now endeavor to answer the questions as to the 
 quantity of the water to be used per day, for how long a time, and at 
 what periods of the day. I have already said that at the pres- 
 ent day mineral waters are employed in lesser quantities than 
 formerly, but the manner of employing them at the different 
 watering places, or even by several physicians at one and the 
 same watering place, is very varied ; I will therefore, in view of 
 the absence of any standard or commonly accepted rule, speak 
 only of that method of employing the mineral waters to which 
 I adhere on the ground of my own experience extending over 
 many years. 
 
 The quantity of the daily dose of the waters depends, of 
 course, on what you have in view when prescribing the water, 
 and consequently on the character of the water chosen for the 
 purpose. Within the limits of the effects of the waters selected 
 by us for comparison, we may note the following most impor- 
 tant objects, that we most frequently strive for : 
 
 1. We strive to secure a direct effect on the mucous mem- 
 brane of the stomach and the upper portion of the intestines, or, 
 besides this, by way of absorption of the mineral water by the 
 intestine and by its entrance into the blood, on the mucous 
 membrane of the biliary, urinary and resjDiratory tracts, on bil- 
 iary calculi and urmary gravel ; provided the intestmal evacua- 
 tions of the patient take place regularly. In such cases we 
 usually prescribe Ems, Obersalzbrunnen, Vichy and Yessen- 
 tucki, in doses, for adults, from two to six times a day (the 
 usual dose is one-half glass, i. e. four ounces, or three-fourths 
 of a glass, i. e. six ounces, but then only four glasses a day): for 
 weak and exhausted persons two or three half-giassfuls of Ems 
 or Obersalzbrunnen ; for strong persons with a good nutrition 
 three to six half-glassfuls of Vichy or Yessentucki. In case 
 there is a tendency to diarrhea I prescribe a smaller number of 
 doses and the warm sprmg, or water warmed up to the required 
 
— 112 — 
 
 temperature. If I find an already existing diarrhoea, then I order 
 only Ems, m smaller doses, and at times, at the beginning, only 
 half-doses, one-fourth of a glass, or two ounces of the water, 
 still more warmed. In cases with a tendency to constipation I 
 use Yessentucki springs and in a greater number of doses. If 
 in addition to an inclination to costiveness the patient be ex- 
 hausted, weak and suffering with pains, that serve as an 
 indication for warm water (gastric pains and liver colic), then 
 I prescribe Ems, warmed, in less frequent doses (for mstance 
 three or four half-glassfuls) and at the same time evacuatmg 
 clysters. I will add here, that both for cases to which I allude 
 now and for those of which I shall. speak later, we can prescribe 
 in summer generally more water than at the cold season of the 
 year ; because movement in the free air assists the organism in 
 better sustaming the mineral waters ; and light summer dress 
 makes out-door movement certainly easier, than the heavy 
 whiter overcoat. Besides, the use especially of warm water is 
 rather risky m winter : at the hours of di'inkuig one must not 
 go out of doors, but must walk aromid the room. In ordering 
 movement, whether out-of-doors or withm the room, while ^^'ater 
 is bemg takmg, you will clearly see from what I said just now 
 and from the examples alluded to above, that every given case 
 must be mdividualized, i. e. we must take into considerstion the 
 season of year, the weather, the quantity of the ordered ^^^ater, 
 the strength of the j)atient and indeed the whole coui'se of 
 treatment. 
 
 2. We have m view the same aims as m the first cases, but 
 we deal with patients who either suffer constantly from consti- 
 pation, or from a constipation that is at times intermittent with 
 a diarrh(pa, and in whom we must therefore take pains to secure 
 a regular evacuation of the bowels, but at the same time to pre- 
 vent severe purging, as that would destroy our chief object, 
 namely, the absorption of the mineral water and its passage into 
 the circulation for further effect. In such cases I either order 
 Yessentucki (as I do for cases with a tendency to costiveness) 
 and. moreover, in larger doses (up to six half-glassfuls), at times 
 with the addition of a bitter water, or, if in case of severe pams 
 (of gastric origin and liver colic) there is also required a warm 
 
— 113 — 
 
 or even a hot water, then Karlsbad — ui wmter three to four 
 half-glass fuls (if necessary I add Karlsbad salt), in summer from 
 four to six doses of three-quarters of a glass each, also with the 
 addition of the salt, if necessary. As referred to above (vide 
 Yessentucki), Karlsbad water may in such cases be often replaced 
 by the warmed Yessentucki, with the addition of some bitter 
 water. 
 
 3. Finally we aim not only at evacuating the bowels, but at 
 inducing a more or less considerable looseness of the same for 
 a certain period of time, as, for instance, for several weeks. For 
 such cases I order Marienbad or Kissingen or Yessentucki (with 
 the addition of a bitter water), three-quarters of a glass per dose, 
 from three to six doses a day, in accord with the desired and 
 obtained results, and usually only during the summer. The use 
 of such a quantity of water in winter or generally at a cold sea- 
 son of the year is inconvenient and risky, as it absolutely re- 
 quires considerable movement or at least a prolonged stay out- 
 of-doors. In the winter and at the cold season generally we can 
 reach the desired effect for such cases, even if somewhat slower, 
 by ordering simultaneously with Yessentucki some bitter water, 
 — of l3oth together some four half-glassfuls per day — adminis- 
 tering more of the one or of tlie other, in accord with the de- 
 sired and the obtained effect. 
 
 For how long a jperiod is the prescribed water to he taken? 
 (The length of the course of treatment.) Certainly, up to the 
 time the desired object is effected ; but I usually do not continue 
 treatment with mineral waters for longer than six weeks at a 
 time. If they are prescribed for a recent catarrh of the stomach 
 and intestines, or of the biliary, urinary and respiratory tracts, 
 then the above length of time, or even a shorter period of five, 
 four or three weeks, is quite sufficient ; just as in the cases in 
 which the waters are ordered as constant laxatives. But for 
 cases of chronic catarrh, biliary calculi, renal gravel and gout a 
 six weeks' course proves frequently insufficient ; but this not- 
 withstanding I often interrupt for a time the use of the pre- 
 scribed water after six weeks or before — for two reasons: 1. 
 A longer, unmterrupted administration of mineral waters tends 
 to disturb digestion and nutrition, as there appear dyspeptic 
 
— 114 — 
 
 phenomena, and the patients grow thin and pale. 2. As the ef- 
 fects of the water last for some time after its employment has 
 been discontinued, we give an opportunity for the results of the 
 treatment to show themselves, after we have ceased employmg 
 the water after a period of six weeks ; then, guided by these re- 
 sults and by the condition of the patient's digestion and nutri- 
 tion, we are enabled sooner or later to return to the treatment 
 by waters. 
 
 The distribution of the prescribed quantity of the water over the 
 course of the day must be made in accord with the aim we have 
 in view. If the water be employed for its action on the mucous 
 membrane of the stomach and of the intestines and also for its 
 absorption and passage into the circulation and for further action, 
 then we must assign the ordered quantity over the whole day — 
 for instance, before morning coffee or tea, midday lunch and 
 dinner (at about 6 p. m. ; it is better to avoid the use of the 
 waters late at night, as that may disturb the sleep). But if the 
 water be taken for its laxative effect, then all the prescribed 
 doses must be taken, in intervals between fifteen and twenty 
 minutes, in the morning on an empty stomach ; this is quite con- 
 venient as it requires at the same time movement during the 
 summer and in vigorous persons of strong constitution and fair 
 strength ; for contrary cases we must order one-half of the doses 
 before the morning tea and coffee, and the other half before the 
 midday meal. 
 
 A mineral water is always to be taken on an empty stomach 
 (the last dose at least one hour prior to a meal), because its 
 action on the mucous membrane of the stomach and intestines, 
 as well as its absorption and its laxative effect, have then a 
 much more favorable influence, not being hindered by the con- 
 tents of the stomach and intestines. A mineral .water taken 
 soon after a meal will have, if an alkalme, only a palliative 
 effect on the dyspeptic symptoms. It will diminish pyrosis, 
 alleviate belching and the feeling of heaviness m the stomach, 
 but, as I said once already, will with difficulty exert its princi- 
 pal, most important action, m fact may completely lose it. The 
 practice of some of administering the mineral waters with the 
 meals, — usually Vichy or some other alkalme water for renal 
 
— 115 — 
 
 gravel and gout — deserves positive condemnation. Notwith- 
 standing its constant administration, the gout and the attacks of 
 renal colic are not influenced at all, while the patient's nutrition 
 and digestion suffer from the constant introduction of a mmeral 
 water ; besides, the use of the mmeral waters in the ordinary 
 regular manner, as during a course of treatment, does not bear 
 as good results in these patients, as it does m patients not habit- 
 uated to the constant use of waters. The employment of alkaline 
 mmeral waters m cases of gout and renal gravel for a continu- 
 ous period of time, but with interruptions, in a small daily 
 quantity and m the usual manner, i. e. on an empty stomach, 
 deserves undoubted preference over the above-mentioned 
 practice of constant drinking of waters during meals. The 
 quite extensive employment at the present time of the alkaline 
 mineral waters, natural and artificial, as a constant beverage, is 
 prejudicial on the same ground. 
 
 From a great deal of what I said concerning the mternal use 
 of mmeral waters, it is easy for you to comprehend, where the 
 cold water is indicated and where the warm one. We must 
 now give more precisely the temperature of the prescribed waters. 
 Under a cold water we mean water of such a temperature as 
 can be Ixjrne comfortably by the stomach, usually not below the 
 temperature of an ordinary apartment in winter, i. e., about 14° 
 R. (64°#.). Of the waters we discussed,. Marienbad, Franzens- 
 bad, Kissmgen and Yessentucki are given at such a temperature 
 (sometimes a little higher) for their laxative effect. Alkaline 
 waters, indicated for their action on the mucous membrane of the 
 stomach and intestmes and for aljsorption, are admmistered to 
 persons mclmed to constipation, at a temperature of about 18^ to 
 20°'i?. (74° to 78°jP.), and to those with a tendency to diarrhfjea 
 at the temperature of freshly drawn milk, i. e. about 25° to 2.1° IL 
 (88.2° to 92.T°i^.), while for diarrhcea with severe gastric and 
 intestinal pains as well as for kidney gravel, they are given 
 warmer still. 
 
 While drinld]ig the mmeral waters such a diet is ordered 
 as is, firstly, required by the condition of the patient; and sec- 
 ondly, all the very sour articles of food are to be excluded, as 
 the use of vmegar with meals, lemon, also cucumbers, mush- 
 
— 116 — 
 
 rooms, berries and fruits, so as to avoid a possible diarrhcea, fre- 
 quently of a severe nature, accompanied by acute intestinal 
 pains, and so obstinate, as to require not only an interruption in 
 the treatment, but a prolonged cessation of the same, because a 
 return to the use of the mineral water brings on a recurrence of 
 the diarrhoea. Ripe, sweet berries are sometimes borne well 
 while the mmeral waters are employed, but this is always risky, 
 as together with the sweet ones there may be some that are 
 unripe and sour. 
 
 The mineral waters, used as they are at the present time in 
 smaller and moderate, as compared with the past, quantities, are 
 contraiyidicated only in considerable disturbances of the circu- 
 lation, h(jematopoiesis and nutrition, in conditions of cachexia 
 and marasmus. — We have often seen anaemic and exhausted 
 persons, as, for instance, our patient, or, still more frequently, 
 women exhausted by pregnancies and diseases of the sexual ap- 
 paratus, but with an undoubted gastric catarrh, for whom, in 
 view of their ansemia and exhaustion, one rather hesitates to 
 order a mineral water, hoping to cure them by directly ordering 
 forced alimentation, iron and arsenic, but without first improvmg 
 the condition of the stomach. Such attempts — I repeat again, 
 m the presence of an undoubted gastric catarrh — always fail : 
 the " nutritious " food does not nourish the patient, as it is not 
 digested ; on the contrary, introduced in large quantities (at the 
 advice of the physician — the so-called forced alimentation) and 
 in conjunction with iron and arsenic, it tends to derange diges- 
 tion still more and through that the general condition. On the 
 contrary, — by regulating strictly the hygiene, and, particularly, 
 the diet and physical exercise (i. e., prohibiting any fatigue), and 
 by ordering general massage, it becomes possible, even in such 
 cases, by the moderate use of the light mineral waters and 
 bitter drugs, to so improve the condition of the patient's stomach-, 
 as to make it possible to further improve the general condition 
 and, consequently, that of the stomach itself. Our patient may 
 serve as a good example of the results of such a mode of treat- 
 ment. 
 
 Nervous dyspepsia certainly does not present any contra- 
 indication for the use of mineral waters, if it be accompanied by 
 
— 117 — 
 
 certain morbid conditions presenting an indication for their use, 
 as, for instance, gastric catarrh, renal gravel, gout, etc. ; in the 
 absence of such indications it would be erroneous to rely on 
 the mineral water alone as a cure for nervous dyspepsia. Of 
 the treatment of this so frequent and so important morbid con- 
 dition we shall speak when discussing cases of patients subject 
 to it. 
 
 Condition of patient October 18th, 1889. Patient is given the 
 same food. His condition is as good as it was five days ago, when 
 we saw him last. During these five days he gained one pound 
 in weight, — he weighs now ninety-nine pounds, eight pounds 
 more than he weighed on admission. Of the morbid symptoms 
 there remain, although constantly dimmishing, the former pains 
 in the left kidney on motion, leanness and physical weakness. 
 
 What is to be done further? Having finished the analysis 
 of the present case, and the plan of treating it, and having 
 brought the patient to a very satisfactory condition, we must 
 proceed to the analysis of other patients ; it will thus be 
 impossible for us to return to him as frequently as heretofore, 
 and it is therefore necessary to outline the plan of future 
 treatment for a longer time, which is at jDresent, after our treat- 
 ment has been justified by the obtained results, certainly more 
 possible than it was at the beginning. 
 
 The patient has been taking the Ems-Kesselbrimnen for the 
 last five weeks ; notwithstanding the complete absence of dys- 
 peptic phenomena, still caution requires, that we do not dis- 
 contmue at once the use of this water, but continue it for 
 another week. First, because the patient has had the catarrh 
 for such a long time ; secondly, the dyspeptic phenomena are 
 absent when very light food is taken with due care (little at a 
 time and frequently), whereas the patient has to return to his 
 habitual rougher food ; and, thirdly, to meet as much as possible 
 the renal indications (oxalic acid gravel). 
 
 We will also continue for another week the drops of coto, 
 dimmishing the dose contmually for the same reasons, — so as 
 to secure the obtained result, the cessation of the diarrhoea. 
 
 The bitters (condurango and tinctura nucis vomicae) we will 
 continue for a long period, very likely up to the time he leaves 
 
— 118 — 
 
 our clinic, as experience has shown the utility of their prolonged 
 administration after an obstinate catarrh of the stomach and in- 
 testines of such duration, especially in emaciated patients, and 
 also in view of the approaching change in his food. 
 
 The baths, which continue to influence the patient favorably, 
 will be ordered for him only at rare intervals, in view of the 
 fact, that he will soon begin taking out-door walks in the free 
 air. 
 
 We will continue massage up to the time when the pa- 
 tient will become strong enough to be able to walk and to 
 generally move around in a measure satisfactory to his health. 
 The pains in the region of the left kidney depend, as was 
 explamed above, partly on the oxalic acid gravel and partly on 
 the displacement of this organ. Instead of the former abdom- 
 inal bandage the patient put on yesterday a kidney truss, and 
 to judge by the considerable relief thereafter of the above-named 
 pains on motion, we may well hope to remove them entirely. 
 
 What shall we do to further improve the patient's nutrition 
 and his physical vigor ? 
 
 We cannot thmk of resortmg to an}' fattening- means ; the 
 use of koumyss at this season of the year and under hospital 
 conditions is out of the question. It were besides risky to 
 order koumyss, kephir or cod liver oil on account of the only 
 recently passed dyspeptic phenomena and the diarrhoea that 
 ceased not long ago. We must then confine ourselves to 
 the correct regulation of the food. 
 
 For the same reasons it would be risky to give arsenic and, 
 although not to such an extent, also iron. But then, our 
 patient's appetite is so good, and his weight increases so consid- 
 erably, that there appears to be no necessity for resorting to 
 these drugs. 
 
 After he will have discontinued the use of the Ems water, 
 we will think of prescribing for him silver nitrate, m view of the 
 considerable weakness of the patient's nervo-muscular apparatus, 
 and also in view of the recently ceased intestinal catarrh, so that 
 we may the better secure the now present good condition of the 
 intestinal tract. Until now we have not yet ordered any out- 
 door walks for our patient, although, considering his prei- ent 
 
— 119 — 
 
 condition, lie could take these to some extent, and they would 
 certainly benefit him ; but we did not allow them on account of 
 the extremely unfavorable weather — it being damp, windy and 
 cold. It would be beneficial for the patient to spend the winter 
 in the South, in a warm climate, where he would be able to stay 
 out-of-doors for a long time and move around clad in a light 
 garment, convenient for a weak patient : this would tend to rap- 
 idly improve his nutrition and strength, and through these also 
 his constitution (growth). It certainly would be cruel irony, in 
 view of the patient's poor or even wretched circumstances, to- 
 recommend him a trip to the South ; but my duty, as that of a 
 clinical instructor, requires that I point out to you the indica- 
 tions for climatic therapy, that you may take advantage of them 
 in treating other patients. 
 
 FROM THE LECTURE OF NOVEMBER 28, 1889. 
 
 Almost six weeks have passed since we saw the patient last. 
 He continued taking after that, for a whole week, the Ems water 
 and the coto drops, and then left them off. Five weeks have 
 passed since, and his digestion remains good, notwithstanding the 
 fact that his food is coarser now. He continues the use of the 
 bitters. In accord with our propositions he was given three 
 weeks ago pills of silver nitrate, of one-twentieth grain per dose 
 (with extr. trifolii), at first three times a day, the last ten days 
 four times a day, every time immediately before a meal. We 
 discontmued the baths recently, and instead of these he is 
 sponged twice a week, m the morning, with a mixture of brandy 
 and water, half and half, at first of the temperature of fresh 
 milk and later somewhat cooler, followed by rubbmg with 
 flannel ; this he bears well, does not feel chilly, but feels hale 
 and hearty. Massage is continued less frequently than before, 
 as the patient walks around a great deal. Three days ago 
 (November 25th), m a light frost and during pleasant, dry 
 and quiet weather, the patient began his fresh-air walks, at first 
 twice a day, half an hour each time — and this seemed to do him 
 good : he is not chilly, does not become fatigued and sleeps 
 
— 120 — 
 
 better after it. Some three weeks previous to these walks, which 
 could not be taken on account of the uninterruptedly bad 
 weather, the patient, being confined in the room and deprived of 
 fresh air, began to sleep poorly, but he was improved by frank- 
 linization (static electricity), which was resorted to rather than 
 the use of hypnotics internally. 
 
 Patient's condition at presetit. He gets rougher food: more 
 than a pound of bread — half of white bread, the other half 
 pound of rye-bread; instead of chicken and beef cutlets — a 
 pound of beef ; instead of chicken soup — lately, cabbage-soup, 
 besides — six eggs, three glasses of milk with cognac, two spoon- 
 fuls of wine. Digestion entirely normal. With the kidney truss 
 on, pains in the left kidney are experienced only when maldng 
 very abrupt movements, and even then they are slight, while in 
 ordinary walking, and especially when at rest, none at all are 
 experienced. Examination of the abdomen elicits but slight 
 sensitiveness in the region of the left kidney. Pulse of normal 
 strength. The patient has grown considerably m body (his 
 weight now is 111 pounds, or 20 pounds more than what he 
 weighed on admission) and loolcs hale ; there appeared even a 
 slight flush on his cheeks. His sleep is good, mental condition 
 splendid and physical strength very much improved. " 
 
 The patient, or rather the convalescent, desires to leave our 
 clinic in about two weeks, before Christmas, so as to visit his 
 parents. Up to that time he will continue the bitters, the silver 
 nitrate pills and the sponging, and also, at intervals, franldiniz- 
 ation and massage, till the gradually mcreasing walks will per- 
 mit us to dispense with them. We will also continue to gradu- 
 ally introduce our patient to food that approaches Ms habitual 
 one. 
 
 Patient left the clinic December 15th, strong and havmg 
 become stout (his weight 115 pounds — 24 pounds more than 
 he weighed on admission), and digesting freely, for the last 
 week, cabbage-soup, buckwheat-gruel and rye-bread. On his 
 departure he was advised not to eat much at a time, to avoid 
 fatigue, and not to go to any bathing establishment in bad 
 
— 121 
 
 weather, but to sponge himself mstead with a mixture of 
 water and brandy. 
 
 Our clmical assistant, Dr. Nikulin, received two letters from 
 the former patient, one in the middle of February, and the 
 other mthe middle of April, 1890. He writes in the firft 
 that he IS well and bears the wmtry weather well fdoes not 
 catch cold), and also the ordmary peasant's food, and in the 
 second, that at the time of the great fast days (before Easter) 
 he a e well and has borne well the fast meal, has not experi- 
 enced with this any abdominal pains, has neither grown thin 
 nor weak. ^ 
 
SECOND CASE 
 
 LECTURES OF OCTOBER 20 AND 24, 1889. 
 
 The patient before you has been in the cluiic for three weeks 
 already. The detailed analysis of the first patient I presented 
 to you terminated only with the last lectm-e, preventing me until 
 now from presenting before you this one. Meanwhile the con- 
 dition of this patient has undergone a considerable change for 
 the better ; but the case is so mstructive that I consider it 
 necessary to acquaint you with it. 
 
 The patient is fort}'' years of age, was admitted to the clinic 
 September 29th, complaming of constant heaviness and pain 
 in the stomach, aggravated by meals, of belching of gas of 
 the odor of rotten eggs, of pyrosis, nausea and vomiting of 
 large masses. 
 
 Conditions and mode of living. Patient spends about three 
 summer months in the country, the rest of the year he lives in 
 the city; in either of the places in a healthy locality and a 
 good house. Is not habituated to open air bathing (sea or 
 river), but takes his bath in the public bath-house once a 
 month. Smokes a great deal (about forty cigarettes per day), 
 does not drink any brandy, and but little and seldom wine 
 and beer. Used to drink formerly a little very sweet tea, 
 but discontinued it lately on account of the pjTOsis, and drinks 
 only water, four glasses a day. Has three meals daily ; is fond 
 of fat, sweet and cold articles of food (as ice-cream), dislikes 
 meat, nor can he, as he says, bear it. Patient Ls married, denies 
 ever having been affected with syphilis, and presents, neither 
 from the investigation of his present condition nor from his 
 past history, no indication of the latter. Patient is occupied 
 durmg the summer, in the capacity of a manager of a country 
 place, with rural economy ; has much to do, and is subjected to 
 
— 123 — 
 
 a great deal of worry; never sleeps enough, is constantly 
 fatiguing himself, eats irregularly and always in a hurry ; in 
 winter, the other extremes : has no responsible occupation, 
 leads a secluded life, plays cards, reads, moves very little in 
 the open air and has little exercise. 
 
 Anamnesis until his admission to the clmic and for the time 
 he has been there. — Patient comes from a healthy family. Does 
 not remember having had any sickness until his fifteenth year ; 
 in his sixteenth year he had some febrile affection ; in his 
 twenty-first had passed through an attack of typhoid fever. 
 Since his twenty-fifth year he began his activity as a country 
 manager, leading the above-described mode of life. It is to this 
 period, that he refers the beginning of his present illness, the 
 appearance of heaviness (but no pains) in the stomach, of belch- 
 ing, heartburn, nausea and, very seldom, of vomitmg. Some 
 three years later these phenomena became aggravated and to 
 them was added constipation. Two years later, that is, about 
 ten years ago, along with the aggravation of the above-named 
 symptoms, there appeared severe pams in the stomach, and 
 vomiting of dark, ground-coffee like masses. Patient began 
 to take Yessentucki water and improved considerably; but the 
 morbid symptoms again became worse in the course of a year. 
 Patient drank Karlsbad water, was treated with silver nitrate, 
 and another period of improvement, lasting one and a half years, 
 followed; but returning to his former mode of living, the 
 morbid condition became agam aggravated, and since then 
 until the present time there took place no considerable im- 
 provement of even a temporary nature, but, on the contrary, 
 the condition grew steadily worse. Patient began to grow 
 thin and weak, slept badly, became low-spirited and irritable. 
 He always felt better durmg summer than in winter, thanks 
 to the constant outdoor occupation and notwithstanding the 
 irregularity of his life. Since his treatment with Karlsbad 
 water, or since more than seven years ago, the patient has 
 not been treated any more with mineral waters, but has been 
 takhig various pharmaceutical preparations, without deriving 
 any substantial benefit therefrom. ISTor was he treated by 
 gastric lavage. For the last six weeks the morbid symptoms 
 
— 124 — 
 
 have become especially aggravated: the pains m the stomach 
 became excruciating ; to obtain a relief from them, the patient 
 at times caused vomiting intentionally ; besides, spontaneous 
 vomiting of large, coffee-like masses took place once in ten days ; 
 the vomited matter usually contained particles of food, more 
 frequently of meat, ingested several daj^s previously. 
 
 Directly on the second day of his admission the patient's 
 stomach was washed out with Ems water; this brought away 
 an enormous quantit}' of mucus — through the sound and 
 along its sides. The washing was repeated on the next day, 
 but m view of the great quantity of mucus the Ems water 
 was replaced by a stronger (two per cent) solution of sodium 
 bicarbonate, so as to more certamly clear the mucous mem- 
 brane of the stomach of the accumulated mucus. This 
 second washing also brought away a great quantity of mu- 
 cus. After the washings the pams and heavmess were con- 
 siderably relieved. He was given internally Ems-Kesselbrun- 
 nen at the temperature of freshly drawn milk, a half glass- 
 ful three times a day, each time one hour before the meal ; 
 five drops of tinct. of nux vom. twice a day, after each meal 
 (the decoction of condurango, prescribed at the beginning, was 
 set aside, as it tended to increase the pyrosis) ; for severe 
 pyrosis magnesia usta, about one-fourth of a teaspoonful for 
 a dose ; for the relief of the severe abdoinuial pams we tried 
 first bismuth subnitrate (in 5 gr, doses) and tinctura canna- 
 bis indicee (in doses of 10 drops), but they were of little avail, 
 and we replaced them successfully with one-fourth gr. doses 
 of codeine (+5 gr. of carbonate of sodium). For constipation 
 a clyster of two to three glasses of water at the temperature 
 of warm milk, every other day. In view of his wealaiess and 
 the exacerbation of the pains on motion, the patient was advised 
 to repose (which he preferred himself) and to avoid sudden 
 changes of position. The abdomen was protected by a flannel 
 bandage. A preferably liquid food was ordered — neither cold, 
 nor hot, at the temperature of warm milk, of a bland charac- 
 ter and in small quantities at a time. At first the patient was 
 given, for a whole day, only two glasses of chicken bouillon, 
 one glass of milk, about one-half a glass of milk-manna gruel. 
 
— 125 — 
 
 two eggs and about one-fourth pound of white bread, ^Yithout 
 the crust. The quantity of food was increased proportionately 
 with the improvement in the patient's condition. 
 
 Strong Crimea wine, which the patient drank rather reluctant- 
 ly, but which had to be given on account of some weakness of 
 the pulse, was administered in tablespoon doses once or twice a 
 day ; to the milk was added some cognac, a teaspoonful to a 
 glass of milk. All these included his food and drink the fhst 
 time. He was advised to smoke as little as possible. 
 
 During the early time of his residence in the clinic, the pa- 
 tient had two attacks of vomiting, but of less abundant contents 
 than formerly. Examination proved the vomited matter to con- 
 tain leucocytes, sarcina ventriculi, heematin and free HCl. the 
 latter in a quantity even greater than normal (three and one- 
 half in one thousand), while a specimen portion of fibrin was 
 completely and rapidly digested. Another washing of the stom- 
 ach after the second vomiting, with a two per cent solution of 
 bicarbonate of soda, brought away much less mucus than the 
 first two washings. Xotwithstanding the fact, that he felt very 
 much relieved after each washing, which apparently exerted a 
 favorable miiuence on the course of the disease, the patient sub- 
 jected himself to them rather reluctantly ; iDut after the thiid 
 washing the disease took such a favorable course, that there 
 appeared no necessity to insist on further washings, and we are 
 satisfied with the above outlined treatment. 
 
 The present condition of the patient is, as I said before, much 
 better than it was on his admission. The appetite is keener. 
 The first days the patient was given for a whole day two 
 glasses of chicken bouillon, a glass of milk with cognac, about 
 one-half glass of milk soup with manna, two eggs, and about 
 one-fourth pound of white bread ; he gets now one-half pound 
 of white bread, four eggs, two glasses of milk soup with manna, 
 two glasses of bouillon with manna semolino and four- glasses of 
 milk with cognac (outside of this no beverage but one and one- 
 half glasses of Ems water) and, as you will hear presently, he 
 is able to digest all this food much easier than before. He gets 
 his wine, as heretofore, one or two spoonfuls per day. As he 
 takes meat rather reluctantly and observes after its ingestion an 
 
— 126 — 
 
 aggravation of the gastric symptoms, we do not insist upon his 
 eating it. The gastric symptoms may at the present time be 
 summed up as follows:, at about five P. M. the patient experi- 
 ences pains at the pit of the stomach, (he takes his dinner at one 
 P. M. and drinks a glass of milk at about three P. jM.), which are 
 quite bearable while he is resting, but increase on his moving 
 about, and which are relieved by an easy belching of odorless 
 gases ; they disappear at seven p. M., when food is taken again. 
 During the rest of the day the patient is almost free from any 
 gastric symptoms ; whereas on his admission he ahiiost continu- 
 ously suffered from painful belching of fetid gas and sour liquid, 
 conjoined with a feeling of very severe heartburn, nausea, and 
 acute, at times even excruciating, pains in the upper part of the 
 abdomen simultaneously with pain in the opposite part of the 
 back. The improvement of the patient is also evident from 
 the fact, that for the last ten days there appeared no necessity 
 for resorting to the above-mentioned palliative means against 
 pyrosis and the pains. There was no vomiting for about two 
 weeks. The obstipation also begms to disappear : there were 
 normal movements for the last three days without the aid of 
 clysters. The urine is somewhat pale, but, outside of this, 
 normal. The organs of both respiration and circulation present 
 nothing abnormal : pulse 60 to 70, was somewhat weak on ad- 
 mission, but is of almost normal strength now. The patient, 
 who never was fat, naturally became yerj thin while ailing. 
 The temperature is below normal, about 36° (about 98°^.) 
 seldom a little higher. The sleep is short, about six to seven 
 hours, but much more sound, than it was on his admission, 
 when it was disturbed by abdominal pains. Mental condition 
 now better. Dizziness and the pains at the nape of his neck, to 
 which he was subject while suffering with obstinate constipation, 
 do not trouble him any more. The patient is stronger than he 
 was on admission. 
 
 The objective examination of the abdomen gives, as you see, the 
 foUowmg results. Abdomen not distended, whereas on his 
 admission there was considerable bulging of the upper part of the 
 abdomen, and especially so in its median portion and left half. 
 There is no cutaneous hyperEesthesia, Tenderness on pressure 
 
— 127 — 
 
 along the median line, from the xyphoid cartilage to the umbili- 
 cus, is more noticeable in the direction upwards ; below the 
 umbilicus along the same line there is no tenderness. Both 
 hypochondrial regions, especially the left one, are tender on 
 pressure : the right at a point that corresponds more to the 
 position of the pylorus than to the gall-bladder. There is sensi- 
 tiveness on pressure in the region of the caecum and the ascend- 
 ing portion of the colon. No other abdominal morbid condi- 
 tion is elicited by the objective exammation. 
 
 ' Diagnosis * It is evidently the stomach that is chiefly ai3^ected 
 in our patient, and, besides, not by one, but by several morbid 
 conditions. The great accumulations of mucus and the presence 
 of leucocytes in the gastric contents point to an unquestionably 
 severe catarrh of the stomach. Vomiting of dark liquid, that 
 accompanies the attack of acute pains over the whole epigastric 
 region, and especially at the pit of the stomach, and the presence 
 of hcematin in the above-named liquid, speak in the present case 
 for gastric ulcer ; we shall see later, why cancer is excluded. 
 We also observe symptoms of nervous dyspepsia ; that is, a 
 greater or weaker development of the dyspeptic phenomena 
 under the influence of a respectively better or worse mental con- 
 dition, though this latter, as well as the general nervous symp- 
 toms (poor sleep, general weakness) depend evidently in their 
 turn on the affection of the stomach and the pains and the insom- 
 nia resulting therefrom : from the anamnesis and from observation 
 of the patient we learn, that a gloomy and irritable mental con- 
 dition, insomnia and general weakness run parallel to the condi- 
 tion of the gastric symptoms, and that they mcrease or diminish 
 in proportion as these are better or worse. Finally, the patient 
 has a considerable dilatation of the stomach. This is shown by 
 the following : the very marked inflation of the whole epi- 
 gastrium, especially at the pit of the stomach and m the left 
 hypochondrium, which was so noticeable before the washings, 
 but has disappeared since ; the vomiting of great masses, that has 
 troubled the patient for such a long time, the great quantities of 
 
 *After the investigation is finished, further explanations, regarding diag- 
 nosis, prognosis, etc., are always, in every case, conducted in the patient's 
 absence. 
 
— 128 — 
 
 tlie gastric contents, that were bronght np by the first washing 
 made on an empty stomacli ; the presence in these masses, as ob- 
 served by the patient more than once, of food mgested several 
 days ago ; the pamful belching of great quantities of fetid gases 
 and sour liquids, which pointed to stagnation and dj-speptic 
 decomposition of the gastric contents. On patient's moving 
 about, the abdominal splashing was also clearly heard. I men- 
 tion this sj'mptom simply because it was present; but I would 
 certainly not attempt to cause its appearance mtentionally : 
 iirst, because it would be inexcusable, in view of the former 
 attacks of acute pams and the great sensitiveness in the region 
 of the stomach, to call out this phenomenon, as there would be a 
 risk of simultaneously causmg the appearance of such an attack; 
 and secondly, because, as has been ex^Dlained before, I do not 
 consider this phenomenon as a reliable symptom of dilatation of 
 the stomach. I will add here, that I know of cases, where the 
 splash was caused intentionalh^ and where the somid, mtroduced 
 immediately after that, showed the stomach to be empty, while 
 after the sound was taken out, the splashing could agam be pro- 
 duced. In view of the above midoubted sj^mptoms of consider- 
 able gastric dilatation it would be a profitless task to resort, for 
 diagnostic purposes, to such doubtful methods of investigation, 
 as the mtroduction into the stomach of gas-producing mix- 
 tures and the like ; not to speak of inconveniencmg the patient 
 or even of subjectmg him to dangers, that may arise from such 
 attempts. As regards the mtroduction uito the stomach of 
 salol and the consequent determination of the length of time, 
 when salyciluric acid could be detected m the urine, — the appli- 
 cation of this method of investigation in our case, in the pres- 
 ence of the determmed diagnosis of gastric dilatation, would be 
 but a " scientific '" ornament to an already erected structure ; not 
 to mention the fact, that time must yet prove the degree of 
 reliabilitj" and practicability of such a diagnostic method. I 
 must also add, that not only does our patient present undoubted 
 symptoms of considerable gastric dilatation, but that the absence 
 of such a morbid condition would be unmtelligible in his case. 
 Dilatation of the stomach may appear as a result either of gas- 
 tric catarrh or of nervous dyspepsia. Our patient has a severe 
 
■ — 129 — 
 
 gastric catarrh of long duration, and also nervous dyspepsia. 
 The symptoms of gastric ulcer in the given case have also been 
 observed for a long time, some ten years, but they would at 
 times disappear for a year or a year and a half, which fact would 
 lead us to think of former cicatrization of the ulcers and of 
 present scars. However, these latter seem to be so located, 
 that they do not, at least not to a great extent, embarrass the 
 egress of food : we are led to think thus by the rapid relief from 
 the constipation, which indicates a sufficiently free passage of 
 the gastric contents into the intestines. 
 
 Does not the patient also have a cancer of the stomach? 
 There is certainly much that speaks against it : the sum total of 
 the gastric symptoms is sufficiently explained by the undoubted- 
 ly existing affections, namely : by the catarrh, the ulcer and the 
 gastric dilatation, and also by the nervous dyspepsia ; the dura- 
 tion of the illness, the absence of a swelling in the region of the 
 stomach, and the abundance of free HCl in the gastric contents 
 all speak against cancer. But all the enumerated data make 
 the absence of a gastric cancer in this case only very probable, 
 but not fully certain : there is also in gastric cancer observed 
 sometimes an abundance of free hydrochloric acid in the contents 
 of the stomach ; nor is it rarely, but in fact frequently, that we 
 are unable in cases of cancer to detect a swelling in the region 
 of the stomach ; it is not at all impossible, that to the long con- 
 tinued gastric suffermg of a non-cancerous character in our 
 patient, there was also superadded of late a cancer of the stom- 
 ach. But then, such apprehensions could only be entertained on 
 the patient's admission to the clinic ; at present, after a consider- 
 able improvement has taken place, an improvement that is 
 generally absent in cases of gastric cancer, and would be so 
 particularly in one as broken down as our patient is, — at 
 present such apprehensions are untenable. 
 
 As regards the other organs in our patient, we will only 
 note the tenderness on pressure in the region of the Ccecum and 
 the ascending portion of the colon, surely dependmg on some 
 slight typhlitis and colitis, as results of the prolonged obstinate 
 constipation. The liver, spleen, kidneys and the urinary blad- 
 der, as well as the organs of respiration and circulation. 
 
— 130 — 
 
 present nothing abnormal. We have already alluded to the 
 failure of nutrition and the disturbances of the nervous 
 system. 
 
 The prognosis is certainly more favorable now, than it 
 was on the patient's admission to the clinic, when we appre- 
 hended the possibility of a gastric cancer. But even now his 
 condition must be considered as very serious, that is, as one 
 that presents no immediate danger, but a great possibility of the 
 same, thus : the obstinate gastric ailment, that has repeatedly 
 reappeared after improvement has taken place, — to be sure, on 
 account of the patient's negligence, — may in the end completely 
 destroy his now already failing health ; some accidental cause 
 may bring about a rupture of the thinned-out gastric walls at 
 the sites of the ulcers and of the cicatrices. We have, therefore, 
 while giving him hopes of a return to health, enjoined upon our 
 patient the necessity of a strictly regular mode of living and 
 circumspection in movements and exertions, so as to avoid 
 dangerous consequences. 
 
 Treatmejit. — The gastric therapy of the present case differs 
 from that of the preceding one, chiefly m that in this case we 
 ordered lavage of the stomach, that has given such good results. 
 I shall discuss this important method of treatment, after I will 
 have explained the other therapeutic means ; these latter will 
 take but little of our time now, after our discussion of the first 
 case. It is certainly not necessary for me to explain to you 
 why the patient was ordered the above-described diet, the warm 
 abdominal bandage and rest, and why he was given a mineral 
 water (I shall speak later of my reasons for prescribing the 
 Ems-Kesselbrunnen), and the tincture of nux vomica. We 
 have explained above why we gave codeine and magnesia usta. 
 We did not order any warm baths for the relief of the abdominal 
 pains, first, because the codeine relieved the pains sufficiently, 
 and secondly, that he might avoid movements incident to un- 
 dressing, immersing in the bath and dressing again ; these, as 
 any other movements, would tend to aggravate the pains. 
 
 Why have we selected of all the mineral waters the Ems- 
 Kesselbrunnen ? Within the limits of the waters chosen by us 
 for comparison, we apparently had to avoid the cold springs and 
 
— 131 — 
 
 those rich in carbonic acid, as such would tend to aggravate the 
 gastric pauis and the vomiting in our patient ; and we also had 
 to avoid springs rich in alkaline and laxative salts, because of 
 the patient's exhausted condition. For these reasons we had to 
 exclude, first of all, Marienbad, Kissingen and Franzensbad, they 
 being cold springs, and to select from among Ems, Karlsbad, 
 Vichy (the warm spring of Grande Grille) and the warmed 
 Yeesentucki springs. In view of the patient's debilitated con- 
 dition we gave the preference to Ems, as it does not contain any 
 laxative salts (like Karlsbad) and is less rich in alkaline salts, 
 than Vichy and Yessentucki ; though if the condition of the 
 nutrition were better, the other three waters could be given. 
 And as a matter of fact, it appears from the anamnesis, that the 
 patient, when in a better condition of nutrition and strength, 
 was treated with success by the Yessentucki and the Karlsbad 
 waters. 
 
 All this refers to treatment of the gastric catarrh. How is 
 ulcer of tjie stomach to be treated ? We know of no directly 
 curative remedy, but experience teaches, that an ulcer heals 
 under the same treatment and the same (or even stricter yet) 
 diet, that is so successful in gastric catarrh.* 
 
 How shall we treat dilatation of the stomach ? After having 
 removed the accumulated gastric contents and having cured the 
 catarrh and the ulcer, it would be necessary to attempt to 
 strengthen the nervo-muscular apparatus of the stomach by the 
 aid of massage, electricity and hydrotherapy (douches in the 
 region of the stomach). The ulcers and cicatrices of long 
 standing in the present case would make it very risky to resort 
 to such measures, as their employment would bring about strong 
 contractions of the stomach, and consequently a liability, not to 
 
 * A later supplemental note : For the last few years I add to this treat- 
 ment the use of bismuth subnitrate with undoubtedly successful results. 
 I give at first twenty-grain doses, increasing the dose, later on, to 3 j ss 
 and more, once or twice a day, — always on an empty stomach (in the 
 morning before breakfast, and one hour before dinner). The powder of bis- 
 muth is directly put on the tongue and is washed down with the warm 
 alkaline water, which is indicated for the given case. The patient lies 
 on his back, then turns on the belly, and from side to side, so as to 
 enable the remedy to more certainly come in direct contact with the 
 ulcer. 
 
— 132 — 
 
 speak of the pains, of rupturing the walls in the thmned-out 
 portion of this organ. However, to judge by the favorable 
 course of the disease, we may hope that, on removing the 
 accumulated gastric contents and on curing the catarrh, the 
 ulcer and the nervous dyspepsia, the strength of the nervo- 
 muscular apparatus of the stomach will reestablish itself to a 
 sufficient extent; 
 
 For the treatment of the slight typhlitis and colitis, it will ua 
 all probability be sufficient to establish a regular emptying of 
 the bowels, to see that the abdomen is kept at rest and warm, 
 in connection, of course, with the contemporaneous improvement 
 in the gastric ailment. 
 
 The improvement in the nervous disturbances of the patient 
 is attained as yet through the improvement of the gastric 
 trouble, through the alleviation of the pains consequent 
 upon this last and of the msomnia. Later on, after we 
 will have finished the treatment with the mineral waters, we will 
 think of combating the nervous disturbances and, cojisequently, 
 the nervous dyspepsia, with silver nitrate, which the patient had 
 used before with great success. Arsenic and iron are contra- 
 mdicated by the condition of the stomach. We will besides 
 order for our patient general massage (except massage 
 of the abdomen), in accord with the indications, which we 
 followed in our first analyzed case. We hesitate as yet to order 
 massage under the apprehension, that the movements of massage 
 might aggravate the abdommal pams. The treatment by cold 
 water, with a view of improving the patient's nervous state, is 
 contra-indicated by his exhausted condition. 
 
 I will now take up the subject of gastric lavage. The pres- 
 ent case may be called a typical example of the class of cases, 
 in which lavage of the stomach is an miconditional indication of 
 such importance, that without its previous employment no other 
 kind of treatment can be instituted. In such cases even one or 
 two washmgs are sufficient to rapidly brmg about important re- 
 sults : by carrjdng away a mass of dyspeptically decomposed 
 gastric contents, absorption of the products of such a decompo- 
 sition — certamly very injurious to the patient — is put a stop 
 to, as well as the irritating effect produced by them on the walls 
 
_ 133 — 
 
 of the stomack, causing vomiting and pains ; consequently, as a 
 result, a rapid alleviation of the symptoms .is effected ; further, the 
 mucous membrane of the stomach is cleared of the mucus, and 
 is made accessible to the radical treatment of the catarrh by 
 mineral waters and by bitters ; finally, the nervo-muscular appa- 
 ratus of the dilated or distended stomach is able, on the latter 
 being emptied, to act better, namely to expedite the gastric con- 
 tents into the intestines and thus prevent a fresh accumulation. 
 Therefore, not only in cases of such a prolonged and obstinate 
 morbid condition, gastric dilatation, as seen in our patient, but 
 even in more recent cases of overloading of the stomach, in 
 which the indications for emptying this last are as positive as 
 they are in our present case, I begin the treatment with gastric 
 lavage, repeating it several times till the patient obtains un- 
 doubted relief ; and at the same time I begin the radical treat- 
 ment, if possible, of the gastric disease, most frequently of the 
 catarrh or of the nervous dyspepsia, that has caused the dilata- 
 tion or distention of the stomach; and as soon as the acute 
 symptoms, the attacks of pain, and vomiting, and pain on pres- 
 sure in the region of the stomach, have ceased, I add to the 
 foregoing such remedial means, as would strengthen the weak- 
 ened nervo-muscular apparatus of the stomach, namely, electri- 
 city, massage, or douches, according to the idiosyncrasy of the 
 case. As soon as the sound improvement m the patient's con- 
 dition can last without lavage, I at once discontinue it ; because 
 experience teaches that a prolonged employment of lavage may 
 generate a habit for it, of which it may become difficult to get 
 rid ; an example of this will be presented later. But if the in- 
 dications for lavage are neither so positive, nor so necessary, 
 particularly not in cases of old dilatation, hut in. those of recent 
 distention, then, without resorting to washings, I order radical 
 treatment in conjunction, of course, with regulation of the hy- 
 giene in general and of the diet in particular. 
 
 If the success is prompt and lastmg. then I surely content 
 myself with the adopted treatment ; otherwise I add to it lav- 
 age. Wherever possible I avoid lavage, as it is never, especially 
 at the beginning, an indifferent process and far from beiag harm- 
 less for the patient, not to speak of the feeliag of disgust enter- 
 tained towards it by him. 
 
— 134 — 
 
 We often observe in practice, how lavage — which was for- 
 merly and is to an extent even now a fashionable procedure — is 
 employed quite frequently without success. Let us consider the 
 causes, as I have observed them, of such failures. 
 
 The most frequent cases are as follows : the patient suffers 
 from a gastric catarrh in a condition which does not present any 
 indication for lavage. At first the physician does not resort to 
 lavage, and orders the radical treatment, but he prescribes it 
 either incorrectly or carelessly, without regulating the hygiene 
 and particularly the diet. Failure follows. The physician now 
 resorts to lavage, without having correctly instituted his former 
 treatment and regulated the hygiene, and not having rectified 
 his former errors and omissions, failure is sure to come again. 
 — Or take such a case. The patient has a gastric catarrh in a 
 condition presenting positive indications for lavage : this is or- 
 dered by the physician, but he neglects the radical treatment of 
 the catarrh, forgetting that lavage, though an excellent, is at the 
 same time but a symptomatic, palliative measure. The patient is 
 not only not cured, but acquires the habit of washing his stom- 
 ach, " cannot get along without it," just as one suffering with 
 constipation and habituated to clysters is unable to get along 
 without these. I will tell you in this connection of one very 
 instructive case from my practice. The patient, thirty-five years 
 old, of good constitution, called on me in February, 1888, com- 
 plaining of pain and heaviness in the region of the stomach, 
 nausea, poor sleep and oppressed mental condition. 
 
 Anamnesis. — Up to his twenty-fifth year the patient enjoyed 
 good health ; but has since then abused alcoholic drinks (whis- 
 key and beer), took only one meal a day, but an abundant one, 
 and was at times intensely preoccupied with his affairs (he is a 
 tradesman). He soon grew restless, of a sad mood, and costive. 
 Some five years ago there appeared dyspeptic gastric symptoms 
 and pains at the pit of the stomach. The patient continued 
 drinking and leading his former mode of life. Two years ago 
 the gastric pains became aggravated, and there appeared once or 
 twice a week abundant vomiting, containing considerable quanti- 
 ties of mucus. He left off drinkmg and called on his physicians : 
 these ordered daily gastric lavage with plain water, but no othei' 
 
— 135 — 
 
 treatment, cautioning him only to avoid heavy food. The first 
 two months the patient experienced considerable relief, but 
 later the improvement not only became stationary, but gave 
 way to a more aggravated condition. 
 
 Present state. — - Patient smokes much and drinks a great deal : 
 nine to ten glasses of tea daily with cream, and four to five 
 glasses of soda or artificial seltzer water ; drinks neither beer, 
 wine, nor brandy. Washes his stomach daily for the last year 
 with plain water on an empty stomach; this brings up mucus, 
 at times in considerable quantity. The lavage procures a relief 
 from the heaviness and pain in the stomach, from the nausea 
 and oppressed mental condition for one or one and one-half 
 hours (in the beginning the relief lasted one-half day or even 
 longer), but later he returns to his usual condition. He is con- 
 stipated : movements of bowels every other day — evacuations 
 small and hard. Once or twice a month patient takes castor- 
 oil or some bitter water. Abdomen distended. The liver, 
 spleen, kidneys and the organs of circulation and respiration 
 present nothing abnormal. Nutrition poor. Sleep unsatisfactory, 
 mental condition oppressed. Treatment : Ems water, one-half 
 glass three times a day, one hour before meals, at the tempera- 
 ture of freshly drawn milk ; decoction of condurango and the tinc- 
 ture of nux vomica ; watery clysters ; once during the day fifteen 
 grains of potassium bromide in the last half-glass of the Ems 
 water, and in the morning sponging of the whole body with water 
 at the temperature of 22° to 18° B. (about 82° to 67° i^.). Hy- 
 giene in general and the diet in particular strictly regulated : 
 quantity and quality of food and drink is limited and precisely 
 designated — to be taken frequently, but little at a time. He 
 was advised to gradually rid himseK of the habit of washing his 
 stomach : to do gastric lavage at first twice a week, then once, 
 and later to discontmue it altogether. In about eight weeks of 
 such treatment (the potassium bromide was discontinued before 
 that time), the patient could get along without lavage, and im- 
 proved considerably : there remained only slight retching and 
 some inclination toward constipation ; the pain and heavi- 
 ness in the gastric region, as well as the nausea, disappeared; 
 both sleep and mental condition improved. A prolonged sail 
 
— 136 — 
 
 on a Volga steamer brought about a complete return to 
 health. 
 
 Finally, there are cases, where the emploj^ment of gastric 
 lavage, in nervous dyspepsia, is wrongly applied. 
 
 Take such a case. Some ten years ago there was admitted to 
 our clinic a medical student of the senior class, with a strongly 
 develoj)6d neurasthenia and nervous dyspepsia. The physician 
 whom he consulted before his admission to the clinic, found a 
 " splash " in his abdomen, and concluded that the patient suffered 
 with dilatation of the stomach, requiring gastric lavage. Ex- 
 amination of the patient failed to elicit any symptoms of dilata- 
 tion of the stomach : the abdomen proved to be equably and pro- 
 nouncedly sunken everywhere ; but to quiet the frightened patient 
 a sound was introduced : the stomach proved to be empty, which 
 fact raised the patient's spirits considerably ; while the sub- 
 sequent treatment, with cold water douches and silver nitrate, 
 soon removed the phenomena of neurasthenia and of nervous dys- 
 pepsia. Or here is another case (a later supplement). Patient, 
 thirty-six j'ears old, of good constitution, was admitted to our 
 clinic April Tth, 1890, complaining of heaviness in the region 
 of the stomach and belching, of constipation and pains in the 
 abdomen, which proved on mquiry to be of intestinal origin, of 
 poor sleep and oppressed mental state. Anamnesis : Until his 
 twenty-ninth year patient enjoyed good health; at this age he 
 passed through an attack of t}^hoid, which left him in a weak- 
 er condition than he was before. Later there were superadded 
 some other influences imfavorable to health : the patient, who 
 formerly used to bathe with apparent benefit to his health, had 
 to give up bathing on account of change of residence and ab- 
 sence of a suitable bathing place ; he began to be intensely 
 preoccupied in the capacity of a manager of an estate, and to all 
 this were finally added certain family troubles. Under such 
 conditions there appeared, two years ago, belching, heavmess m 
 the stomach, constipation and, later, intestinal pains. Patient 
 began to be treated, took at various times hydrochloric acid, 
 pepsm, bismuth, carbolic acid, resorcin, soda powders, for a 
 short time silver nitrate, and, for a shorter period still (eight 
 days), arsenic — but all these failed to bring any relief. During 
 
— 137 — 
 
 December, 1889, and in January and February, 1890, he had been 
 given about sixty ivashings of the stomach, which failed to alleviate 
 his condition in the very least. During February and March 
 the patient drank Vichy, cold and aft€r meals, also without 
 success. 
 
 Mode of living. ■ — Patient lives in a healthy locality and re- 
 sides in a good house. Does not bathe in the sea, takes baths 
 at home but rarely. Smokes little ; does not drink anj- beer. 
 wine or brandy ; drinks some five to six glasses of weak, warm 
 and unsweetened tea per day ; drinks neither water nor kvass ; 
 eats two light meals a day ; keeps no fast days. He is smgle. 
 This last year, on account of indisposition or, rather, considering 
 himself sick, he gave up his occupation, which fact tends to 
 more aggravate his oppressed mental state. 
 
 Status presens. — Appetite somewhat worse. There is a con- 
 stant heavmess at the pit of the stomach and light belching of 
 odorless gases, both after meals and on an empty stomach ; there 
 were neither m the past, nor are there at present, any pj-rosis, 
 nausea, vomiting, and pam at the pit of the stomach, neither 
 spontaneous nor on pressure. Being costive, patient resorts 
 often to laxatives, as pulvis liquiritise compos. Intestinal 
 pains. Abdomen somewhat distended. The liver, spleen, the 
 kidneys, the organs of respiration and of circulation present 
 nothhig abnormal. Patient grew thin. The sleep is poor, the 
 mental condition oppressed. 
 
 Treatment. — The, symptoms of neurasthenia and of nervous 
 dyspepsia, so marked even on his admission, became so promi- 
 nent durmg the first days of the patient's stay in the clinic, that 
 we ordered hydrotherapj' (douches, from 22 to 18°it. (81.5 to 
 12.5°F.'), to the exclusion of any other treatment. There fol- 
 lowed a rapid simultaneous improvement in all the symptoms : 
 as heaviness at the pit of the stomach, belching, constipation, 
 intestinal pains, msonmia and oppressed mental condition. 
 Patient left the clinic April 30th, almost completely improved. 
 
 He was advised to make this improvement durable by summer 
 bathing and by a correct mode of living, and among other things, 
 also by a return to his occupation, but without unduly exerting 
 himself 
 
— 138 — 
 
 FROM THE LECTURE OF NOVEMBER 28, 1889. 
 
 Five weeks passed since we saw the patient last. Up to 
 November 17th, he drank the Ems water and took drops of the 
 tincture of nux vomica ; had at times clysters, and but very 
 seldom resorted to codeine. Since the 17th, he is given pills of 
 silver nitrate, at iirst one-twentieth-grain twice a day at meal- 
 time, and since November 2 2d, three times a day. For the 
 last several days he has had general massage. Patient desires 
 to leave the clinic to-morrow. His condition has improved con- 
 siderably. The appetite is good ; patient gets durmg the day a 
 pound of bread, six eggs, two glasses of bouillon, three to four 
 glasses of milk-soup with manna (patient refuses meat), and 
 at times begs for more food. Of the gastric symptoms there 
 remained some heaviness at the pit of 'the stomach, at times easy 
 belching, and, very seldom, slight, rapidly passing pains, that do 
 not require any codeine. He is somewhat costive, and must at 
 times resort to clysters. The tenderness on pressure in the 
 region of the ccecum and ascending portion of the colon dis- 
 appeared. Pulse is good. His nutrition has improved markedly. 
 Has eight hours of quiet sleep. Mental condition better; he 
 feels stronger. Patient was advised, besides a strict persever- 
 ance in a correct mode of livmg and circumspection in move- 
 ments and exertion, to continue the treatment by silver nitrate 
 and the general massage. 
 
THIRD CASE 
 
 LECTURE OF NOVEMBER 3, 1889. 
 
 The patient, a student, twenty-two years old, complains of 
 abdominal pains and constipation, which is at times replaced by 
 a diarrhoea ; of palpitation and of unpleasant sensations in the 
 region of the heart, of pains in the head and spine, and of poor 
 sleep ; he is quickly fatigued b}' physical and mental exertion and 
 is in a despondent mood: he is always disturbed by various 
 anxieties, but chiefly by the apprehension, that he suffers from 
 an " organic heart trouble." 
 
 Circumstmices and mode of living. — For the last four years 
 patient lived continuously m Moscow, summer and winter. 
 Lodgings fair, water-closet cold ; he formerly used to bathe 
 himself, but has not done so lately, as bathing would chill him 
 and cause attacks of cardiac palpitation. He does not go to 
 public baths, but washes himself at home. Drmks but little tea, 
 and neither coffee nor wine. Smoked before, but has discon- 
 tinued it now, as it brought on palpitation of the heart. Order of 
 meals : breakfast, tea with bread in the morning, dinner and sup- 
 per ; his board was always good, with the exception of a period of 
 two weeks, of which more later. The patient is, as I said, a 
 student, and also a private tutor. He goes out of doors for two 
 hours daily. Has enough time for sleep, from 11 p. m. to 8 
 
 A. M. 
 
 Anamnesis. — His parents, according to his statement, are 
 healthy. While yet in the gymnasium (high school), some ten 
 years ago, the patient suffered from constipation, otherwise en- 
 joyed fair health up to the time he took up his residence in 
 Moscow, when the constipation increased and the patient began 
 to grow somewhat thin and weak. He passed through an attack 
 of acute articular rheumatism some three years ago, but it was of 
 
— 140 — 
 
 a light character (he not being confined to bed during the attack) 
 and it passed away in a few days with the aid of sodium salycil- 
 ate ; since then he suffers with palpitation of the heart. About 
 one year ago his sleep became poor, mental condition gloomy, 
 the weakness more pronounced, the attacks of palpitation were 
 accompanied by unpleasant sensations, and at times even by 
 pains in the region of the heart. All these phenomena became ag- 
 gravated because of an affliction, which the patient had suffered 
 some three months ago. A month ago the patient was compelled 
 to have bad meals, which caused a diarrhoea ; this was stopped at 
 first by tra. opii, but it reappeared again ; since then the patient 
 would either be constipated for three or four days, or would have 
 three or four stools a day, with pain m the abdomen, of liquid 
 consistency and with an admixture of mucus. He had a diarrhoea 
 when he was admitted to our clinic, October, 29th. He was 
 given five di'ops of the tincture of opium ; the abdomen was 
 wrapped in flannel, and one-half glass of hot Ems-Kesselbrunnen 
 water was prescribed for him to be taken in the morning on an 
 empty stomach, one hour before his tea, and a tablespoonful of 
 the decoction of condurango (3ij to fiij) with five drops of the 
 tincture of nux vomica after dinner and supper ; a clyster m 
 case of constipation and, after the diarrhoea stopped, one day 
 static electricity (" the bath" — i. e. sitting on the insulated 
 chair at the time of the seance), the next day general massage, 
 excepting the abdomen ; later on, cold water treatment. He was 
 enjoined to avoid physical and mental fatigue — to read but 
 little ; while the diarrhoea lasted he had tea for a drink ; of the 
 food we will speak later. 
 
 Status. — Patient is of average physical stature and, contrary 
 to his assertions that he grows thin, his nutrition is quite satis- 
 factory : the subcutaneous adipose tissue is quite considerable, 
 and the muscles are well developed. The appetite and the gas- 
 tric digestion, as the patient claims, are very changeable : on the 
 days when he has a good rest, and when his mental condition is 
 good, he eats well without experiencing any unpleasant after- 
 effects ; but after a poor sleep, and when feeling poorly, he eats 
 little and still experiences a painful sensation at the pit of his 
 stomach, that passes away only after painful and prolonged belch- 
 
— 141 — 
 
 ing. Until the appearance of the diarrhoea he experienced no 
 other unpleasant sensations in the abdomen ; but with the diar- 
 rh(Ea there appeared also intestinal pains. After his admission 
 to the clinic the diarrhoea ceased and the intestinal pains have 
 almost disappeared. He had yesterday a water clyster, that in- 
 duced a satisfactory evacuation after a constipation of two days' 
 duration ; the abdomen, however, is somewhat distended and 
 slightly sensitive to examination, which latter causes some gur- 
 gling. We are unable to detect any particular tenderness or 
 generally anything abnormal in the regions of the stomach, liver, 
 spleen and kidneys. The urine is normal. The patient was for a 
 long time very intemperate m his sexual relations ; the erections 
 are now weaker, he himself feeling weaker after the acts of copu- 
 lation, although he performs them less frequently than formerly. 
 He had two attacks of gonorrhoea, which passed without leaving 
 a trace, but had aggravated his disturbed mental state. He is 
 free from syphilis. — Some dyspnoea on walkmg. Pulse normal, 
 except durmg the above-mentioned attacks of palpitation with 
 pain in the region of the heart, when it is considerably quickened. 
 Objective examination elicits nothing abnormal in the respiratory 
 organs, heart and blood-vessels, as well as in the chest, with the 
 exception of a small area of cutaneous hypersesthesia around the 
 left nipple, an area smaller than that of the region of the heart, 
 where the patient experiences pain during the severe attacks of 
 palpitation. Fever absent. The nervous phenomena are exact- 
 ly pictured in the complaints of the patient and in the anamnesis. 
 Headaches, when the patient is constipated, are experienced in 
 the occipital region, while after mental exertion, in the frontal 
 part ; at times slight migraine. The pains along the spine seem 
 to be due to cutaneous hypergesthesia in the region of several 
 vertebrae. All the movements of the spine are perfectly free 
 and painless. Reflexes considerably increased. 
 
 As the lecture draws to a close, we will take up the diagno- 
 sis later ; and now a few words about the treatment. After 
 having ingested poor food, the patient suffered from an attack 
 of diarrhoea, evidently due to an intestinal catarrh, for the pain- 
 ful evacuations were mixed with mucus : it is likely, that the 
 gastric catarrh also began then, and that the dyspeptic gastric 
 
— 142 — 
 
 phenomena depend, to some extent at least, on the catarrh ; we 
 therefore prescribed Ems, but in view of the diarrhsea, only one- 
 half glass in the morning, and very warm. The mdication for 
 condurango and the tincture of nux vomica, which proved of 
 such advantage in both constipation and diarrhoea, as you know 
 from the analysis of the first case, requires no explanation, when 
 employed for a patient, who suffers alternately from diarrhoea 
 and constipation. The indications for the use of electricity, mas- 
 sage and hydrotherapy will be spoken of later, after the final 
 diagnosis has been arrived at. 
 
 LECTURE OF NOVEMBER 7, 1889. 
 
 Status. — Patient's condition improved all around. Appetite 
 and digestion are such that for the last three daj's he is given daily 
 two plates of chicken soup, three-fourths of a chicken, over one- 
 half pound of roast meat, six eggs and about one pound of white 
 bread ; he takes all this at four meals, and, outside of slight heavi- 
 ness and belching, and even this rarely, not after each meal, he 
 suffers from no dyspeptic phenomena. Such a condition after 
 only a five days' use of Ems, and of but one-half glass of it per 
 day, speaks against catarrh of the stomach, the more so against 
 ulcer or cancer, especially if you recollect the slow improvement 
 in the appetite and ui the nutrition with the more energetic and 
 continuous treatment and very strict diet in our previously dis- 
 cussed case of a real catarrh of the stomach ; it also excludes 
 dilatation of the stomach, as the evacuations, though with the 
 aid of clysters, are sufficient. The abdomen is less distended 
 and not tender. He had almost no cardiac attacks during 
 these days. He sleeps better, although not every night. His 
 mental state is calm, especially after I examined and positively 
 assured him that he had no organic heart lesion, and that his 
 malady was perfectly curable. There is also less weakness. 
 
 Before taking up the final diagnosis, we will say a few words 
 about the treatment, as indicated by the present condition of the 
 patient. As there is no gastric catarrh, we will discontinue the 
 Ems water, but will continue the condurango and the nux vo- 
 
— 143 — 
 
 mica, for there is still at times a feeliiig of heaviness in the 
 stomach and some belching; besides, the diarrhoea has only 
 ceased recently and the constipation continues as yet. Frank- 
 linization and massage acted well on the patient ; but the ces- 
 sation of the diarrhoea requires hydrotherapy instead. We will 
 also prescribe for the patient silver nitrate (one grain in twenty 
 pills with extract trifolia), at the beginnnig twice a day, imme- 
 diately before each meal. As the sleep is not as yet always 
 sound, and the disappearance of the diarrhoea permits of the use 
 of bromides, we will resort to these if necessary. The reason 
 for the employment of silver nitrate and of the bromides will be 
 made clearer after the final diagnosis, when we will take up the 
 whole plan of treatment. 
 
 Diagnosis. It is evident, from what was pointed out above, 
 that catarrh, dilatation, ulcer and cancer of the stomach may 
 positively be excluded in this case ; while the change in the ap- 
 petite and in the dyspeptic phenomena, and their close connec- 
 tion with the general nervous condition go to show, that the 
 patient suffers from nervous dyspepsia. Besides the gastric 
 there are also present morbid intestmal, cardiac and general ner- 
 vous symptoms. We will begm with the general nervous symp- 
 toms, as even you, though beginners, will easily perceive from 
 the data collected by observation and objective investigation, 
 that they are the most important in this case. 
 
 To better elucidate the importance of the morbid nervous phe- 
 nomena in this patient, I must, refer you to what I said regarding 
 the condition of the nervous system in our first case. ( Vide pp. 
 7 0-72.) From a careful comparison of the two, you will perceive 
 that our present case is just the opposite of that one : in the pres- 
 ence of a good constitution and nutrition, of a normal condition 
 of all the organs, except the nervous system (the trifling diarrhcea 
 appeared only recently, while the constipation and the cardiac 
 phenomena are, as we shall see later, of a neurasthenic origin). 
 The patient leading a life amidst mcomparably better surround- 
 ings, there appeared a primary, obstinate, progressive neuras- 
 thenia, its sum total of symptoms having been made clear 
 by inquiry and by objective examination. It is a case of genu- 
 ine, typical, although not extremely developed, neurasthenia. 
 
— 144 — 
 
 A s far as its origin is concerned, we know nothing definite of the 
 influence of heredity, while the factors that caused its appear- 
 ance are patent ; thus : a three years' residence, during both 
 winter and summer, in a great city, conjoined with considerable 
 uninterrupted mental labor (private tutoring even in summer), 
 lack of bathing all this time, worries, but certainly most impor- 
 tant of all, extreme intemperance in sexual relations and also 
 the attacks of urethritis. In extreme cases of genuine neuras- 
 thenia, it is necessary to call to aid the differential diagnosis 
 from hysteria and even from multiple sclerosis. But in this 
 moderately developed case, where the distinction from these dis- 
 eases is so very evident, such procedure, a differential diagnosis, 
 would be but a waste of time. Although our patient had an 
 attack of acute articular rheumatism — a very slight attack and 
 of short duration — but in the presence of the perfectly normal 
 condition of the organs of circulation, the morbid phenomena 
 met with in this case in the sphere of the plexus cardiaci, as 
 palpitation and pain in the region of the heart, must be referred 
 to the neurasthenia, of which they constitute a very frequent 
 symptom. 
 
 The constipation, that is, the weakening of the nervo-muscu- 
 lar apparatus of the intestines, was at the beginning due to his 
 neglect to attend to the calls of nature while yet in high school. 
 With the development of general neurasthenia this condition of 
 the intestines naturally became more aggravated. The intesti- 
 nal catarrh, which appeared about a month ago, was the cause 
 of the origin of the diarrhoea, and since that time the intestines 
 presented a picture of two contemporaneously existing morbid 
 conditions — of the weakness of their nervo-muscular apparatus 
 and of a catarrh of their mucous membrane. 
 
 Progyiosis. — Whether or not our patient has an innate pre- 
 disposition to neurasthenia cannot be asserted with certainty ; but 
 even if it be present, it is hardly of any considerable extent : the 
 data, obtamed by the investigation, show, that up to a certain 
 period, almost up to the time he entered the university, the pa- 
 tient had no symptoms of weakened nervous activity ; these 
 latter began to develop only after the following evident causes 
 appeared, tending to neurasthenia, namely : constant residence 
 
— 145 — 
 
 and constant occupation (also during summer^ in a great city, 
 lack of bathing, to which he was habituated before, worries of 
 various nature, and chiefly — sexual intemperance. In such 
 cases, that is, where there is no mnate and, besides, obstinate, 
 difficultly removable weakness of the nervous system, but where 
 the neurasthenia is acquired and is, as in our patient, not 
 extremely developed, a perfect cure is possible ; but the stability 
 of the cure, and the absence of recurrent attacks will certainly 
 depend on the will-power and the ability on the part of the 
 patient to avoid the influences, that give rise to neurasthenia. 
 Treatment. — We will begin with the principal ailment m the 
 present case, the disease of the nervous system, neurasthenia. 
 As what concerns his hygiene, we will chiefly advise the patient, 
 first of all, to shorten at once his occupations and return to his 
 native place, there to stay until the beginning of the future 
 semester, in the middle of January ; then to entirely discontinue 
 his work for at least one month every summer, while residing as 
 long as possible in a pleasant suburban locality, to bathe in the 
 s-ea or river, to take due care of his sleep, not to interfere with 
 it (as for instance, by an unnecessary meal or fatiguing mental 
 work immediately before going to bed), nor to shorten it, — to 
 sleep just as long as necessary ; to work only after a sufficient 
 rest, and never to fatigue himself either physically, or mentally. 
 We will advise complete abstinence from sexual intercouse — 
 the most important cause of the morbid condition in the present 
 case. Unfortunately the advice of the physician concerning this 
 matter is not always followed ; but it were erroneous to think, 
 that it is never followed, and that it would therefore hardl}- 
 be worth while giving it. On the contrary, a sensible, decisive 
 and friendly advice will not be followed rather in the minority 
 of cases, but if followed, it will be of mestimable value to the 
 patient, which is the most important aim of the physician's 
 practice in such cases. Nor is the fulfilling of this advice as 
 difficult or impossible, as the patients, of whom we speak, 
 usually think, if the physician but teach them to avoid sexual 
 excitement through physical mfluences (as constipation, soft 
 bedding, tight clothing, alcoholic chinks, etc.), as well as through 
 influences acting in a psychical manner (lascivious thoughts, cer- 
 
— 146 — 
 
 tain books, certain male and female society), and if he explain to 
 the patients the harm in such cases of insufficient physical activ- 
 ity, of mental idleness, of lack of aesthetic impressions and, first 
 of all, impress upon them their moral and religious duties. Be- 
 sides, our patient is twenty-two years old and in a year and 
 a half he will graduate from the University; consequently in 
 the near future we may expect that he will marry. 
 
 The best of all the non^apotheeary means for the treatment 
 of neurasthenia is hydrotherapy, and in proportion as the patient 
 is young and the condition of the internal organs and that of 
 nutrition is good, and the more the nervous disturbances have 
 the character of nervous depression, the more applicable is 
 cool or cold water ; on the contrary, if the patient is older, and 
 the apprehensions excited by the condition of this or that inter- 
 nal organ are great, while the condition of nutrition is bad and 
 the more the nervous disturbances have the character of excite- 
 ment, — mental (total insomnia, anxious mental state) and 
 physical (hypereesthesia, pains and spasmodic attacks of nausea 
 and palpitation, hampered and quickened respiration), — the 
 more applicable is warm water. I usually devote two lectures, 
 at the end of the year, to clinical balneotherapy — to balneothera- 
 py for the practical physician, and I will discuss then the subject 
 in a more detailed manner ; but what I have already said is sufficient 
 to show, that for x)ur patient cool (and later cold) water is more 
 suitable than warm water. One of the best, if hot the best, way 
 of applying cold water to patients of quite strong constitution, 
 as in the case of our patient, is in the form of fan-like douches 
 under high pressure, applied over the whole surface of the body, 
 except the head, on which a cold compress is placed. The diar- 
 rhoea did not permit until now of the employment of these 
 douches, and we therefore, out of the non-apothecary means, 
 used only general massage and electricity. 
 
 General massage is by far not as reliable in the treatment of 
 neurasthenia, as hydrotherapy is : for cases of neurasthenia of the 
 nature of excitement, with hysteroid symptoms, massage is as 
 unsuitable as it is in pure hysteria, and sometimes simply impos- 
 sible of application, for instance, in cases with considerable hyper- 
 sesthesia. But in our patient, in view of the fact, that the symp- 
 
— 147 
 
 toms bearing the character of depression prevail, that the 
 hypersesthesia is insignificant, either by its intensity, or by the 
 extent of the affected area, in view of the chillines of the patient 
 and the trifling amount of physical exercise prescribed for him, 
 and consequently partly to replace this last, we resorted to 
 general massage, and, as we said before, the results have justi- 
 fied our expectations. 
 
 Electricity, particularly static and galvanic, is shown from ex- 
 perience to be beneficial in neurasthenia, but not alwaj's so. 
 We cannot give any precise mdications for its employment : ex- 
 perience decides as to whether it is beneficial or not, and as to 
 which form is to be employed — static or galvanic (either one 
 or the other) ; we have tried the static, and as it proved to 
 exert a good effect on the nervous disturbances from which our 
 patient suffers, we did not change it. 
 
 At present, when the diarrha?a has ceased, the intestinal pains 
 have finally cUsappeared and the abdomen became free from pain, 
 we will leave off massage and electricity and will use the dou- 
 ches, m the beginnmg at 28°i?. (about 97°^.) and later at a lower 
 temperature. 
 
 The chief apothecary remedies used in neurasthenia are silver 
 nitrate, arsenic and iron. The last is suitable in cases of neu- 
 rasthenia with a strongly pronounced ansemia, which is more 
 frequently seen in women than in men. For our patient iron 
 is not only not indicated, as he has no symptoms of aneemia, 
 but is rather contraindicated, as it may easily impair the appe- 
 tite and cause constipation, from which the patient is alreadv 
 suffermg. Arsenic is suitable for cases of neurasthenia in 
 which the patient's appetite is poor and his nutrition has failed 
 greatly ; our patient's appetite, although changeable, is never- 
 theless most of the time good, his nutrition suffered but little, 
 while the recently ceased diarrhoea constitutes a contraindication 
 to the employment of arsenic, as this last causes a diarrhoea so 
 easily. Silver nitrate is particularly beneficial in those cases of 
 neurasthenia in which the morbid phenomena of the nature of 
 depression prevail, as in our patient ; it too tends somewhat to 
 costiveness, but not at all to the extent and frequency, as is the 
 case with iron, nor does it impair the appetite in the least. It 
 
— 148 — 
 
 therefore becomes apparent to you why we employed silver ni- 
 trate. 
 
 Is it always necessary to employ two or more remedial agents 
 in neurasthenia, as we do in the present case — silver nitrate 
 and hydrotherapy? Certamly not always : for cases of moder- 
 ately developed and recent neurasthenia in robust young men 
 it is sufticent — especially in summer, when a prolonged stay 
 out-of-doors is possible — to observe the hygiene and hydrothe- 
 rapy, for example, in the form of river, or still better, sea-bath- 
 ing. The neurasthenia in our patient is quite severe and of long- 
 standing, the season of the year now is the beginning of winter ; 
 besides, the patient contemplates returning soon to his own 
 home, where he will not be able to be benefited by the use of 
 such strong fan-like douches and under high pressure, as he has 
 in our clmic, but will replace them by a hand-douche from a 
 pump, acting certainly much weaker ; this was the reason for 
 our prescribing for the patient hydrotherapy and silver nitrate 
 at one and the same time. 
 
 If the above-named remedial agencies, very good though they 
 be for neurasthenia, will not act with sufficient rapidity — which 
 is very possible in the given case of such obstinate neurasthenia, 
 — and will not with sufficient rapidity remove certain particu- 
 larly burdensome morbid phenomena, dependent on neurasthenia 
 and in their turn prolonging it, principally the poor sleep, then 
 we will order symptomatically bromides (15 grains of sodium 
 bromide m case of insomnia), until the prmcipal treatment, 
 hydrotherapy and silver nitrate, which we may call radical, will 
 securely remove also the insomnia together with the other 
 symptoms of neurasthenia. The bromide preparations, some of 
 the best, if not the best, somnifacient agencies, are particularly 
 indicated in the given case also by the gloomy and worrying men- 
 tal state as well as by the morbidly excited sexual sphere (lascivi- 
 ousness and a tendency to pollutions). I must also observe, 
 that the bromides, as any other symptomatic and palliative 
 means, must be ordered with extreme caution, just in quantities 
 required by the necessity of the case. The abuse of symptom- 
 atic and palliative remedies is the true sign of a poor physician, 
 who is either unable to comprehend the case and to order the 
 
— 149 — 
 
 radical treatment, or, what is more frequent, who is rather 
 annoyed at the necessity of fulfilling this, his duty. 
 
 The cardiac phenomena, since the patient's apprehensions 
 about his heart had been allayed and he generallj^ feels better, 
 have become so quiet, that they require no particular treatment. 
 
 The diarrhoea has disappeared, and there remain only some 
 trifling dyspeptic phenomena, at times slight heaviness and 
 belching, and some constipation. Of the treatment of the con- 
 stipation next time. 
 
 LECTURE OF NOVEMBER 28, 1889. 
 
 Before discussmg the treatment of the gastro-intestinal dis- 
 turbances in neurasthenics, let us see whether there is only 
 one variety of gastric nervous . dyspepsia, and whether this 
 variety is always to be met m the form we see it in our patient. 
 The theoretical attempts to create various, very numerous forms 
 of nervous dyspepsia, basing their classification upon the as- 
 sumed heightened or lowered activity of the gastric nerves — 
 sensory, motor, and secretory, — have all failed ; but practice 
 has proved the existence of at least two varieties of nervous 
 dyspepsia : one, the most frequent, such as seen in the present 
 case (its prmcipal symptoms — a feeling of heavmess after a 
 meal and belching), observed in neurasthenia with the character 
 of depression ; the other, less frequent, of which the chief symp- 
 toms consist of severe pains in the region of the stomach (car- 
 dialgia and gastralgia proper), followed by tormenting, very 
 sour belching and nausea, accompanied frequently by contem- 
 poraneous attacks of severe migraine. This variety is usually 
 seen in neurasthenia with the character of excitement. The 
 treatment and partly the diet differ in either of the varieties of 
 nervous dyspepsia. 
 
 When ordering a diet for nervous dyspepsia, we must be 
 guided, as has already been explamed in discussing our first 
 case, besides the general physiological and dietetic considerations, 
 also by the mdividuality of the given case. Generally speak- 
 ing, for cases of pure nervous dyspepsia, uncomplicated by any 
 
— 150 — 
 
 otlier disease of the stomach, the " delicate " food given for 
 gastric catarrh is unsuitable ; rather, on the contrary, we must 
 order food which is more prone to excite a sufficient excretion 
 of the gastric juice • however, m cases of the above-named sec- 
 ond variety of nervous dyspepsia, careful observation in the 
 administration of such food becomes necessary. In tliis last 
 variety there is quite probably an increased secretion of the gas- 
 tric juice or, at least, of the hydrochloric acid contained in it ; 
 and a still greater excitation of this secretion will brmg about 
 an aggravation of the heartburn and sour belching, as well 
 as of the pains in the stomach and of the sour vomiting. More- 
 over, while directing the neurasthenic patients to eat, though 
 not as frequently nor as little at a time, as we advise patients 
 with gastric catarrh, but still not very much at a time, so as 
 not to overeat, we must bear in mind that the neurasthenic 
 patients are just the ones who are liable to fall into the other 
 extreme of not eating sufficiently, of starving, and thus prolong- 
 ing, through an msufficiency in the nutrition of the nervous sys- 
 tem, their neurasthenia. In prescribing the diet we must also 
 consider the constipation, from which the neurasthenic usually 
 suffers, especially in the beginning ; later on there is superadded 
 a catarrh of the large intestine and there appear intermittently 
 both diarrhoea and constipation ; and to counteract the costive- 
 ness we must vary the food and prescribe, as far as possible, 
 such food to which the patient is not habituated : for instance, 
 in patients who habitually drink tea and no water, costiveness 
 is frequently removed by drinking two to three half glassfuls of 
 water, one half glass in the morning on an empty stomach and 
 in the course of the day, one or two hours before a meal ; in 
 others the same effect is produced by replacing the morning tea 
 with weak coif ee with milk and with chicory ; in others again 
 by the use of raw milk or of curdled milk, but without taking 
 at the same time of any other food and particularly of bread ; 
 by the employment of vegetables, (as, for instance, a half or a 
 full glass of carrot juice in the morning on an empty stomach), 
 of berries and fruits, eaten not together with the other food, but 
 taken on the previously more or less emptied stomach. 
 
 The treatment of gastric nervous dyspepsia and constipation 
 
— 151 — 
 
 begins naturally with the treatment of the general neurasthenic 
 condition. Then the same noyi^apotJiecary agencies are applied 
 also to the digestive organs. For the variety of dyspepsia seen 
 in our patient, the above-described douches are suitable (in these 
 the douche on the abdomen is allowed to play for a somewhat 
 longer time than on the other portions of the body), also ab- 
 dondnal massage, as well as the uiduced and interrupted gal- 
 vanic current applied directly to the abdomen. In the other 
 variety of nervous dyspepsia, accompanied hy gastric pains 
 and acid vomiting, these means may tend to aggravate the mor- 
 bid condition, and we therefore employ warm baths, static elec- 
 tricity (" the bath " and the " fan " to the region of the stomach) 
 and the constant galvanic current (one electrode over the stom- 
 ach, the other on one or the other side of the neck, at the region 
 of the vagus and the great sympathetic nerves). 
 
 If with the nervous dyspepsia there is also abdominal suffer- 
 ing, causing attacks of pain and sensitiveness of the affected 
 organs (for instance, liver and kidney colic, acute or subacute 
 catarrh of the biliary and urinary tracts, as well as of the stom- 
 ach and intestines), then only warm baths are suitable and 
 probably also franklinization ; douches, massage, the induced and 
 the interrupted galvanic current will onl}^ tend to aggravate 
 the condition of such patients (and at times even to a danger- 
 ous extent, as douches and massage by causing hsematuria and 
 acute exacerbation of pyelitis). 
 
 Silver nitrate is apparently suitable in an equal degree to 
 either variety of nervous dyspepsia. Bitters, and particularly 
 nux vomica, are beneficial in the variety of neurasthenia seen in 
 our patient, but are unsuitable where there is pyrosis and severe 
 belching, gastric pains and acid vomitmg, as they aggravate these 
 symptoms, evidently by creating a still greater excitation of the 
 secretion of the gastric juice or at least of its hydrochloric acid. 
 It was thus in the second case discussed by us (vide p. 122). 
 In such patients, if there be at the same time a gastric catarrh, 
 requiring the use of an alkaline mineral water, for instance of 
 Ems, this last must be given after a meal, say' in about an hour ; 
 it is then borne well (probably because the secretions of the 
 gastric juice caused by it is used up for digestion), whereas, if 
 
_. 152 — 
 
 given one hour before a meal it tends to call out pyrosis, acid 
 belching and even pain in the stomach. 
 
 At times the constipation is rapidly put a stop to by the radi- 
 cal, above-outlined method of treating general and gastro-intesti- 
 nal neurasthenia ; but at other times it is slow in disappearing 
 and we then must resort to temporary means, to clysters, and, 
 much less frequently, to laxatives ; but we first of all insist upon, 
 that the patient respond promptly to the inclmation to stool. I 
 have spoken elsewhere of the prmoipal mdications for the 
 regular employment of clysters. I will add here, that it is 
 usually sufficient to make a clyster of two to three glasses of 
 water of the temperature of 20°i?. (about 79°i^.). The best 
 time to employ a clyster is in the morning, after the first meal 
 (especially after the coffee) and before beginnmg one's usual work, 
 which may weaken the already lessened mclination to stool. 
 Havmg put in the clyster, some would do better to at once re- 
 spond to the consequent inclmation to stool, while for others it 
 is better to resist for a few minutes : experience will teach in 
 which case one or the other advice is more beneficial. The ap- 
 prehension to become habituated to clysters is without any 
 ground, if we employ at the same time all the therapeutic and 
 hygienic measures for curmg the general and the gastro-mtestinal 
 neurasthenia. 
 
 In case the clysters do not sufficiently empty the intestines, 
 then, until the radical treatment of the constipation has not done 
 its work completely, resort must be had to the employment of 
 laxatives. In view of the great number of laxatives recom- 
 mended, I consider it necessary to enumerate those that have 
 proved themselves preferable over others, in my experience. 
 1. Magnemi usta — burnt magnesia — a light laxative. 2, Po- 
 tassium tartrate — much stronger. 3. Sodium sulphate ( Grlau- 
 hers salt), still stronger (it is best to administer this with the 
 addition of some sodium bicarbonate, or in some alkaline mm- 
 eral water, otherwise it may cause intestinal pains and unneces- 
 sary looseness of the bowels. 4. Poivdered rhubarb — either by 
 itself or, m case of pyrosis, in conjmiction with half its quantity 
 of burnt magnesia ; it acts moderately, but effectually. 5. Aloe 
 is probably the best laxative because of the reliability of its action. 
 
— 153 — 
 
 which, besides, approaches normal laxation ; nor does one become 
 habituated to its use for a long time ; (the best formula : 5^. — 
 Extr. Rhei comp., extr. aloes aa. 3ss. M. f. 1. a. pilulse 20 v. 30. 
 Consp. lycopodio). 6. Folia sennae — acts well and not strongly 
 in a cold infusion (when hot will rather tend to cause pain), 
 which is readily prepared at home. 7. Infusum sennae salinum 
 (i. e., with the addition of Glauber's salt) is a strongly acting- 
 laxative, especially suitable when a sure and rapid effect is 
 desired, as, for instance, in cases of dangerous cerebral attacks 
 (congestion of the brain threatening apoplexy): it is then given 
 every hour in wineglassful doses (contammg two tablespoon- 
 fuls), till the desired effect is obtamed. 8. Podoioliyllin^ 9. Gas- 
 car a sagrada^ and 10. Cortex rliamnifraugulae are all very useful, if 
 it become necessary to temporarily replace the rhubarb, aloe and 
 the semia leaves, to which the patient became habituated, and 
 which have therefore ceased to be effective. 11. Calomel ; this 
 is probably borne by the gastro-intestmal organs better than all 
 the other laxatives, and is particularly suitable in diseases of 
 the biliary passages and in acute mfectious diseases of the mtes- 
 tinal canal, but it has also its contra-indications. (This will be 
 spoken of in another lecture.) 12. Castor-oil acts effectively, 
 but is unsuitable for frequent use. The doses of the laxa- 
 tive remedies are approximately given by pharmacology : 
 each given case must be individualized, beginning, in case there 
 are no urgently necessary indications, with a small dose. 
 
 To judge by the course of his health, it will not be necessary 
 to employ the clysters m our patient for a long time, nor will 
 there hardly be any urgency for the administration of laxatives ; 
 but there occur cases, usually in elderly persons whose muscular 
 apparatus is not only in a condition of asthenia, but already in 
 that of atrophy, where there are found at one and the same 
 time morbid conditions of the abdominal and thoracic organs 
 absolutely contra-indicating the employment of hydrotherapy, 
 massage, and of the induced and interrupted galvanic currents, 
 and where the exhaustion of the patient constitutes an obstacle 
 m the way of applymg correct hygiene, as, for mstance, sufficient 
 exercise ; m such cases the business of the physician consists 
 .wholly in the skilful contemporaneous employment of clysters 
 
— 154 — 
 
 and of laxatives, in the dexterous selection and careful inter- 
 changing of these last. 
 
 In our first analyzed case we had to treat diarrhoea, in the 
 present case, constipation ; either of the patients have, com- 
 paratively speaking, simple cases of diarrhoea and constipation. 
 Quite different is, of course, the treatment of constipation, that 
 intermits with a diarrhoea, in cases of intestinal neurasthenia 
 with, at the same time, a chronic, obstinate catarrh of the large 
 intestme ; this presents a wide field for the systematic employ- 
 ment of clysters, simply evacuatmg and medicated ones — with 
 tannin, bismuth, boric acid, etc. ; different also is the treatment 
 of diarrhoea in acute and chronic infectious diseases of the intes- 
 tinal canal, in stagnation of blood in the portal vein because of 
 hepatic diseases, m the various neuroses, as in Basedow's dis- 
 ease ; different is the treatment of constipation, if along with it 
 there are found other morbid conditions, thoracic, abdominal and 
 cerebral. 
 
 The general question : " how to treat constipation," or " how 
 to treat diarrhoea " is just as unreasonable as the question " how 
 to treat a cough " : in each given case the ordermg of treat- 
 ment must be preceded by a precise diagnosis. 
 
 We will now turn to our patient, who is leavmg the clinic to- 
 day, intending to go to his home. 
 
 For the eleven days which passed smce we saw the patient 
 the last time, he took bitters and silver nitrate in pills (one- 
 twentieth grain twice a day), when necessary he had watery 
 clysters and the daily employment of the fan-like douche under 
 high pressure, in the beginnmg at 20°i?., the last days at 18°^.; 
 on the abdomen the douche played somewhat longer than on 
 the other parts of the body. The patient bore the douches very 
 well : he rapidly warmed himself and felt heartier after the 
 douche. For this period we had to resort to the bromides four 
 times (fifteen grams at bedtime) : he slept sounder after this. 
 
 Status. — The patient, as you hear, declares hunself much 
 better than what he was formerly ; the appetite is good, the dys- 
 peptic gastric phenomena disappeared, the stool is mostly regu- 
 lar, the clyster is used only at times, the former painful sensations 
 in the abdomen passed away ; the former cardiac attacks hardly 
 
— 155 — 
 
 at all trouble him now ; the physical strength is good (patient 
 began taking out-door walks), but the sleep is not always 
 sound, while mental occupation still causes headache, although 
 not a severe one, and a feeling of fatigue. 
 
 On the morning of the day before yesterday, the patient, 
 while rising awkwardly from his bed, felt a sudden pain in the 
 right inguinal region. The cause of the pain was shown by 
 mvestigation to be due to a slightly displaced kidney ; after this 
 was pushed back into its place, the pain disappeared. There is 
 no doubt but that the kidney was movable before (before the 
 appearance of pain the patient did nothing that could displace 
 and make movable a kidney that was until now normally im- 
 planted in its place), but it was supported in its place by the 
 intestines, which, on account of the constant constij)ation, were 
 considerably distended with gases. At present, when with the 
 regular evacuation of the bowels, the meteorism passed away 
 (the abdomen is not distended), a trifling cause, such as an 
 awkward movement, was sufficient to displace the now mov- 
 able kidney. However, the displacement is not great and it 
 is quite likely that he will be able to get along without a kid- 
 ney truss, and a belt worn either separately or attached to the 
 mider-dress may suffice. While movmg about, the patient will 
 have to tighten the belt, and when at rest to loosen it, otherwise 
 the constant tightening of the part of the abdomen under the 
 belt will aggravate the constipation. 
 
 Our advice to the patient : after leavmg the cluiic to take 
 silver nitrate (it apparently does not increase the constipation 
 in our patient) for another month, gradually mcreasing the 
 dose (the first two weeks three pills daily, the next two, four 
 a day, while the last days to reduce by one pill daily) and 
 then continue for another six weeks the fan-like douche from a 
 hand-pump, gradually lowering the temperature to 16°it. ; to 
 resort to potassium bromide as rarely as possible, and when 
 necessary to use a clyster. 
 
 We have spoken already of the hygienic mstructions. 
 
FOURTH CASE, 
 
 FROM THE LECTURE OF NOVEMBER 24, 
 
 The patient, of whom we will speak presently, since his 
 admission to our clmic was so exhausted and suffered from 
 such torturing pains, that we could hardly think of transfer- 
 ring him from his ward to the class-room for demonstration. 
 However, not only were all the hospital attendants well informed 
 about his condition and our views concerning it, but almost all 
 of you, while visiting the ward, had the opportunity to see 
 everything that could possibly be demonstrated before a large 
 audience : chiefly the emaciated and cachectic appearance of the 
 patient and the attacks of tormentmg vomiting, from which he 
 suffered ; therefore in view of the interest m the case I will take 
 it up now. 
 
 The patient, a retired military man, fifty-nme years old, was 
 admitted to our clinic complaining of oppressive pain in the 
 stomach, pyrosis, belchmg of the odor of rotten eggs, of vomitmg 
 and constant, tormenting nausea (which compelled him at times 
 to induce vomiting by irritating the pharynx by tickling), and 
 also of emaciation and debility. 
 
 AnamneBis and mode of living. — Since his youth patient has 
 lived almost his whole life m the Caucasus, where he frequent- 
 ly suffered from malaria, for which he was treated with quinine. 
 For the last ten years patient was always subject to costiveness, 
 and he frequently experienced after a meal slight heaviness in 
 the stomach and belchmg, that annoyed him but little. For the 
 rest, luitil last summer (1889), our patient, bemg of strong con- 
 stitution and leading a quiet life under favorable conditions, 
 could hardly complain of anything. The chief irregularity in 
 his mode of living consisted m a lack of exercise, constant 
 sittmg, while reading, writing or at times playing cards, in a 
 
— 157 — 
 
 very plentiful table and considerable use of alcohol — two to 
 three wine-glasses of whiskey daily, about two glasses of .local 
 Caucasian wine and tea with cognac. Durmg June the pa- 
 tient passed through the customary attack of malaria, which 
 quickly yielded to quinine, but after this the usual gastric 
 symptoms, heaviness and belching after meals, became aggra- 
 vated and were accompanied by others — pjTosis and nausea ; 
 the constipation became more obstinate. Until the middle 
 of August the patient's condition was bearable enough and he 
 did not resort to treatment. But since then the condition be- 
 came rapidly aggravated : the appetite disappeared, the sensation 
 of heaviness in the stomach gave way to oppressive pain, belch- 
 ing (now malodorous, of rotten eggs) and pyrosis increased; 
 patient began to vomit, the nausea became a torture, and the 
 patient was compelled to intentionally provoke vomiting ; he 
 grew thin and weak. He then called in his physician. The 
 treatment (at first HCl, later the bitters, condurango and nux 
 vomica, and Vichy water m one-half glassful doses tlrree times 
 a day, then gastric lavage) brought but little relief and for a short 
 time : the gastric symptoms kept on growing worse, while his 
 nutrition and strength failed with ever increasing rapidity, till 
 in this condition he was admitted into our clinic. 
 
 The clinical investigation elicited the following. The ner- 
 vous system in a normal condition (inquiry has failed to estab- 
 lish the existence at any time even of neurasthenia); and so are 
 the organs of respiration. There are signs of arterio-sclerosis ; the 
 arteries are somewhat hard ; there is a slight systolic mui'mur over 
 the sternum and a moderate enlargement of the left ventricle : the 
 heartbeat is felt the clearest in the mammillary line ; the pulse is 
 frequent and somewhat weak ; the temperature of the body is 
 subnormal, and there is extreme emaciation. The urine con- 
 tams some sugar (one per cent) and some albumen. The inquiry 
 failed to elicit any clearly pronounced sj^mptoms of diabetes 
 mellitus, as immoderate thirst and appetite, m the past. By 
 objective examination nothing abnormal is to be noted in the 
 liver, spleen and kidneys. Patient had no syphilis. 
 
 The digestive organs. — All the above enumerated symptoms, 
 that progressively increased before the patient's admission to the 
 
— 158 — 
 
 clinic, continued to augment rapidly, accompanied by a corre- 
 sponding failing of the strength ; almost from the very first day 
 the patient failed to retain the administered trifimg quantity of 
 food and of medicme, the latter consisting of some Ems water 
 and condurango, tra. valer. eether., and morphine. The food 
 was ejected completely undigested. The ejecta, as proved by 
 repeated exammation, contained, besides the undigested food, 
 very little mucus, very little hydrochloric acid (0.33 per 1,000) 
 and usually some bile ; there was never an}^ blood. The sub- 
 gastric region was slightly distended and somewhat sensitive ; 
 no swelling in the abdomen could anywhere be palpated. Gas- 
 tric lavage done the very first day with a solution of soda, 
 brought but a trifling relief from the gastric symptoms, while 
 lavage on the next day failed even in this. The clyster brought 
 away a small quantity of dry excreta. 
 
 In speaking of the diagnosis, I will take up only the organs 
 of digestion; on the others I will touch but lightly. The im- 
 portance of abnormal phenomena in the organs of circulation 
 was already alluded to. The constant presence of albumen in 
 the urine (although cylinders are absent) depends, most likely, 
 on the presence of a slight, so-called senile^ interstitial nephritis, 
 that usually accompanies arterio-sclerosis in aged people. 
 The failure in nutrition and strength must certainly be consid- 
 ered as a result of the disease of the digestive organs, and not 
 of diabetes, which never presented any pronounced symptoms, 
 while the percentage of sugar was trifling. We will have time 
 to discuss m detail the importance of the symptoms and diagnosis 
 of arterio-sclerosis, as well as of the nephrites and of diabetes 
 mellitus later on in suitable cases, m which these diseases play 
 the chief role. 
 
 What disease of the digestive organs is our patient suffermg 
 from ? It is evident from the first that it is a disease of the 
 stomach. Which is it ? Nervous dyspepsia can surely be ex- 
 cluded ; not to speak of the fact, that nervous dyspepsia can 
 hardly ever bring one to the condition in which we find our pa- 
 tient, there is nothmg that would speak for it : neither did the 
 patient ever suffer from general neurasthenia, nor do the gastric 
 symptoms present the important feature of nervous dyspepsia. 
 
— 159 — 
 
 namely, changeability ; on the contrary, they are very con- 
 stant. 
 
 Does our patient have an ordinary gastric catarrh ? To cause 
 the gastric symptoms to the degree seen in our patient, the 
 catarrhal condition should have been extremely developed, con- 
 sequently there would have been a great accumulation of mu- 
 cus, whereas, on the contrary, there is very little of it. 
 
 Grastric ulcer may evidently also be excluded, as there are no 
 attacks of acute pain so peculiar to this condition (cardialgia), 
 nor was there any blood m the vomited matter. 
 
 Our patient has, first of all, atrophic gastric catarrh, an 
 atrophy of the gastric glands ; this is apparent from the fact, 
 that the vomited food is undigested and the quantity of hydro- 
 chloric acid is very much diminished (0.33 per 1,000 instead 
 of the normal 2.00 per 1,000). But atrophic catarrh of the 
 stomach is observed in various diseases, which lead to exhaus- 
 tion, to marasmus of the organism. Which of these diseases is 
 the most probable in this case ? It is cancer, because the pa- 
 tient, who only four or five months ago enjoyed his ordinary, 
 for the last ten years, good health and even a florid nutrition, 
 was reduced m such a short time to extreme marasmus ; of 
 chronic diseases, leading to marasmus, it is the malignant 
 growths which have a particular tendency to such a rapid course. 
 The absence of signs of other chronic diseases, that may bring 
 about a condition of marasmus (as, for instance, inveterate 
 syphilis or tuberculosis, etc.), as well as the patient's age, also 
 speak for cancer. The localization of this, in view of the obsti- 
 nate vomiting, is most likely to be in the pylorus of the stomach 
 (no swelling is anywhere to be palpated), although the almost 
 constant presence of bile in the vomited matter speaks some- 
 what against a difficult passage in this place. Cancer pan- 
 creatis is to be excluded to some extent by the absence of 
 permanent jaundice, which could be expected in a cancer of 
 this organ, of sufficient size to compress the duodenum, on ac- 
 count of the pressure exerted by the cancerous growth on the 
 ductus choledochus (not to mention the possible ascites from 
 pressure of the same swelling on the vena portse). We are 
 generally unable to obtam am^ definite symptoms of a pancre- 
 
— 160 — 
 
 atic cancer, that would result from the mfluences created by a 
 cessation of the functional activity of this organ, nor can we 
 certamly do so in the present case, as everything mtrocluced 
 into the stomach is vomited up. 
 
 The treatment, in view of the impossibility of introducmg any- 
 thmg mto the stomach and of the rapidl}^ approaching dissolu- 
 tion, could only consist of nutritive enemata (two to three raw 
 eggs with the addition of some water and table salt, the whole 
 contained in a glass and warmed to the temperature of 30°i2.), 
 to which were added some eight drops of laudanum, so that the 
 clyster could be better retained, and a dessertspoonful of cognac 
 as a stimulant ; for the excruciatmgly pamful vomiting we some- 
 times mjected morphine hypodermically (one-eighth grain at a 
 time). 
 
 Patient died on the thirteenth day after his admission to the 
 clinic. Autojjsy showed : sclerosis of the arteries, among others 
 also of the aorta ; left ventricle dilated, its walls pale and 
 flabby, but presenting at some places traces of hypertrophy ; a 
 moderate nephritis, the liver, spleen and pancreas present 
 no changes ; catarrh and atrophy of almost the whole mucous 
 membrane of the stomach (it is very much thinned out and 
 is perfectly smooth, its surface not presenting that normal 
 mammillary appearance, surface mamelonnee^, the muscular 
 layer of the stomach is also atrophied ; the duodenum is so con- 
 stricted in its lower third, that it hardly admits an ordinary 
 pencil : on the inner surface of the posterior wall of the mtestme 
 in this locality there is a cancerous ulcer the size of a ten cent 
 piece — situated in the cancerous growth of the intestinal wall, 
 this last — the tumor — being the size of a walnut ; the neigh- 
 boring mesenteric glands present a series of cancerous me- 
 tastases. 
 
 Thus m the four patients demonstrated by me, you had the 
 opportunity to observe, besides a great many other ailments, the 
 prmcipal varieties of diseases of the stomach, namely : pure 
 nervous dyspepsia (m the third case), — a pure chronic gastric 
 
— 161 — 
 
 catarrh (in the first), — simultaneously (in the second), chronic 
 catarrh, ulcer and gastric dilatation, with additional phenomena 
 of nervous dyspepsia, where, however, notwithstandhig- the 
 co-existence of several diseases of the stomach, it was possible to 
 diagnose each of them, — and, finally, an atrophic catarrh of the 
 stomach, and cancer, if not of the pylorus, then of the duo- 
 denum, which is so similar to it m its symptoms. 
 
FIFTH CASE. 
 
 FROM THE LECTURE OF DECEMBER 7, 1890. 
 
 The patient, a peasant, fifty years old, was admitted to the 
 clinic November 24th, complaining of pain in the epigastric 
 region and in the right hypochondrium, of jaundice, emaciation 
 and general weakness. 
 
 Anamnesis and mode of living. — Until his twentieth year pa- 
 tient lived in a village, since then in Moscow, in the capacity 
 of a janitor. His lodgings are fair. He bathes himself during 
 summer in the sea, at other seasons of the year takes his bath — 
 a sweat bath — every week. Drinks a great deal of hot tea, a 
 moderate quantity of whiskey during the last year, but used to 
 drink to excess formerly. His food is the ordinary food of a 
 workingman. Until the appearance of the disease he did not 
 fi^nd his occupation fatiguing. Is married and has many 
 children. 
 
 When nine years old, patient passed through an attack of va- 
 riola; when twenty-one years he had some febrile disease from 
 which he completely recovered, enjoying good health since and 
 until last August. Patient had no syphilis. Last May patient 
 had a severe affliction. Last August there appeared some pains 
 in the epigastric region and in the right hypochondrium, the 
 appetite became impaired, and he grew costive. Three weeks 
 ago — in the beginning of November — there appeared jaundice 
 and the patient grew markedly emaciated and weak. While in 
 the clinic he continued costive (every one or two days he had 
 some dry excreta, not in the least colored by bile), and the abdo- 
 men was somewhat distended. Patient was given, November 
 30th, seven powders of calomel, each containing one grain (the 
 first five every hour, the last two every two hours) : the stools 
 were a little loose, and only slightly colored by bile, but they 
 
— 163 — 
 
 were not the characteristic calomel stools ; patient was not 
 weakened after this, but neither did he experience any relief 
 (the pains remained as heretofore). Besides calomel the patient 
 took daily (except November 30th) three half-glassfuls of warm 
 Ems water, once or twice (during the exacerbation of the pains) 
 one-quarter grain of codeine, and during the day some four 
 tablespoonfuls of strong wine (the pulse was all the time some- 
 what weak). As the evening temperature rose to 38.5° (101.3° 
 ^.), he was sometimes given quinine (five grains per dose once 
 a day) ; this apparently diminished the febrile condition. Be- 
 sides, he had some warm baths, that tended to relieve somewhat 
 the pains and the itching of the skin. 
 
 Status. — The patient is of good constitution, but very emaci- 
 ated ; the skin and the sclerotics are severely jaundiced. The 
 appetite is very poor. There are almost no dyspeptic phenom- 
 ena, except some slight heaviness after a meal : he never had, nor 
 has he now any constant and painful belching, pyrosis, nausea 
 or vomiting. The pains in the epigastric region and in the right 
 hypochondrium do not become aggravated after a meal, but do 
 so on pressure on the painful parts. The abdomen is dis- 
 tended. The liver is enlarged and sensitive to pressure, but 
 does not present any palpable unevenness or any protuberance ; 
 the gall-bladder is distended to the size of a considerable swel- 
 ling, but is almost insensitive to pressure. The spleen is some- 
 what enlarged. Patient is constipated : after the calomel he 
 had every other day watery clysters, which brought away a 
 small quantity of uncolored by bile evacuations. The urine is 
 very much jaundiced, contains neither sugar nor albumen. The 
 arteries are slightly stiff, the pulse is frequent and somewhat 
 weak. The organs of respiration present nothing abnormal. 
 Patient, as I said once, is feverish ; his evening temperature 
 ranges between 37.5°i^, (99,5°i^,) and 38,5°i^, (101,3°^,), His 
 sleep is poor, he is at times dizzy ; his skin itches. 
 
 Diagnosis. — A morbid process, which develops in a man no 
 longer young, approaching old age, but of strong constitution 
 and good health heretofore, — especially if developed after a 
 severe affliction, — and leading the patient to a rapid failure of 
 nutrition and of strength, is usually a cancer (generally a malig- 
 
— 164 — 
 
 nant new formation), less frequentl}' diabetes mellitus. Our 
 patient has neither diabetes nor any other pathological process 
 (except a cancer) which could explain his dangerous condition. 
 Syphilitic gumma, compressing the ductus choledochus, is most 
 certainly out of the question : not only does the patient deny 
 infection, but he presents absolutely no signs of syphilis (besides, 
 his wife had eleven children and not a single abortion). Hy- 
 pertrophic biliary cirrosis and multilocular echmococcus of the 
 liver, which one may be led to suspect in view of the enlarge- 
 ment of the liver and because of the jaundice, are to be excluded, 
 besides other considerations, by their much slower courses ; so 
 that only cancer remains. Which organ is affected by it? It 
 is evidently not the stomach, because there are neither severe, 
 nor in fact any gastric symptoms, and besides it is apparent, 
 that the ductus choledochus is compressed (the evacuations are 
 not in the least colored by bile, there is jaundice, the gall-blad- 
 der is very much distended), and consequently the tumor must 
 be located about it. It is evident that the tumor is most likely 
 to be assumed as lying on the lower surface of the liver (in the 
 porta hepatis), or that it is a cancer of the pancreas. We have 
 already stated in connection with the previous case that we 
 have no reliable symptoms, outside of a localized swellmg, that 
 would indicate a cancer of the pancreas, nor can we detect any 
 such swellmg in our patient. Cancer of the liver is to be ex- 
 cluded — though not absolutely so — by the fact that m the 
 part of the liver accessible to palpation there is observed neither 
 any unevenness, nor any protuberance, and besides, its sensitive- 
 ness is not great and is everywhere equable, and not severer in 
 some places than in others. This sensitiveness and at the same 
 time the enlargement of the liver is fully explamed by the stag- 
 nation of the bile in. this organ and the consequent distention 
 of its capsule. 
 
 Prognosis — is but too evident. 
 
 Treatment. — - Notwithstanding the improbability of the pres- 
 ence of such a process in the biliary tract in our patient, on 
 which treatment could produce an effect, we nevertheless at- 
 tempted in the beginning to treat the case by calomel and Ems, 
 but failed to obtain any results. It only remains now to sus- 
 
165 
 
 tain the patient's strength and relieve the particular!}^ painful 
 symptoms ; the means for this were spoken of before. 
 
 FROM THE LECTURE OF JANUARY 18, I89I. 
 
 The condition of the patient grew continually worse and 
 January 16th he died ; the last two days of his life were marked 
 by a surprismg lowermg of the pulse and strength, and by ex- 
 treme paleness. 
 
 The autopsy made to-day showed the f olloAving : cancer of the 
 pancreas, that extended by ulceration into the duodenum and 
 caused a severe haemorrhage ; the intestines (except the sigmoid 
 flexure and the rectum) are filled with clots of blood ; the ductus 
 choledochus is very much distended above the seat of pressure, 
 and so are all the other biliary ducts, as well as the gall-bladder 
 (this last to the size of an ostrich egg^. 
 
SIXTH CASE. 
 
 LECTURE OF OCTOBER 25, 1889. 
 
 The patient, a peasant, twenty-nine years old, was admitted 
 to the clinic October 20th, complaining of jaundice, weakness 
 and pains all over the abdomen, but particularly in the right 
 hypochondrium ; he claims, that he took sick one week before his 
 admission here. 
 
 Anamnesis and mode of living. — Patient comes from a healthy 
 family ; until his twentieth year he lived m a village, then 
 served in the militia, and for the last two years, as a member of 
 the reserve army, he made Moscow his place of residence. His 
 lodgmgs are fair; the water-closet cold. While m Moscow, he 
 does not bathe in the river (bathed formerly and felt very 
 good) ; goes frequently to the public bath-house ; drinks a great 
 deal of hot tea ; is subject to sweating. Twice a week drinks some 
 three wineglassfuls of whiskey. Order of his meals : in the morn- 
 ing tea with bread, later dinner, and supper. His board is good 
 (fish on fast days), but patient is very much occupied — he 
 supervises the forwarding of goods and accompanies the wagons 
 packed with them — so that he frequently takes his dinner not 
 at home, nor m time, eating whatever he may get hold of (as 
 sausages, salted fish, etc.) ; nor does he sleep enough on account 
 of his occupations. For the last two years patient had a great 
 deal of worr}^ partly on account of the very responsible nature 
 of his occupation, partly on account of some family troubles. 
 Patient is single, had no venereal affections. 
 
 With such data on hand, we certainly could not rely on the 
 patient's statement, m reply to the first question, that until the 
 present illness he had never been sick. As a matter of fact, 
 the inquiry about the patient's condition, about the functional 
 activities of his organism immediately before the present illness. 
 
— 167 — 
 
 has elicited the fact, that although his appetite, digestion, urm- 
 ation, respiration and circulation were perfectly normal, still the 
 patient while residing in Moscow, in better rooms and eating 
 better food than formerly, lost flesh and his hale and hearty 
 mental state, became impressionable and irritable ("began to 
 take things too seriously to heart ") ; besides, since October 1st, 
 or some two weeks previous to the present illness, he began to 
 experience, most frequently while riding on the street pavement 
 (as he often rode in a wagon while forwarding the goods), some 
 pain in the right hypochondrium (patient pointed directly to 
 the region of the gall-bladder). 
 
 October the 13th patient had eaten some fat soup of the flesh 
 of white sturgeon, and the same day, having remained for a 
 long time out of doors, he became verj- much chilled; in the 
 evening he felt pain at the pit of the stomach and weakness. 
 The next day the pain grew worse, and the appetite tecame im- 
 paired ; on the third day the white of the eyes became yellow. 
 October 16th patient took some very salt and fat cabbage 
 soup made of kidney, and after this drank some cold beer. 
 There appeared on the same day severe pains around the 
 umbilicus and an attack of diarrhoea, which continued into 
 the next day. October 18th the pains around the umbilicus 
 diminished and the diarrhoea ceased, but the pains in the 
 right hypochondrium grew worse and the urine became dark. 
 October 20th the patient entered our clinic. For the last 
 few days the patient excreted daily small quantities of dry 
 fetid evacuations entirely uncolored b}^ bile. 
 
 October 21st the patient was given seven grains of calomel 
 (in powder, one grain every hour) : patient had good loose 
 stools the 21st and the 2 2d, copious and characteristic 
 calomel dark-green evacuations, after which the pains around 
 umbilicus completely disappeared, and those in the right 
 hjrpochondrium were relieved, the urine became clearer, the 
 heaviness in the head was relieved, and the appetite returned. 
 The 23d the patient was given one-half glass of warm natural 
 Karlsbad water (Miihlbrunnen sprmg), one hour before dinner, 
 and the 2 2d two half-glassfuls, one an hour before dinner, the 
 other an hour before supper. 
 
— 168 — 
 
 Yesterday, the 24th, the patient had a severe attack of 
 pain, lasting from five to seven p. M., in the right hypochon- 
 drium and under the right scapula, and at the same time the 
 temperature, which was normal until then, rose to 38.5° R. 
 (101.3° #.). 
 
 ^to^its. _ The temperature is as yet 37.6°i2. (99.7°i^.), but 
 the patient, as you may hear, claims to feel much better now 
 than he did before admission. The appetite is very good, 
 but he is given as yet but little to eat. Dyspeptic phenomena 
 are absent ; a clyster, administered yesterday, brought away a 
 sufficient quantity of evacuations markedly colored by bile. 
 The urine is much more limpid, than it was before, but ex- 
 amination shows, that it contains still some biliary pigment 
 and the biliary acids, but neither albumen nor sugar. The 
 abdomen (protected smce his admission by flannel) is sensitive 
 only in the region of the gall-bladder, and is not distended. 
 The liver is somewhat enlarged, the gall-bladder does not 
 permit of palpation. Nothing abnormal found in the region 
 of the spleen and of the kidneys. The organs of respiration 
 and of circulation are in a normal condition. Patient's sleep 
 is generally better, than it was before admission, but still it 
 is not perfectly normal, partly on account of the abdominal 
 pains, and partly — in the absence of these last — simply 
 because of the msomnia caused by worrying about his illness. 
 We alluded in the anamnesis to the somewhat gloomy and 
 irritable mental state of the patient. 
 
 Biagiiosis. — Outside the light nervous sjanptoms, — of the 
 significance of which we have spoken already in connection with 
 the discussion of neurasthenia in the first and third cases, — we 
 observe in the patient at present only symptoms of an affection 
 of the biliary tract, namely : jaundice, sensitiveness on pressure 
 and pains in the region of the gall-bladder, usually not severe, 
 but at times very severe and acute, in the form of clearly 
 definable attacks. For a week before the patient's admission 
 to the clinic he suffered from gastro-intestinal disturbances 
 (loss of appetite, intestinal pains and diarrhoea), which passed 
 away rapidly in the course of two days. Up to that time the 
 appetite and digestion were perfectly normal, and after that the 
 
— 169 — 
 
 appetite returned quickly, the dyspeptic phenomena disap- 
 peared, the intestinal pains passed away and there are, properly 
 speaking, no intestinal symptoms : if the patient is costive and 
 if his evacuations are not bile-colored, it is to be ascribed to 
 the small quantity of food and the damming back of the 
 bile ; that is, to the affection of the biliary tracts, which proves 
 itself to be a more obstuiate morbid condition, than the rapidly 
 disappearing gastro-intestinal disturbances. It were therefore 
 erroneous to consider the present case as one of a gastro- 
 intestinal catarrh, that spread into the biliary tracts : the 
 above-mentioned quickly passing away gastro-intestinal dis- 
 turbances could hardly originate from any more or less firmly 
 established gastro-intestinal catarrh ; while the affection of the 
 biliary tracts, I must say again, proves itself to be very firmly 
 established. Besides, its symptoms, as pains in the region of 
 the gall-bladder, appeared even two weeks previously to the 
 before mentioned gastro-intestinal disturbances, at a time when 
 both the appetite and the digestion were as yet perfectly 
 normal. It is evident that the disease of the biliary tract 
 existed before the appearance of the enumerated gastro-in- 
 testinal disturbances and only became aggravated after them. 
 
 What disease then of the biliary passages does our patient 
 suffer from? Guided by your knowledge of the special 
 pathology of the internal organs and by what I said of biliaiy 
 calculi in connection with the first case discussed by us, you 
 have probably concluded, by this time, that our patient is suf- 
 fering with calculi m the gall-bladder, and you are not in error : 
 our patient is really suffering from this disease, which, although 
 not completely developed, presents, nevertheless, all its charac- 
 teristic symptoms ; — a disease of great importance, because of 
 its frequent occurrence and because it is so easily cured by a 
 correct treatment and regimen (hygiene), while otherwise it 
 may ruin one's health and become dangerous. I consider it, 
 therefore, necessary to stop here to discuss the importance of 
 its symptoms, its diagnosis and therapy. 
 
 What is the formation of gall-stones due to ? All are agreed 
 on one point, namely, that it is promoted by the sluggish pas- 
 sage of the bile along the biliary tracts. This fact explains the 
 
— 170 — 
 
 frequency of biliary calculi in women (the wearing of a narrow 
 corset and pregnancies limit the movements of the diaphragm, 
 which assist in propelling the bile along its passages and its 
 entrance into the intestines) and in men of sedentary habits 
 of life (m these also the movements of the diaphragm are 
 hmdered, and are neither as free, nor as extensive as in men 
 leading a lively, physically active mode of life). It was 
 further assumed that the cause of the formation of biliary 
 calculi is to be found in the secretion of a bile of an altered, as 
 compared with the normal, character ; but exact investigations 
 failed to substantiate this assumption. It is more probable, as 
 supposed at the present time, that biliary calculi are formed 
 within the normally secreted bile, through the influence of 
 causes which emanate from the intestinal canal and which call 
 forth a precipitation of the cholesterin, of the biliary pigments 
 and of the lime salts — the chief component bodies of biliary 
 calculi. According to some, these causes (it is most likely 
 assumed, that it is the microbes, so abundant and various in 
 the intestinal canal) call forth a catarrhal condition of the gall- 
 ducts and of the gall-bladder, which impedes the passage of the 
 bile and which, through its products, occasions the alterations 
 in this fluid, and the formation within it of the above-named 
 precipitates ; while others assert that these causes are directly 
 responsible for the changes produced in the bile and its pre- 
 cipitates. All these assumptions require further investigation 
 and verification. 
 
 The clinical facts coincide in so far with these suppositions, 
 that they substantiate the frequency of the co-existence at 
 one and the same time of gall-stones and of a catarrhal con- 
 dition of the biliary passages (it must in this connection be 
 kept in mind, that the irritation of these last by the calculi may 
 also lead to a consequent catarrh of the same) : constant ten- 
 derness, and at times direct sensitiveness on pressure in the 
 region of the gall-bladder, and frequent jaundice are the charac- 
 teristic symptoms of biliary calculi. But as the peculiarly 
 characteristic symptoms of this disease are to be considered 
 attacks of biliary colic accompanied by sharp, at times excru- 
 ciatmg pain, which develops rapidly, and which disappears 
 
— 171 — 
 
 after a certain period of time just as rapidly. I will not 
 stop here to describe an attack of colic : that you know well 
 from your study of special pathology. The attacks of biliary 
 colic are considered as due to neuralgia of the hepatic plexus, 
 probably in conjunction with a contemporaneous tonic spasm 
 of the gall-bladder. It is assumed that these attacks are 
 caused by the passage of the calculi through the narrow por- 
 tions of the biliary tracts, which occasions, as a consequence, 
 an irritation of these last; but as we shall see later, this is 
 hardly always the case. I said just now, that as the most 
 characteristic symptoms of biliary calculi are considered the 
 attacks of biliary colic ; but it would be very erroneous to 
 thmk that their absence would speak against the presence 
 of biliary calcuK. On the contrary, we very frequently come 
 across cases of this disease which do not present attacks of 
 sharp pain, i. e. of biliary colic, but in which a constantly 
 present pain of only moderate severity in the region of the 
 gall-bladder is observed, of which the patient complams himself, 
 or which may be elicited only on investigation by pressure. 
 Sometimes, in these cases, in their further course, we observe 
 also the appearance of attacks of biliary colic, at other times 
 we do not. These cases yield to the usual treatment of bili- 
 ary calculi, as do cases characterized by attacks of liver-colic. 
 It may be stated, that if we consider the attacks of biliary 
 colic as the most characteristic symptom of biliary calculi, then 
 we may say that the most frequent, and the most constant 
 symptom of this disease, is a constantly present pam in the 
 region of the gall-bladder, aggravated by pressure. 
 
 It appears, then, that our patient has unmistakable symptoms 
 of biliary calculi and of a catarrh of the biliary ducts. Even 
 now there is some pain in the region of the gall-bladder, ag- 
 gravated on pressure, while on his admission it was much 
 more severe. He had yesterday quite an acute attack of 
 biliary colic, and slight attacks, as seen from the anamnesis, 
 made their appearance since the beginning of October. While 
 the jaundice, which developed in connection with the trifling 
 and rapidly disappearing gastro-intestinal disturbance (it pre- 
 sented on the patient's admission a complete failure of the 
 
— 172 — 
 
 bile to enter the intestine), proves the fact, that, up to the time 
 this disturbance made its appearance, there was a catarrhal 
 condition of the biliary ducts, severe enough to become exacer- 
 bated from a trifling cause. 
 
 Some consider it necessary for the diagnosis of gall-stones to 
 search for passed calculi in the evacuations. I consider such a 
 search an idle task for practical purposes. In the great ma- 
 jority of cases, to which may be referred the present one, the 
 diagnosis is easy, and does not present any difficulties. In the 
 rare cases of a difficult diagnosis, the detection of calculi in 
 the excreta is, firstly, of such casual occurrence, and fails so 
 frequoiitiy, that it can not be relied upon, and, secondly, even 
 when successful, it is of but small assistance in the matter. 
 Let us touch upon these, generally quite interesting, cases of 
 difficult diagnostication. 
 
 It is at times necessary to decide as to what the patient 
 suffers from — biliary calculi or cancer of the liver. We 
 usually have to do in such cases with very emaciated patients, 
 who present a slight jaundice and who have severe pains in the 
 region of the liver (which is also sensitive on pressure, especially 
 at the seat of the gall-bladder), but without any pronounced 
 objective symptoms of cancer of that organ. A search is made 
 for the stones in the evacuations, and, let us assume, it is 
 successful — the stones are found ; but will this fact exclude 
 a contemporaneous affection by a cancer (patients who suf- 
 fer for a prolonged period with gall-stones become quite 
 frequently victims of cancer of that organ) ? And to settle 
 the fact of the presence or absence of this last is usually the 
 most important diagnostic task in such cases. It is not the 
 detection of calculi in the excreta, but the careful objective 
 examination and attentive analysis of the patient's past and 
 present conditions, of the course of the disease, — ^at times it is 
 the success or failure of the treatment, — that clear up the 
 diagnosis in these cases. 
 
 We further meet patients with symptoms which excite a 
 suspicion of both gall-stones and of disease of the stomach, 
 usually of an ulcer (less frequently of cancer) about the py- 
 lorus : such patients have attacks of severe pains, with vomit- 
 
— 173 — 
 
 ing (but without the characteristic icteric phenomena and 
 without blood in the vomited matter) and tenderness on pres- 
 sure to the right of the middle abdominal line, between the 
 umbilicus and the costal edge, at a seat corresponding at times 
 to the gall-bladder and at other times to the gastric pylorus. 
 Here also, even if the search for gall-stones be successful, the 
 question, as to whether there is not also with the biliary calculi 
 a gastric ulcer, remains unanswered; here also the diagnosis is 
 cleared up by the aid of the same procedure as in the foregomg 
 case (least of all, however, by the results of the treatment, that 
 may be similar in both diseases). As regards the objective ex- 
 amination in such cases, I will say, that if the pain is felt 
 distmctly by pressure on the mentioned region in the direction 
 upward, toward the right hypochondrium, it points to sensitive- 
 ness of the gall-bladder, but if the pain is felt in the direction 
 downward and inward (to the umbilicus), then it is sensitive- 
 ness of the gastric pylorus. 
 
 Finally, while speaking of cases in which the diagnosis of 
 biliary calculi is made with difficulty, I must mention the 
 difference between them and the attacks of neuralgia of the 
 hepatic plexus caused by them (i. e. of attacks of biliary colic) 
 and attacks of pure neuralgia of the plexus. We first of all 
 ask whether there is such a thing as a pure neuralgia of this 
 last? Some assume that there is : thus the well-known 
 clinician, and the author of a capital work on diseases of the 
 liver, Frerichs, described a case of biliary colic, for which re- 
 peated treatment at Karlsbad failed, while a strengthening and 
 anti-nervine treatment was successful, and he considers this 
 case as one of pure neuralgia of the hepatic plexus (hepa- 
 talgia). But Frerichs' case is, in my opinion, not convincing, 
 chiefly because the anti-nervine treatment in the case was 
 preceded by the repeated treatment at Karlsbad : it is probable 
 that this last removed the biliary calculi, while the attacks 
 remained, having become an independent hepatalgia, which 
 in its turn yielded later on to the anti-nervine treatment. An 
 example of this we see in the neuralgia of the facial nerve, 
 caused by aching teeth, which persists (though not always, 
 but at times for a long period) after these are cured or ex- 
 
— 174: — 
 
 tractecL I have not met with cases which could be considered 
 as presenting a genuine and withal primary, idiopathic hepa- 
 talgia, but I have frequently seen such in which the period 
 of undoubted symptoms of gall-stones, during which the usual 
 treatment was available (calomel and mineral waters), was 
 followed by one in which the attacks of biliar}^ colic continued, 
 although somewhat weaker, and only yielded to treatment 
 directed towards strengthening the condition of the nervous 
 system (and local treatment to the region of the gall-bladder 
 with static and galvanic electricity). It is likely that the cal- 
 culi in these cases have already disappeared and there remained 
 only an independently established biliary colic in the form, con- 
 sequently, of a hepatalgia not of a primary, but of a secondary 
 origm, consequent upon the formerly present calculi. The 
 diagnostic difficulties for me consisted not in my inability to 
 make up a decision, as to whether the biliary colic in the 
 given case presented symptoms of gall-stones, or whether it 
 was a primary genuine hepatalgia, but in deciding as to the 
 period of the disease, whether there are as yet present biliary 
 calculi to be treated accordingly, or whether the attacks of 
 biliary colic presented an established neuralgia, which was to be 
 treated as such. It is not always easy to decide on this point, 
 and a conclusion can be reached through a careful analysis 
 of the condition of the patient, the course of the disease and the 
 results of the preceding treatment ; but at times only fresh 
 therapeutic attempts decide the matter. 
 
 The present case, as I said already, does not belong to those 
 in which a diagnosis is difficult. In view of the so distinctly 
 prominent data in the sphere of biliar}^ tracts and the slight 
 nervous symptoms in our patient, pure hepatalgia is positively 
 to be excluded, as well as ulcer of the stomach, m view of the 
 condition of the digestion, and finally also, cancer of any organ, 
 in view of the patient's youth and physical strength as well 
 as on account of the rapid improvement in his condition. 
 
 Again, there are cases in which the diagnosis, properl}^ speak- 
 ing, is easy, but the physician — certainly if negligent — may 
 commit an error. The fact is, that patients suffering from 
 biliary calculi, who do not have any attacks of biliary colic, but 
 
— 175 — 
 
 only a constant pain in the region of the gall-bladder, complain 
 frequently of pain in "the pit of the stomach," without dis- 
 tinctly designatmg the seat of pain, which is so easily done 
 in view of the vicmity of the gall-bladder to the " pit of the 
 stomach." 
 
 The physician, yielding to the first impression, mvestigates, 
 makes pressure only ia the region of the stomach, asks the 
 patient about it, receives in reply that the pain is aggravated, 
 and concludes that the patient has a gastric catarrh ; whereas a 
 careful mvestigation, i. e. such as would also include the neigh- 
 boring organs, would show in such cases the seat of the max- 
 imum sensitiveness in the region of the gall-bladder. There 
 may certainly be present at one and the same time both 
 biliary calculi and a gastric catarrh, but hi such a case we 
 must find a complete summary of the symptoms of both 
 diseases. 
 
 In speaking of the diagnosis, we must say a few words con- 
 cerning yesterday's attack of biliary colic. The patient felt 
 very much relieved by the action of calomel : the sensitiveness 
 on pressure in the region of the gall-bladder has considerably 
 diminished since then and remains so at the present time. 
 But he had another attack of colic yesterday. What could 
 have caused this ? The usual causes, which call out such 
 attacks, — as traumata (as we saw in our patient when it 
 resulted from riding in a jolting wagon over the pavement), 
 mental disturbances, dietetic errors, and colds — were all absent 
 in the clinic. We can only say this much, that such attacks 
 are frequently observed at the beginning of the treatment of 
 biliary calculi with Karlsbad (or generally with any alkaline) 
 water, which fact, however, prevents in no way its further 
 curative action.* The above-mentioned attack was accom- 
 panied by a slight febrile condition — a not infrequent phe- 
 nomenon : in my article on calomel I have described a case of 
 
 * A similar plienomenon is observed in the treatment of renal gravel 
 by mineral waters, namely, the attacks of renal colic appear or become 
 aggravated at the beginning of the treatment; so that in either case, that 
 is, in the treatment of either biliary calculi or of renal gravel by min- 
 eral waters, it is advantageous to warn the patient of the possibility of 
 such an initial aggravation of the attacks. 
 
— 176 — 
 
 gall-stones, in which the attacks of biliary colic were almost 
 always accompanied by a febrile condition. 
 
 Prognosis is favorable : the disease is curable ; but the 
 stability of recovery and the absence of recurring attacks 
 depend on the patient's will and ability to fulfil all the re- 
 quirements of hygiene and therapy. 
 
 Treatment. — The patient was at first given calomel, which pro- 
 duced such a considerable and usual improvement in these 
 cases.* We then prescribed the warm alkaline and slightly lax- 
 ative mineral water (Karlsbad Miihlbrunnen). Why did we 
 prescribe it? Surely not because we were guided by theoretical 
 considerations, which change m accord with the changes in 
 the views concerning the formation of gall-stones : thus, when 
 the cause of these last was supposed to be found in the altera- 
 tions of the secreted bile, then the eifect of alkaline mineral 
 waters was attributed to the influence on the secretion of bile, 
 to the fact, that by the aid of the alkaline, the secretion 
 of the bile becomes more abundant and more fluid (this was 
 evidently also substantiated by experimental mvestigation), and 
 it was consequently thought that it would thus tend to dissolve 
 and remove the stones ; at the present time, when the chief 
 cause of the formation of biliary calculi is considered to be due 
 to alterations m the already secreted but sluggishly (stagna- 
 tory) passing bile on account of the catarrhal condition of the 
 biliary tracts, the beneficent influence of the mineral alkaline 
 waters on the gall-stones is chiefly ascribed to their action on 
 this catarrhal condition. There is perhaps to an extent some 
 truth in either of the views, but the chief guide for the employ- 
 ment of mineral alkaline waters in gall-stones are not all these as- 
 sumptions, but the facts that practice has proved the utility of 
 the employment of these waters for this disease and has taught 
 the method of employing them. 
 
 Why did we prescribe Karlsbad water, and no other alka- 
 line water, as Ems, Marienbad, Vichy and Yessentucki? I had 
 occasion to go into particular explanations regarding the selec- 
 
 * The indications for calomel for biliary stones liave been fully discussed 
 by me in my article on calomel, and to avoid repetitions, I must refer the 
 reader to it. 
 
— 177 — 
 
 tion of mineral waters ; I would therefore, for the sake of a short 
 explanation of the present case, say but a few words. If the 
 patient were subject to diarrhoea, we would give him Ems ; but 
 as he is slightly costive, he was given Karlsbad. As a strongl}^ 
 laxative water Marienbad is not indicated in this case, and being 
 a cold water and rich in carbonic acid, it would tend to aggra- 
 vate the pains, and is consequently contra-indicated. If the he- 
 patic colic and the gall-stones would play but a subordmate part 
 m our case, and the principal trouble would consist in renal 
 colic and renal uric-acid-gravel, while the patient himself would 
 present unmistakable symptoms of gout (arthritis urica), then 
 we would prescribe Vichy, Yessentucki (warmed), etc. 
 
 The patient declares, that as he apprehends the loss of his 
 occupation, he would like to leave the clmic as soon as possible ; 
 we will therefore prescribe for him a somewhat larger dose of 
 Karlsbad than what is usually admmistered during the cold sea- 
 son of the year with constant coniinement within the house : 
 thus, the day before yesterday our patient drank one half-glass- 
 ful of the above-named water, yesterday he had two half-glass- 
 fuls ; we will prescribe to-day three, and from to-morrow he will 
 take four half-glassfuls, two doses one hour before the early 
 (mid-day) dinner, in the interval of one-quarter of an hour one 
 from the other, and the other two one hour before supper (7 
 P.M.) in the same order. The gradual increase in the quantity of 
 the mineral water, beginning with one half-glassful per day, is in- 
 dicated in the present case by the fact, that first the patient had 
 recently a diarrhoea, and secondly, he had only lately loose stool 
 from calomel : four half-glassfuls of Mlililbrunnen from the very 
 first day would have caused a diarrhcjea, which is far from being- 
 desirable. 
 
 Besides the Miihlbrunnen we shall order for the our patient 
 a warm bath, which we are likely to repeat, as a very beneficial 
 agency in pains caused by biliary calculi and by catarrhal 
 jaundice. In case the patient has another attack of biliary col- 
 ic, he will get one or two doses of one-fourth of a graui of 
 codeine, which, to judge by yesterday's attack, is sufiicient to 
 subdue the pain (in very acute attacks a resort to morphine be- 
 comes necessary). The patient, as I said before, is somewhat 
 
— 178 — 
 
 nervous and subject to sleeplessness : he will be given at times a 
 few drops of the sether-valeriana preparation (the more so, as the 
 pulse becomes weak at times), and at bedtime, to overcome the 
 sleeplessness, daily doses of fifteen grains of potassium bromide. 
 
 FROM THE LECTURE OF OCTOBER 27, 1889. 
 
 Status. — There were no attacks of biliary colic, the temper- 
 ature is normal, there is improvement all around. The former 
 treatment will be continued. 
 
 FROM THE LECTURE OF NOVEMBER 15. 
 
 Status. — The patient, as you hear, declares that he is com- 
 pletely cured. As a matter of fact, his appetite and digestion 
 are normal (stool for the last few days without a clyster), the 
 jaundice disappeared, attacks of biliary colic are absent, there 
 is neither pain, nor tenderness on pressure in the region of the 
 gall-bladder, the sleep is sound (he was given the bromide only 
 during one week), and the mental condition is hale (we found 
 it necessary to give him only two warm baths, while for the few 
 last days he was given cool spongings 20° JR.. (about 11° F.'), 
 with a mixture of water and brandy, which exerted a beneficial 
 influence on his nervous system). Until to-day, patient drank of 
 Miihlbrunnen four half-glasses daily ; to-day we will give him 
 only two haK-glassfuls, because his affairs require that he leave 
 the clinic to-morrow. 
 
 The patient was made to understand that onl}^ the visible symp- 
 toms of his disease had disappeared, that time would show how 
 lasting his recovery would be, and that to avoid the return of the 
 morbid attacks, he must beware of irregularities in his mode of 
 living, which we discovered by our investigation (his sojourn in 
 our clinic has served as a good hygienic schooling for our pa- 
 tient). We told him that it may very likely become necessary 
 to resort to repeated treatment by Miihlbrunnen, and that this 
 treatment must be postponed till the warm season of the year, 
 (i. e. so as to avoid at least until then a return of the morbid 
 
— 179 — 
 
 attacks), when he would be able to undergo treatment by mui- 
 eral waters, without being compelled, at least altogether, to 
 give up his occupation. 
 
 I do not advise our patient to drink any Miihlbrunnen at home, 
 first, because at the present season of the year, with his occupa- 
 tion out-of-doors, it would subject him to a risk ; and secondly, 
 because the drmking for twenty-four days of the Miihlbrunnen, 
 which he finishes to-day, may perhaps suffice ; already for the 
 last ten days there is no jaundice, nor any pain in the region of 
 the gall-bladder, while no attack of biliary colic took place since 
 the one of which we spoke October 25th. In other cases it is 
 frequently necessary to prolong the course of treatment with 
 mineral waters for six weeks. Further than that I usually do 
 not continue the treatment with mineral waters, but make an 
 interruption, and if necessary, repeat it ; I do this because, fii'st, 
 a more prolonged, uninterrupted employment of mineral waters 
 may exert a deleterious influence on nutrition and digestion, 
 and secondl}^, to enable me to clearly define the results obtamed 
 by the treatment. If, during this necessary interruption the 
 patient be sulf ering with pains in the region of the gall-bladder, 
 I then prescribe ether, — ten, fifteen or twenty drops three times a 
 day (exercise special care, so as to administer the smallest 
 dose to men already advanced in age, who may have a hyper- 
 trophy of the heart, or in whom it is generally easily excitable), 
 or, for men with good digestion, ether (§j) and oleum tereben- 
 thinse rectificatum (3j) in the above-named dose. These reme- 
 dies (the remedy of Durande consists, properly speaking, of one 
 part of oleum tereb. and four parts of ether) are sometimes un- 
 doubtedly effective. 
 
 But ordinarily I contmue the treatment of gall-stones until 
 all their symptoms have disappeared (and even somewhat be- 
 yond that time) ; chiefly not the attacks of biliary colic (which 
 appear so vaguely, that they can hardly serve as a guide), but 
 the constant pains and sensitiveness on pressure at the seat of 
 the gall-bladder. It is always a most reliable way to be guided 
 by these last symptoms ; the attacks of biliary colic, however, 
 cease usually before the disappearance of the above-named con- 
 stant pains and of the sensitiveness on pressure. 
 
— 180 — 
 
 While discontinuing the treatment, as per above-named indi- 
 cations, I am far from assummg that the gall-stones have been 
 "cured," removed, or are absent: we frequently observe cases, 
 where the above enumerated symptoms have disappeared, and 
 the patient feels absolutely no pain in the region of the gall- 
 bladder, no attacks of biliary colic have taken place for a very 
 long time, and the patient leads a faultless hygienic life, when 
 all at once, through an accidental cause (most frequently follow- 
 ing strong mental excitement) an acute attack of biliary colic 
 breaks out unexpectedly, showing the presence as yet of one or 
 many stones in the bladder. It is true such cases are very rare ; 
 ordinarily the return of the attacks of biliary colic is preceded 
 by a return of a constant, although slight, pain and sensitiveness 
 on pressure in the region of the gall-bladder, that reminds us of 
 the necessity for a repetition of the treatment and usually of the 
 necessity for a stricter observance of hygienic rules. But, I re- 
 peat again, the treatment must be conducted only till the disap- 
 pearance (and somewhat longer) of the above-named symptoms. 
 To continue treatment until " the stones have completely disap- 
 peared," is unreasonable (not to speak of the possible danger from 
 a too prolonged treatment), because, what can guide us in pro- 
 longing the treatment, and for how long a period can we do it? 
 Then there is no necessity for it : experience shows, that with 
 the observance of hygiene, with regularity in all the functional 
 activities of the organism, calculi may remain in the bladder 
 without giving rise to any morbid phenomena ; but if the 
 hygienic rules be neglected and there be superadded gastro-intes- 
 tinal, nervous and other disturbances, then even the complete 
 removal of the stones (if such be successfully accomplished) will 
 be of no avail, as others will be formed again. I alluded once 
 already to the fact, that on the return of the symptoms at the 
 seat of the gall-bladder it is necessary, in order to anticipate an 
 attack of biliary colic, to repeat the treatment with mineral 
 water. 
 
 Sodium salycilate and olive oil, recommended recently for the 
 treatment of biliary calculi, do not, in my opinion, deserve any 
 consideration. 
 
 The present case does not present sufficient cause for the 
 
— 181 — 
 
 discussion of the operative treatment of biliary calculi, which is 
 at times (to be sure, in conjunction with correct therapy and 
 regimen, in very rare cases) the sole means for the relief of the 
 unbearable sufferings or even the means of saving the patient's 
 life. 
 
SEVENTH CASE, 
 
 LECTURE OF MARCH 24, 1892. 
 
 The patient, a private of the reserve army, complains of jaun- 
 dice, enlargement of the abdomen, oedema of the legs, a febrile 
 condition and general weakness. 
 
 Mode of living and anamnesis. — Patient lives in a healthy, non- 
 malarial locality (a village) of the Vladimir Government. 
 The residence is an ordmary peasant's house, the stable serves as 
 a water-closet. Used to bathe durmg summer until the appear- 
 ance of his sickness. Takes a hot bath every week. Smokes 
 some and is a moderate tea-drmker, but drinks daily a goodly 
 quantity of whiskey and at times considerable of it. His board 
 is good. He is single. Denies syphilitic infection, and investi- 
 gation substantiates this denial. In view of his sickness he 
 has had no occupation lately, but served in the army formerly. 
 
 Patient comes from a healthy family. He began drinking 
 whiskey when eighteen years old and suffered since then with 
 burning and belching after meals. Entered the military service 
 in his twenty-first year (served as an artillery man in Warsaw), 
 when he was compelled to abstain from drmking, and noticed 
 that both the burning and the belching disappeared ; but in June 
 1891, he seems to have passed through an attack of typhus 
 (during six weeks he had suffered from high fever, debility and 
 unconsciousness), after which, at the end of July, he was given 
 a leave of absence " to recover his health." He began drinking 
 while at home, when there soon reappeared belching, burning 
 and pams in the stomach, especially after a cold drink and 
 rough food. By the end of September there appeared the jaun- 
 dice, and at the same time the gastric symptoms became aggra- 
 vated, especially the pains, which were this time accompanied 
 by vomiting. The patient left off' drinkuig, became more care- 
 
— 183 — 
 
 ful witli his food, and took some Karlsbad salts and some pow- 
 ders (apparently containing rhubarb) ; by the middle of Novem- 
 ber the pains and dyspeptic phenomena were relieved and the 
 jaundice, as he claims, disappeared. Patient again took to 
 drinking, and again there appeared jaundice, pains and vomiting 
 (now of daily occurrence), and also a slight febrile condition, 
 enlargement of the abdomen, cedema of the legs and general 
 weakness. Patient entered our clinic the first time December 
 6th, with the following most important data (besides those 
 above enumerated) : the liver is very much enlarged, firm, 
 smooth (edge sharp), not tender to pressure, nor is the region 
 of the gall-bladder sensitive ; the faeces are but slightly colored 
 by bile, the urine is very much jaundiced, contains neither albu- 
 men nor sugar ; the spleen is slightly enlarged, there is moder- 
 ate ascites ; the heart is somewhat raised by the high position 
 of the diaphragm, its tones are clear, the pulse is weak ; the or- 
 gans of respiration and the nervous system are m a normal con- 
 dition. The patient was prescribed a diet, Ems, the bitters 
 (extr. condurango fl. and tra. nux vom.) and stimulating drops 
 (tra. valer. aether, and liqu. anod. Hoff. aa) ; the vomiting 
 ceased, and the dyspeptic phenomena were relieved. 
 
 December 11th he was given ten powders of calomel aa 
 gr. j, after which he had abundant loose characteristic calomel 
 stools, followed by almost normally colored evacuations, while 
 the urine became more limpid and the febrile condition passed 
 away. After the calomel we continued the former treatment 
 (Ems, bitters and stimulants), but December 20th, the pa- 
 tient, before the termination of the laid-out plan of treatment, 
 left our clinic, considerably improved however : the jaundice 
 and the dyspeptic phenomena have almost completely passed 
 away, as well as the oedema of the legs, the ascites diminished, 
 and his strength began to return. After leaving the clinic 
 the patient again took to drinking and began eating indiscrimi- 
 nately, but this notwithstanding he felt comfortably well until 
 the middle of February. Since then his condition grew rapidly 
 worse : there appeared considerable jaundice, almost daily vom- 
 iting and diarrhoea (three to four very fluid, painless stools per 
 day), the abdomen enlarged rapidly, the legs became oedematous, 
 
— 184 — 
 
 there appeared a febrile condition with daily chills, weakness 
 and later on haemorrhage from the nose and gums, and hemera- 
 lopia. He was again admitted to our clmic March loth. 
 
 Since admission patient has been taking all the time remedies 
 to strengthen the heart's action (wine, tra. valer. aether. + liqu. 
 Anodyn. Hoffm., twenty-five drops four times a day, and fre- 
 quently caffeinum natro-salycil., five grains three times a day), 
 and December 17th he was given five one-gram powders of 
 calomel with good effect. The febrile condition, which reached 
 in the evenings 40.2° (104.5 ^.), diminished after the admin- 
 istration of the calomel and later disappeared altogether, so that 
 it was entirely absent these last three days ; but to-day he had 
 again a slight chill. The urine became more limpid after the 
 calomel, while the evacuations are tolerably colored and became 
 less frequent and more solid (twice a day). The dyspeptic 
 phenomena passed away. The pulse and general condition of 
 the patient became better, but the ascites is on the increase. 
 
 Status. — A slight appetite appeared. With the disappearance 
 of the fever the thirst diminished and the dryness of the tongue 
 passed away. The gums are spongy and bleed. The pain in 
 the stomach, the vomiting and the other dyspeptic phenomena 
 passed away. The stools are as above. The urine is less 
 jaundiced, than it was on the patient's admission, contains 
 neither albumen nor sug-ar, its quantity amounts to 1,500 c. c. 
 There are no pains in the abdomen, the ascites is very consider- 
 able, the superficial abdominal veins appear very much dis- 
 tended. The ascites does not permit of palpating the liver and 
 the spleen at present, but on his admission investigation 
 showed, that the liver was very much enlarged (its free edge is 
 some four fiugers' width below the normal), but otherwise m 
 the same condition as it was during the patient's first sojourn in 
 the hospital ; it is also perfectly msensitive to pressure (and so 
 is the region of the gall-bladder), although the spleen emerges 
 one and one-half to two fingers' width from under the edges of 
 the ribs (patient never had malaria), it is firm and also insen- 
 sitive. The heart is raised by the high position of the dia- 
 phragm, but it is not enlarged ; at both the apex and the base 
 there is a perceptible systolic murmur of equal intensity. 
 
— 185 — 
 
 Pulse 112, regular, stronger than it was on his admission, but 
 still somewhat weak. There is no pam in the chest : d.js23n(t!a 
 on moving about (when at rest, respiration 30 per minute), 
 a slight cough with a trifling amount of mucous expectoration; 
 auscultation elicits some dry rales here aiid there ; the voice is 
 very hoarse (laryngoscopic examination shows a catarrhal con- 
 dition of the vocal cords). Patient is very thin and weak. 
 We alluded above to the febrile condition ; with its disappear- 
 ance the sleep became better, while the formerly occurrmg (in 
 the evening during the increase of the fever) headaches have 
 almost completely disappeared. Movement gives rise to dizzi- 
 ness. The consciousness is clear, but the memory has weakened 
 somewhat durmg the last half-year. The mental condition is 
 oppressed. There is hemeralopia. Hearing is normal. No 
 pains in the back, arms and legs. The legs up to the knees 
 are considerably (jedematous. Severe jaundice: the sclerotics 
 and the visible mucous membranes are colored yellow, the skin 
 brown-yellow. 
 
 ' Diagnosis. — The dyspeptic phenomena as well as the pains in 
 the stomach, which appeared with such regularity while the 
 patient was drinking and committing dietetic errors, and which 
 passed away as soon as the patient gave up drinking and exercised 
 due care in his food and which so rapidly yielded to the treatment 
 by Ems water and bitters durmg the first sojourn of the patient m 
 the clinic, point undoubtedly to a catarrh of the stomach. Caused 
 at the beginnmg by excesses in drinking whiskey and by dietetic 
 errors, this sickness is now perpetuated by the so markedly appa- 
 rent impediment in the circulation of the vena portse due to the 
 disease of the liver. The diarrhcjea, too, is chiefly to be ascribed 
 to this impediment m the circulation : the trifling admixture of 
 mucus in the evacuation points only to an msignificant intesti- 
 nal catarrh, while the evacuations, although mfrequent, are abun- 
 dant, watery and entirely miaccompanied by pains (m a catarrh, 
 on the contrary, they would rather be frequent, not so abundant, 
 rather more of a mucous than of a liquid nature, and to a great- 
 er or lesser extent accompanied by pains). The urinary organs, 
 outside of the presence of biliary elements in the urine are 
 healthy. Except for the pains in the stomach, which were ac- 
 
— 186 — 
 
 companied by vomiting and which disappeared now, the abdo- 
 men is entirely painless and has always been so ; in view of this 
 we must consider the great ascites in our patient as a result of 
 the impeded circulation of the vena portse, which fact is also 
 substantiated by the considerable distention of the subcutaneous 
 abdominal veins, by the above-named diarrhoea and by the en- 
 largement and thickening of the spleen. 
 
 This last condition cannot be referred to anything else : the 
 patient never suffered with malaria, while there is no sufficient 
 reason to ascribe this enlargement to the results of an (assumed) 
 former typhus ; such an enlargement and thickening of the 
 spleen is rather unusual after typhus. The sharply pronounced 
 symptoms speak clearly for an affection of the liver and of the 
 biliary passages, but this we shall discuss at the end, after we 
 will have analyzed the condition of the other parts of the organ- 
 ism. The catarrhal condition of the pharynx, larynx and the 
 slight bronchial catarrh, so usually seen in drinkers, requires no 
 special explanations. The cause of the displacement of the 
 heart upward is clear. The weakness of the pulse and the sys- 
 tolic murmur may depend partly on the displacement of the 
 heart, partly on trophic changes in the cardiac muscle (which it 
 would be so natural to find in a patient, who passed but recent- 
 ly through a severe febrile affection, and who, this is most im- 
 portant, has so ruined his health in general, and particularly his 
 nutrition, by drinking) and partly on account of some distur- 
 bance of the mnervation of the heart caused by chol?emia, the 
 presence in the blood of biliary elements, because the patient 
 presents already unmistakable signs of the presence of cholsemic 
 phenomena — bleeding of the gums and hemeralopia. 
 
 There is not the slightest foundation for considermg the sys- 
 tolic murmur as a symjDtom of affection of a cardiac orifice or of 
 a corresponding valve, first because the most important proof of 
 the existence of such an affection^ a resultmg enlargement 
 of the heart — is absent, and secondly because m December, 
 during the patient's first sojourn in the clinic, the tones of the 
 heart were clear, there were no murmurs, although the principal 
 morbid phenomena in our patient (the abdominal) were already 
 at that time in evidence, though to a slighter degree. The 
 
— 187 — 
 
 frequency of the pulse is due to the same causes, and also un- 
 doubtedly to the febrile condition. The oedema of the legs is 
 kept up by the weakness of the pulse, but it certainly depends 
 principally on the pressure of the fluid (which accumulated m 
 the peritoneal cavity and distended the abdomen), exerted on 
 the inferior vena cava and the great veins of the abdominal cavi- 
 ty terminating in it. We can find no other causes for the feb- 
 rile condition outside of disease of the liver and of the biliary 
 passages. After all that was said, we hardly need to stop here 
 for the explanation of the nervous symptoms. 
 
 What disease of the liver does our patient have? I must 
 first of all observe, that cases of hepatic diseases, in which the 
 diagnosis is directly apparent by the collection of the symptoms, 
 are less frequently seen, than such which for their diagnostica- 
 tion require a resort to differential diagnosis ; as an example of 
 the first class, we may instance a case in which a large, painless 
 liver with undoubted fluctuation at some point on its surface in 
 conjunction with a complete absence of any other morbid data 
 either m the liver itself, or in the rest of the organism, points at 
 once to an echinococcus cyst of this organ, or when an enlarged, 
 tuberous and extremely sensitive liver in a cachectic patient, 
 who is apparently free from syphilis, speaks for cancer or gener- 
 ally for a malignant new formation in this organ. Our present 
 case belongs to the second class of cases, and we will therefore 
 apply to it the above-named method of differential diagnosis. 
 It is evident that the sum total of the symptoms in our 
 patient can not be ascribed to either hypersemia of the liver, or 
 to fatty degeneration of this organ. Amyloid degeneration of 
 the liver is to be excluded by the considerable ascites, by the 
 phenomena of icterus and the absence of albuminuria, which 
 could be expected as a symptom of a contemporaneous amyloid 
 affection of the kidneys, if we admit such an advanced amyloid 
 degeneration in our patient as would be necessary to assume 
 in order to explain the great enlargement of the liver as well as 
 of the spleen. Syphilis of the liver could give rise to the symp- 
 toms observed in our patient (with the addition, however, of 
 pains in the hepatic region, which usually accompany syj)hilis 
 of this organ, but which were and are now absent in the present 
 
— 188 — 
 
 case) ; but this is not onl}^ to be excluded by the fact that the 
 patient, not by any means a man of deceitful nature, denies 
 syphilitic infection, but chiefly by the fact, that neither the an- 
 amnesis nor the present history give the least clue as to its pres- 
 ence. Against cancer of the liver speak the patient's youth, the 
 absence of roughness, and complete insensitiveness of this organ, 
 as well as the repeated improvement (and even disappearance) 
 of the phenomena of icterus and the parallel cessation of the feb- 
 rile condition after the employment of calomel, which could 
 not be thought of, were they conditioned by cancer of the liver, 
 Echinococcus cyst could not give rise to the symptoms ob- 
 served in our patient, not to mention the fact of the absence of 
 any symptoms of this affection (fluctuation). Multilocular 
 echinococcus, which emigrated into the biliary passages and 
 caused the chronic jaundice, differs from the present case in 
 this, that it occasions a very pronounced alteration in the shape 
 of the liver (the right lobe is particularly enlarged), that it 
 takes a more chronic course, is usually unaccompanied by as- 
 cites, and especially of such magnitude, but principally by the 
 fact, that a diminution, the more so the disappearance, of the icte- 
 rous symptoms caused by it, is never effected by the employ- 
 ment of calomel. There remams, therefore, that disease of the 
 liver, which, in view of the etiology of the given case — abuse of 
 alcohol in conjunction with an assumed attack of typhus — 
 would first of all suggest itself, namely cirrhosis of the liver, as 
 a result of an interstitial inflammation of the organ (hepatitis 
 interstitialis). 
 
 Our knowledge of the cirrhoses of the liver is far from being- 
 perfect. The pathologo-histological data concerning these af- 
 fections are interpreted in various ways. As based on these, 
 some assume the following cirrhoses : vevious, in which the inter- 
 stitial inflammation begins from the branches of the vena portse ; 
 biliary, in which it progresses from the small biliary passages, 
 and the mixed, when the disease advances contemporaneously 
 from both the venous and the biliary branches ; others again as- 
 sume that there is only one kmd of cirrhosis, that the interstitial 
 inflammation of the liver involves at the same time both the 
 branches of the vena portye and the biliary ducts and that it 
 
— 189 — 
 
 only predominates to a greater extent in one case around the 
 first, in the other case around the second, but that eventually 
 it spreads everywhere. The clinic proves the following : there 
 are, iirst, cases of cirrhosis, which present only results of im- 
 peded venous circulation in the liver (as ascites, enlarged 
 spleen, diarrhoea, intestinal as well as gastric haemorrhages) 
 without an arrest in the flow of bile ; second — cases, in which, 
 on the contrary, the last condition is observed, without any 
 disturbance of the circulation of the portal vein ; and third, 
 - — such, where both classes of symptoms are to be seen. It 
 appears then, that the clinical data are in greater accord with 
 the first of the above-named views, which was first promulgated 
 by the French investigators Charcot, Hanot and others ; the 
 second one is defended by the Germans. 
 
 It is also from an etiological point of view more probable, 
 that m some cases the exciting agencies of the inflammation 
 reach the liver through the blood vessels, in others through 
 the biliary ducts (from the intestinal canal) and in others 
 agam contemporaneously through both tracts. The fact, that 
 the interstitial inflammation, originating at one point, for in- 
 stance at the biliary ducts, and accompanied at the beginning 
 only by signs of an arrested flow of bile, may later on spread 
 also over the circumference of the system of the vena portse 
 and give rise to phenomena of disturbed circulation in this 
 last, can surely not serve as a proof that the process com- 
 menced everywhere at one and the same time. I will also 
 say that in cases of cirrhosis accompanied by disturbances of 
 the portal venous circulation, the liver is sometimes very much 
 diminished in size (the cirrhosis first described by Laennec, 
 called by his name), at other times it is greatly enlarged. 
 Some think that such an enlargement takes place only at the 
 beginnmg, and that later on it is followed by a diminution 
 m size, and that if this decrease does not take place, it is to 
 be ascribed to the fact that the exhausted patient does not 
 last long enough for this process to develop. 
 
 As a matter of fact, it has been proved by various investi- 
 gations that the liver, enlarged at the beginning, undergoes 
 a process of shrinkmg later on. But we much more frequently 
 
— 190 — 
 
 meet cases, in which the liver remains enlarged up to the 
 patient's death, although the patient may live long enough, 
 even longer, than those with a small liver, and we cannot 
 therefore assert, that such an enlarged liver always undergoes 
 diminution later on. The pathologo-histological investigations 
 fail as yet to clearly elucidate this point. 
 
 Thus the clinic presents the following forms of cirrhosis : 
 1. Venotis, or cirrhosis accompanied by the phenomena of dis- 
 turbed venous portal circulation, in which the liver is either 
 extremely dimmished in size (Lcennec or atroijldc cirrhosis^ or 
 very much enlarged (hypertrojjliic venous cirrhosis, by which 
 we mean a hypertrophy of the connective tissue of the liver, 
 while its glandular element, the hepatic cells, are always af- 
 fected in cirrhosis). 2. Hypertroijhic biliary cirrhosis, accom- 
 panied by phenomena indicating the retention of the bile, and 
 3. Mixed cirrhosis, with symptoms of both. What form of 
 cirrhosis does our patient suffer from? The first impression 
 of the case, the jaundice and the ascites would suggest a mixed 
 cirrhosis ; but a further investigation will lead us to another 
 conclusion. As evident from the anamnesis, there appeared 
 repeatedly in our patient after a drinkmg debauch and a faulty 
 diet, an attack of jaundice contemporaneously with pronounced 
 signs of a severe gastric catarrh (dyspepsia, pains, vomiting), 
 while a corrected diet and treatment caused their disappearance 
 at one and the same time, so that it (the jaundice) undoubtedly 
 depends on a catarrhal condition of the great biliary passages. 
 It is true, that this last, being present for a long time or recurring 
 frequently, may also spread over to the small biliary ducts and 
 thus give rise to inflannnation of the connective tissue around 
 them, i. e. it may bring about a condition of biliary cirrhosis, 
 but the investigation of the given case speaks against the 
 presence of this last, for the jaundice has so rapidly yielded 
 to the regimen and treatment, and particularly to the calomel, 
 which it usually fails to do in biliary cirrhosis (the phenomena 
 of impeded flow of bile in this yield to successful treatment 
 much slower). Consequently our patient has venous cirrhosis 
 and of the hypertrophic form at that (the liver is much enlarged) 
 and at the same time also catarrh of the biliary passages, cho- 
 
— 191 — 
 
 langitis catarrhalis. There are no symptoms of biliary calculi. 
 The febrile condition of the patient, which accompanied the 
 jaundice and disappeared with it at the previous, as well as at 
 the present, sojourn of the patient in the clinic, seems evidently 
 to be due to the just mentioned cholangitis. 
 
 Treatment. — In view of the discussions conducted m the pre- 
 vious lectures, it is, of course, superfluous for me here to enter 
 into particular explanations regarding the use of calomel, of 
 Ems, the bitters and the stimulating drops durmg the patient's 
 first sojourn in the clinic, as well as of calomel and the stimu- 
 lants (together with the diuretics, as wine, the above-named 
 drops and the caffeme) employed at the present time. After 
 the calomel the high temperature fell rapidly, and for the 
 last few days the patient had no fever at all; at the same 
 time there took place a pronounced and considerable dimmu- 
 tion of the icterous phenomena and the dyspepsia disappeared. 
 Thanks to the effect of the stimulants the pulse became 
 stronger, but the quantity of urine was not perceptibly in- 
 creased, while the most threatening symptom — the ascites, 
 so distressing to the patient, causing such a disturbance of 
 the breathing and of circulation — became more aggravated, so 
 that in the near future we shall have to resort to operative evac- 
 uation of the peritoneal cavity. We will agam administer to-day 
 to our patient some calomel, as he again had a slight chill and 
 the jaundice has not passed away ; we may also expect a diu- 
 retic effect from the calomel. We will, of course, continue the 
 wine, the above-named drops and the caffeine in increased 
 doses. The other diuretics, as potassium acetate and the strong 
 ones (as adonis vernalis, squilla, etc.) are unsuitable for the 
 present case on account of the diarrhoea (after the calomel 
 the patient's bowels move better, not worse). However, the 
 irresistibly advancing ascites can hardly encourage us to hope 
 for a considerable effect of the diuretics, and the performance of 
 paracentesis abdominis is inevitable. 
 
 Prognosis. — A fully developed venous cirrhosis of the liver, 
 hypertrophic and atrophic, is incurable in the present condition 
 of therapy ; not one of the tried remedies, among them also the 
 iodine preparations, realized oui' expectations : the rarely ob- 
 
— 192 — 
 
 served cases of effective action of these last remedies are very 
 likely due to the fact, that these cases present a mixed cirrhosis, 
 from alcohol and syphilis. Given a relatively favorable condi- 
 tion of the other organs and good surrounding circumstances, 
 we may succeed in prolonging the patient's life by keeping in 
 good order the digestion, circulation and the secretion of urine 
 and by operative evacuation, at times, of the peritoneal cavity. 
 The greatly disturbed condition of our patient's health gives us 
 but small encouragement for considerably prolonging his life. 
 
 FROM THE LECTURE OF MARCH 27, 1892. 
 
 After the second administration of calomel there was no 
 fever, the secretions are sufficiently colored, the biliary pigment 
 disappeared from the urine and the sclerotic became clear, but the 
 ascites progresses further and it becomes necessary to tap the 
 abdomen to-day. 
 
 The further history of the disease. — March 27th we obtained 
 by tapping 2500 c.c. of limpid, lemon-colored fluid of a purely 
 transudative character; this afforded the patient considerable 
 relief. Since April 1st patient became delirious (the delirium 
 simulates delirium potatorum). At the entreaties of his 
 parents patient left the clinic, April 4th, for his home. At 
 the end of the month he again returned to Moscow and was 
 examined by the clinical assistant under whose care he was 
 formerly : the delirium disappeared, there is not a trace of 
 jaundice (the hemeralopia and the systolic murmur disap- 
 peared) ; there is enormous ascites and oedema of the legs ; 
 by tapping 3000 c.c. were drawn ; investigation showed that 
 the liver is just as enlarged and solid as it was during the 
 patient's sojourn in the clinic. Patient went home, returned 
 to Moscow at the beginning of June again with an enormous 
 ascites and oedema of the legs. Again 2500 c.c. were drawn, 
 he was given sodium iodide (20-50 gr.) and six glasses of 
 milk per day : the result of this treatment in two weeks 
 amounted to absolutely nothing, and the accumulated ascites 
 again necessitated tapping, by which 3000 c.c. were drawn. 
 Patient has gone home and we have lost track of him smce. 
 
EIGHTH CASE. 
 
 FROM THE LECTURE OF DECEMBER I, 1889, 
 
 The patient, a peasant eighteen years old, complains of pam 
 in the right hypochondrium, of jaundice of one and one-half 
 years' duration and of general weakness. 
 
 Mode of living and anamnesis. — P'or the last ten years pa- 
 tient has Lived constantly without intermission in Moscow 
 (formerly lived in a village), all the time in damp and cold 
 rooms (usually m a basement) ; does not bathe in the river, takes 
 a weekly steam-bath. His board is tolerably good. Has been 
 addicted to drinking whiskey for the last two years. His oc- 
 cupation is that of a shoemaker, he works from morning till 
 evening, and, except holidays, is seldom out-of-doors. 
 
 Patient enjoyed good health until two years ago. Since 
 then, as I said before, he began to drmk whiskey ; six months 
 after this he began to feel pain in the right side and soon after 
 there appeared jaundice, which is severely aggravated at the 
 present time. The pain in the right side is of a double nature : 
 it is either constant and bearable, or at times very acute, lasting- 
 three to four hours. The attacks of this last pain became more 
 frequent and more acute in the course of time, and have been 
 accompanied of late by vomiting (evidently attacks of biliary 
 colic). Patient grew thin and weak and was admitted to our 
 clinic November 27th ; he was never treated before. He denies 
 syphilitic infection and presents no signs of it. 
 
 Status. — Patient is of fair constitution; there is very con- 
 siderable emaciation and jaundice of the skm and of the 
 sclerse. The appetite is good ; patient digests daily about 
 three-fourths of a pound of meat, one-half pound of bread, two 
 eggs and two plates of soup, without the least dyspeptic signs, 
 and even begs for more food. He is somewhat constipated: the 
 
— 194 — 
 
 evacuations are diy, fetid and apparently not at all colored 
 'by bile. The urine contains a moderate quantity of biliary 
 pigment, but neither sugar nor albumen ; to judge by the 
 absence of color in the secretions, pointing to a failure of the 
 bile to pass mto the intestines, we should expect a darker dis- 
 coloration of the urine (an mdication that the glandular ele- 
 ments of the liver, the hepatic cells, are already affected and 
 hindered in their activity). The spleen is normal. The liver 
 is enlarged, more solid than normally, but of regular outlines 
 and smooth, and very sensitive to pressure. The organs of 
 respiration and circulation, as well as the nervous system, 
 present nothing abnormal : the sleep is good. Fever absent. 
 
 Diagnosis. — It is evident, that our patient has biliary calculi 
 and a severe catarrh of the biliaiy passages, — cholangitis catar- 
 rhalis, — to which must be ascribed the pains, the failure of the 
 bile to pass mto the mtestines, its retention in the liver (this 
 again caused the enlargement of the organ and probably an im- 
 pediment also of its bile-formative function and through this of 
 its other activities by compressing the hepatic cells) and gen- 
 eral jamidice. But is this all? Is there no further affection 
 of the liver, and if so, what is its nature? The etiology, 
 the course of the disease and the condition at present show, 
 that such a further affection could be an interstitial inflammation 
 around the minute biliary ducts of the liver, that is, a develop- 
 ment of a hypertrophic biliary cirrhosis (I shall not review the 
 differential diagnosis applied in the former case). We can 
 neither deny nor affirm the presence of such a cirrhosis in tbis 
 case ; on one hand the disease has lasted for a time long 
 enough for a cii'rhosis to develop ; but on the other hand it may 
 safely be assumed that the observed symptoms were caused by 
 cholangitis and biliary calculi. We shall wait for further 
 observations. 
 
 We must also wait with our prognosis, the more so as it 
 always depends not only on the diagnosis (even if clearly 
 defined), but also on the degree of success of the treatment. 
 We cannot, however, deny the fact, that in view of the patient's 
 youth, his good constitution and the healthy condition of his 
 other organs (outside of the liver), as well as because the 
 
— 195 — 
 
 patient did not subject himself to any treatment, his future 
 jjrospects are favorable. 
 
 Treatment. — We will iirst prescribe calomel in a slightly 
 laxative dose, without inducing a diarrhcea ; later on we may 
 employ a mineral water, namely Karlsbad, as the patient is 
 inclined to be costive ; in the former case, with a tendency to 
 diarrhrea and weakness on the part of the patient. Ems was 
 prescribed. We will also order for the patient one or probably 
 more warm baths. 
 
 FROM THE LECTURE OF DECEMBER 12, 1889. 
 
 Status. — December 3d, 4th and 5th patient took four one- 
 grain powders of calomel daily with the best of results : the 6th. 
 7th and 8th, he had, once a day, sufficient, soft, normally colored 
 stools. The 9th we again observed that the evacuations were 
 poorly colored, and he was therefore given, the day before 
 yesterday and yesterday, four powders of calomel. The effect 
 was again good, but there ajjpeared slight salivation, which we 
 combat with the usual means of rinsing his mouth with potas- 
 sium chlorate and pamting the gums with tra. gallarum; out- 
 side of this, the patient's condition is entirely satisfactory : the 
 appetite is normal, the dyspepsia disappeared, the circulation, 
 respiration and the nervous system are in good order, he feels 
 much stronger ; the urine contams almost no biliary pigment, 
 the acute pains in the region of the liver have almost passed 
 away, the liver itself is almost insensitive, but it has diminished, 
 though markedly, not much so, which circumstance speaks for 
 the presence of a cirrhosis, though of small extent. 
 
 We will certamly give no calomel to-day, but from to-mor- 
 row on he shall take Karlsbad ; later on, in case of necessity, 
 we will again resort to calomel. 
 
 The further Jiistory of the disease. — Patient drank four half- 
 glassfuls of Karlsbad water daily until January 2d, when he 
 left the clinic ; we did not administer calomel any more. By 
 the time he left not only were the evacuations all the time 
 entirely colored and the urine always limpid, containing no 
 biliary pigment, but the general jaundice had almost disap- 
 
— 196 — 
 
 peared, the patient gained eleven pounds in weight (he 
 'weighed 121 pounds on admission, his weight when he left 
 was 132 pounds), and gathered strength; the liver is entirely 
 msensitive to pressure, but it remained of a rather more en- 
 larged size than it would be normally. 
 
 At our insistent advice patient gave up drinking, and about 
 six months later he appeared before our clinical assistant in the 
 same satisfactory condition, as he enjoyed when leaving our 
 clinic. 
 
 Thus the dxth case presents biliary calculi and cholangitis, 
 the sevew^A — hypertrophic venous cirrhosis and cholangitis, the 
 eighth — hi\idi,v J calculi, cholangitis and a slight hypertrophic 
 biliary cirrhosis. In my article on calomel the reader will find 
 not only a fully characteristic, but also a very severe case of 
 hypertrophic biliary cirrhosis, which however, terminated favor- 
 ably. 
 
NINTH CASE. 
 
 FROM THE LECTURE OF NOVEMBER 16, 1890. 
 
 The patient, a peasant twenty-nine years old, was admitted 
 to the clinic a week ago, complaming that the abdomen " swells 
 up," and that he is weak ; he added, that he was once before 
 taken care of in the hospital, where he was told, that his 
 disease is called echinococcus of the liver. 
 
 Mode of living and anamnesis. — -During the last year, on 
 account of his illness, patient has been liviug m a village of 
 the Ryazan Government, in a healthy locality ; formerly he 
 lived alternately in both Moscow and in the village, under the 
 ordinary conditions of life of a peasant and of a workingman. 
 While in the country his occupations are those of a peasant; 
 in the city he is a joiner. He drank but little whiskey. He 
 is married and has several children ; his wife never aborted. 
 
 Patient comes from a healthy family and until the last four 
 years enjoyed good health. Four years ago he began to notice 
 a swelling in the right hypochondrium, which was painless, 
 
 but kept constantly growing, until he was finally so much 
 hindered in his occupation and movements, that three years 
 ago he entered the hospital, where they performed an oper- 
 ation, drew the fluid and told him (he has a distinct recol- 
 lection of the name) that his disease was called echino- 
 coccus of the liver. He remained in the hospital for seven 
 months and left without a trace of the former swelling. The 
 next year and a half he enjoyed good health; but about a 
 year ago he again observed a swelling in the right hypochon- 
 drium, somewhat painful at that time, which also began to grow 
 in size and interfered with his work ; at the same time patient 
 began to grow thin and weak. Two weeks ago the swelling 
 suddenly diminished, and almost disappeared, but at the 
 
— 198 — 
 
 same time tlie abdomen began to swell rapidly, it l)ecame pain- 
 ful and there appeared chills, fever and diarrhoea; he had some 
 ten liquid stools daily ; in the course of two days the fever 
 and the diarrhcea passed, and soon the abdominal pains quieted 
 down, but the abdomen began to increase m size ; the patient 
 then came to Moscow and entered our clmic. 
 
 Status at the day of admission. — The appetite is good, but the 
 patient eats little at a time ; otherwise he feels uncomfortable, as 
 respiration grows difficult. Outside of this there are no dyspep- 
 tic phenomena; stools regular. The quantity of urine is 1100 
 c. c, containing neither albumen nor sugar. Tliere is a pro- 
 nounced ascites of considerable size (distinct fluctuation) : the 
 circumference of the abdomen at the level of the umbilicus 
 is 98 c. m., the distance between the anterior superior spine of 
 the ileum and the umbilicus is 28 c. m. The tension of the 
 stretched abdominal walls does not permit of palpatmg the liver. 
 There are neither pains nor sensitiveness on pressure m the ab- 
 domen. The diaphragm is very much raised. There is dysp- 
 noea on moving around, breathing while in a state of rest is 26 ; 
 pulse 76, regular, but weak ; outside of this there is nothing ab- 
 normal in the organs of respiration and cu-culation, as well as in 
 the nervous system, except that the sleep is not sound on ac- 
 count of the large size of the abdomen, which hinders motion 
 and freedom of abdominal breathing. Fever absent. The pa- 
 tient, as I said before, has grown weak and thm. He denies 
 syphilitic infection, nor are there any indications of it. 
 
 The patient was placed amidst normal conditions of life, the 
 abdomen was protected bj' flannel, and he was given internally 
 potassium acetate as a diuretic, and six to eight tablespoonfuls 
 of port wine per day. 
 
 Status to-day. — Patient feels somewhat better : his breathmg 
 became freer, his strength mcreases, and the sleep is also 
 better ; the dimensions of the abdomen do not present any 
 marked decrease ; the quantity of urine has almost doubled 
 (2000 c. c). 
 
 Diagnosis. — It is evident, that within the last year there agam 
 formed ui our patient an echinococcus bladder, which burst 
 into the peritoneal cavity, and probably, at the same time, also 
 
— 199 — 
 
 into the intestines. The absence of severe pains and of fever for 
 the time — one year — the disease lasted speaks agamst its being 
 an abscess of the liver : the pains were very trifling, while there 
 was no fever at all ; the appetite remained always good, but the 
 patient could not eat as much as he desired, in view of the pres- 
 sure exerted by the enlarged liver on the stomach, and he there- 
 fore grew thin and weak. Tlie emptying of the contents of the 
 echinococcus bladder into the peritoneal cavity caused a slight 
 peritonitis, which soon passed, but it produced ascites. 
 
 Treatment. — Accumulations m the peritoneal cavity do not 
 in the majority of cases yield to internal treatment, but require 
 operative interference — either radical, or, in case of impossi- 
 bility, palliative, namely, the drawing off of the fluid. Fortu- 
 nately m the present — very rare — case, the condition is more 
 favorable. The phenomena of peritonitis were so trifling (the 
 pains were not of an acute character, there was no vomiting, 
 the fever was slight), and passed away so rapidly, that we hope 
 for a favorable, hardly at all changed condition of the perito- 
 neum, and consequently may expect a possible absorption of 
 the accumulated fluid. That part of the liver, which escaped 
 the invasion of the echmococcus, performs its functions normally, 
 as evidenced by the regular digestion and the fact, that the in- 
 testinal evacuations are well colored by the bile ; consequently 
 we may hope for a sufliciently free circulation in the liver, and 
 therefore also in the portal system. The appetite is good, the 
 stomach, intestines, kidneys and the other organs are healthy. 
 
 All these circumstances encourage us to hope for the possible 
 absorption of the fluid accumulated in the peritoneal cavity ; it 
 would therefore be erroneous to resort at once to the operation, 
 befo're first attempting internal remedies. 
 
 Having surrounded our patient by correct hygienic conditions, 
 we prescribed a diuretic to encourage the absorption of the accu- 
 mulated fluid. Sudorific treatment, as, for example, warm baths, 
 pilocarpine, would tend to weaken the heart's action and would 
 thus, instead of encoiiraging absorption, rather add to the accu- 
 mulation ; not to speak of the fact, that in the patient's condi- 
 tion, with his difficultly performed respiration and circulation, 
 such treatment would become dangerous ; while treatment by 
 
— 200 — 
 
 the aid of laxatives would tend to disturb digestion and nutri- 
 tion, thus aggravating, mstead of improving, the patient's con- 
 dition. In prescribing the diuretic treatment, we aimed at the 
 two principal agencies of urinary secretion — the heart and the 
 kidneys : for the first we gave the wine, as the patient's pulse 
 was weak, for the second potassium acetate (strong diuretics, 
 as adonis vernalis, squilla, etc., would disturb digestion, and 
 weaken the patient), half a drachm per day, thus: IJ. — Potas. 
 acetatis 3j, aquse petroselini jvj, for two days, in tablespoonful 
 doses ; this was given during four days, after which it was 
 stopped for two days. 
 
 The condition of the patient is apparently improving, and 
 the plan of treatment will therefore remain as heretofore ; but 
 as the dose of the potassium acetate — 3ss. for a whole day — is 
 rather small, and the patient bears it well, we will increase the 
 dose to one drachm per day: I^. — Pot. acetatis 3ij, aquae petro- 
 selini jij, for two days, in tablespoonful doses. As before, we will 
 interrupt the administration of the drug after four days for two 
 days : thus the power of digestion will more certainly be 
 preserved in a good condition, nor will there be formed a habit 
 for the drug, which would bring on a weakened effect of this 
 last on the patient. 
 
 FROM THE LECTURE OF DECEMBER 12, 1590. 
 
 Status. — Patient declares that he feels entirely well. As 
 a matter of fact, his appetite is good, digestion regular, the 
 quantity of urine 2000 (it even reached 3000), the spleen 
 is normal, the abdomen is of normal dimensions, its circum- 
 ference is 72.5 cm., the distance from the superior spine 
 of the ileum to the umbilicus is 15 cm., the diaphragm is at 
 its normal position, there are no traces of any former accumula- 
 tion, the respiration, circulation and the nervous system are 
 in a normal condition, the patient became stout and quite 
 strong. The liver is entirely insensitive and is markedly 
 enlarged in its left lobe ; nothing abnormal to be noted in the 
 right one. Echinococcus bladders are most frequently found 
 
— 201 — 
 
 in the right lobe of the liver: limited functional activity of 
 this portion of the organ may bring on an increase in the func- 
 tional activity and hypertrophy of the left lobe. 
 
 The patient was told of the possible failure of a fresh forma- 
 tion of the swellmg, but in case of its reappearance he is to 
 apply at once for medical aid. 
 
TENTH CASE. 
 
 FEBRUARY, 1890. 
 
 The patient is thirty-three years old and was admitted to our 
 clinic February 3, 1890, complainmg of pams in the right side 
 and of difficulty in breathing. 
 
 3Iode of living and anamnesis. — Patient is a resident of 
 Moscow, inhabits fair lodgings, the water-closet is cold. Fre- 
 quents public baths ; is subject to sweating-. His occupation 
 is that of a foreman at a railroad station : he is a bookkeeper 
 and superintends the reception and delivery of goods ; this 
 occupation is not a fatiguing one. He is married, but his wife 
 had no children. Has strongly abused alcohol since his twenty- 
 third year, but since his illness, from July of last year, he gave 
 up drinking altogether. 
 
 In December 1877, patient became infected with syphilis, and 
 was treated for two months with potassium iodide, and one 
 year later he entered the hospital m St. Petersburg, where he 
 was treated with mercurial inunction, and also with potassium 
 iodide. Since then, in the course of the next ten years, up to 
 the summer of 1889, he observed nothing to require a resort 
 to treatment. During the summer of 1889 he began to ex- 
 perience heaviness in the abdomen and d3'spnoea, and soon after 
 that pains in the right hypochondrium aggravated at night- 
 time and on movmg around. The patient left off drinking 
 abruptly ; after this the appetite grew worse, and he began to 
 grow thm and weak, the dyspnoea increased, and he became 
 costive. At the advice of his physician, w^ho already at that 
 time detected a considerable enlargement of the liver, he drank, 
 during one month, Yessentucki waters No. 17 and took laxa- 
 tives, but without any avail. Since September 1889, patient 
 was treated during three weeks in the hospital with mercurial 
 
— 203 — 
 
 inunctions — altogether about ten times — and with potassium 
 iodide internally, and later on took the same, without increasmg 
 the dose, at home for another three weeks ; the pain improved 
 for some time. From that time on until his admission to the 
 clinic the patient was not treated, and his condition continued 
 growmg woi'se. 
 
 Status on February Sd. — Patient is of a strong constitu- 
 tion. Appetite fair, but patient eats little, as the feeling of 
 heaviness in the abdomen becomes aggravated after a meal. 
 There is no dyspepsia. He is very costive. Urine shows ab- 
 sence of albumen and sugar. The abdomen is enlarged, there is 
 slight ascites. The spleen is somewhat enlarged ; the liver 
 very much so : on percussion the superior border is higher than 
 normally, while the free border is palpated at a distance greater 
 than the width of the palm below the costal edge ; it is moreover 
 not sharp, but dull to the touch ; there are no other alterations 
 in the shape of the liver ; it is more solid than normally, and 
 besides, it is sensitive to pressure all over ; the mobility of the 
 liver in respiratory movements is of slight extent. There was 
 no jaundice before, nor- is there any at present. The heart is 
 displaced upward, its tones are clear, the pulse — 66 — is weak, 
 there is some dyspnoea. The organs of respiration present 
 nothing abnormal ; there is no fever. The patient is very weak 
 and thin. The impeded breathing and the nightly exacerbation 
 of pains on the side of the liver prevent sound sleep. The 
 head, and especially the occiput, aches while patient is consti- 
 pated, but the pam is relieved by a good evacuation of the 
 bowels. 
 
 Diagnosis. — If certam persons, who are habituated to drink- 
 ing -strong alcoholic drinks for a long time, leave off the habit 
 abruptly, then as a consequence there appears a whole series of 
 disturbances : the appetite is impaired, the patient has either 
 constipation or diarrhtjea instead of the former regular evacua. 
 tion of the bowels, the pulse grows weak, there appears 
 dyspnoea, the patient grows thin, sleeps badly and weakens 
 physically and mentally. As seen from the anamnesis, some of 
 the disturbances observed in our patient are undoubtedly of 
 such an origin, while the others depend on an evident disease 
 
— 204 — 
 
 of the liver : this last is very much enlarged and sensitive, and 
 •the ascites and the enlarged spleen speak of impeded circulation 
 in the portal system. 
 
 What hepatic disease is to be found in this case? The 
 anamnesis, and partly the symptoms, as the regular aggra- 
 vation of the hepatic pains at night, pomt to syphilis as the 
 immediate cause of the affection of the liver ; we cannot at the 
 same time deny the influence of a prolonged abuse of alcohol. 
 With such data on hand and in view of all that we said.^ while 
 discussmg the foregoing cases, regarding the diagnosis of dis- 
 eases of the liver in general and their differential diagnosis in 
 particular, there seems to be no reason to further discuss the 
 exclusion of other affections of the liver in this case. Of the 
 two affections, the presence of which is possibly indicated by 
 the anamnesis, which is more probable, the syphilitic or the 
 alcoholic ? The data which speak for syphilis of the liver are 
 incontestable : the liver is pamful, which is only to a slight 
 degree the case in alcoholic affection of the org^an ; the pains are 
 aggravated at night-time, specific treatment relieves the pains, 
 and the liver is very much enlarged (this again is but to a 
 slight extent the case in the alcoholic affection of the liver) ; 
 there are no dii'ect indications of the existence also of an 
 alcoholic affection of the liver (as impeded portal venous circula- 
 tion is also peculiar to syphilis of the liver), but we simply can 
 not deny the possibility of its existence in the given case. 
 
 What is the nature of the sj^Dhilitic affection in the given 
 case? There is* first of all an mdication of a syphilitic perihe- 
 patitis, namely : tenderness of the liver, the aggravation of pains 
 at night-time, and the restriction of the respiratory movements 
 of this organ ; however, the value of this last symptom is les- 
 sened by the fact, that m the presence of an enlarged liver and 
 of tension of the abdominal walls, the respnatory movements 
 of this organ are liable to be less free than under normal con- 
 ditions, even if we exclude the possible adhesions due to the 
 perihepatitis. There are no iiidications of any considerable 
 gummatous swellmg, as the surface of t^ie liver is smooth. 
 There remain, therefore, out of the number of various sj'^philitic 
 affections of the liver, minute disseminated gummatous new 
 
— 205 — 
 
 formations, disseminated interstitial hepatitis and its result in 
 the form of cirrhosis of the liver, to which in this case we must 
 ascribe the enlargement of this organ. Which of these just 
 mentioned aif ections prevails is rather diificult to say : the 
 symptoms of impeded portal venous circulation pomt to an 
 already existing cirrhosis. 
 
 Prognosis. — The pams in the liver, caused by the perihepa- 
 titis, yield readily to specific treatment, especially to the iodide 
 preparations. But the prognosis is most favorable, when there 
 are gummatous swellmgs, even if considerable, but without af- 
 fections of other parts of the organ ; in such a case complete 
 cure is possible. Much worse is the prognosis in diffuse mter- 
 stitial hepatitis and in the cirrhosis of the liver resulting there- 
 from : here the success of the treatment is liable to be rather 
 insignificant and of short duration ; if aggravated, after a tem- 
 porary improvement, the disease yields with greater difficulty to 
 treatment and usually termmates in death. The same process 
 evidently takes place in the liver, as in the nervous system (and 
 probably also in the other organs), namely, an outspoken syphilit- 
 ic affection (gummatous? — as in the nervous system, in case of 
 lues of the brain and spmal cord), which yields completely to 
 specific treatment, and also such, in which the connection with 
 syphilis is apparent (as shown from the statistics of the affections 
 of the nervous system, progressive paralysis and tabes dorsalis), 
 but in which the specific treatment falls short of havmg this ef- 
 ffect. The prospects, as regards the termuiation of the disease in 
 our patient, who presents such evident symptoms of affection of 
 the ivhole liver and together with this also symptoms of an 
 already progressive impediment in the portal venous circulation, 
 are certamly not favorable ; but as the patient was never sub- 
 jected to a continuous, sufficiently persistent and intensive 
 treatment, the last word in the prognosis will depend on the 
 treatment. 
 
 Treatment. — Having surrounded the patient by regular hy- 
 gienic conditions, we will prescribe for him some strong wine, 
 as the pulse is weak and the patient at the present more than 
 at any other time is m need of his habitual stimulus : for the 
 constipation, — watery clysters, and for the principal affection 
 
— 206 — 
 
 specific treatment, at the beginning iodine in the form of sodium 
 •iodide. We will give him the iodide, and not mercury, first, 
 because m the last stage of syphilis, which, as seen from the 
 anamnesis and from the very nature of the sj^philitic affection, 
 our patient is passing through, iodide is more applicable ; and 
 secondly, because the patient's health has become greatly im- 
 paired, and the mercurial treatment by itself is more liable to 
 weaken, than the treatment with iodides ; and thirdly, because 
 the syphilitic pains particularly yield readily and rapidly to the 
 iodine treatment. We will administer the sodium iodide in an 
 alkaline mineral water, as in Vichy, one and one-half glasses per 
 day because the iodides are better borne by the organism when 
 dissolved in it, and also because our patient's urine is red, very 
 acid and saturated with uric acid salts. In such cases as the 
 present one, the iodine preparations are to be administered, as 
 experience teaches, in constantly increasmg and generally large 
 quantities. We will be guided in our further treatment hj the 
 results of the iodine treatment. 
 
 Status on February 28th. — The patient took sodium iodide 
 as follows : 
 
 February 4th, 20 gr. ; February 5th and 6th, 30 gr. each day ; 
 February 7th to 10th, -tO gr. each day; February 11th to loth. 
 50 gr. each day ; February 16th to 20th, 60 gr. each day ; Febru- 
 ary 21st to 28th, 70 gr. each day. 
 
 The iodide was administered in solution (3ij in fvj aquse 
 dest.) in tablespoonful doses, with the addition in the begmning 
 of a small quantity of Yichy-Celestins, and later — in view of 
 a beginning looseness of the bowels — of Ems-Kesselbrunnen, 
 about one and one-half glass per day. 
 
 To-da}' the patient announces that he feels so well, that, ap- 
 prehending the possible loss of his situation, he mtends to leave 
 the clinic. His condition is as follows : the appetite is very 
 good, bowels move regularly (the clysters were necessary only 
 during the first daj^s of the patient's sojourn at the clmic), the 
 quantity of urine is greater, it is limpid and not red, all the 
 pains disappeared, the pulse is better, the sleep is good, patient 
 gathered considerable strength, the liver is entirely painless, 
 but it has dimmished in size but very little, and so did the 
 ascites. 
 
— 207 — 
 
 The patient was inforined of the seriousness of his condition ; 
 he was told, that, although the pams have disappeared, the ap- 
 petite and sleep improved and he became stronger physically, 
 still the most important and the most dangerous symptoms — • 
 namely, the enlargement of the liver and the ascites, have not 
 yielded markedly to the iodide treatment; that the treatment 
 must be continued persistentl3% and that at present he must be- 
 gin the mercurial treatment ; he was made to understand, that 
 a correct employment of such a powerful drug as mercury, to 
 avoid any risk of harm, is onl}- possible under immediate medi- 
 cal supervision and under suitable circumstances, namely, m the 
 Hospital, and that any postponement of this treatment will 
 exert a dangerous tendency as regards a favorable termination 
 of the disease. The patient insisted that he must return to his 
 occupation and that he would try to be treated at home ; he left 
 the cluiic the next day. 
 
 The further hhtory of the disease. — Patient continued taking 
 sodium iodide during March in small quantities and irregularly, 
 but up to June he felt almost as well as he did on leaving the 
 clinic. Since then there reappeared the severe pains in the 
 right side, and the patient began to take calomel, four powders 
 a day (the dose is unknown ; he had slight looseness of the 
 bowels) in the following manner : one week calomel, the next 
 week none ; during this time rinsed his mouth with pot. chlor. 
 and his gums were not affected. Tliis treatment was continued 
 through June, July and August. The patient improved some- 
 what and his tolerable condition contmued up to February 1891, 
 when the right side became agam painful, the abdomen began 
 to enlarge rapidly, and later on the legs began to swell. Feb- 
 ruary 18th patient again entered our clinic. 
 
 Status on February ISth. — Appetite very poor; there is 
 properly speaking no dyspepsia, but the nausea and vomiting- 
 are rather of ursemic nature, as they take place not after a meal, 
 but in connection with heavmess in the head and with paui. 
 There is at times constipation, at other times diarrhoea. The 
 urine contains a considerable quantity of albumen, and also 
 some cylmders — hyaline and granular ; the quantity of urine 
 in twenty-four hours is 500 c. c. The ascites is great, while the 
 
— 208 — 
 
 oedema of the legs extends up to their middle ; the spleen does 
 •not admit of palpation. The liver is in the same condition in 
 which it was a year ago, the tenderness on pressure is not con- 
 siderable. The heart is displaced upward, the pulse is 96 and 
 weak. The respiratory organs are normal. Fever is absent. 
 The sleep is very poor. The patient became very much ema- 
 ciated and weak. 
 
 Treatment. — Correct hygienic conditions, wine, and an injec- 
 tion when necessary. As the patient has been treated for a 
 long time with mercury, and has not taken any iodide for almost 
 a year, we prescribed for him sodium iodide, at the beginning in 
 a small quantity of Ems water, and later on in boiling milk. 
 As the tendency to diarrhoea increased while the iodide was 
 being administered, we also gave at the same time ten to twenty 
 drops of tra. coto four times a day, which enabled us to con- 
 tinue the administration of the iodide for six weeks, and to in- 
 crease the dosage to ninety gr. per day ; but there was no im- 
 provement: February 27th we had to di'aw 3000 c. c. of 
 fluid of a purely transudative character from the peritoneal 
 cavity. Smce March 19th we added to the sodium iodide also 
 mercurial inunction — a half-drachm of mercurial ointment per 
 day. March 25th, however, we were again compelled to draw 
 3,000 c. c. By the end of March the specific treatment with 
 the iodide, as well as with the mercury, was discontinued (we 
 made altogether about ten inunctions) and we contmued to 
 strengthen him as much as possible. April 12th patiei^t left 
 the clinic in the same condition in which he was admitted ; the 
 accumulation in abdominal cavity, after the last tapping, did 
 not as yet reach the former dimensions, but it continued on the 
 increase. 
 
RHEUMATISM AND GOUT. 
 
 ELEVENTH CASE. 
 
 LECTURE OF NOVEMBER 29, 1889. 
 
 The patient, a peasant water-carrier, twenty-five years old, 
 was admitted to the clinic, complaining of severe pains m the 
 articulations, loss of appetite and weakness. 
 
 Mode of living and anamnesis. — Patient lives in ^Moscow. 
 His lodgings are very warm, the water-closet cold. Goes 
 often to public bathing house and drinks a great deal of hot 
 tea ; is very much subject to sweating. Is a moderate whiskey 
 drinker. His food is that of an ordinary workingman. He 
 works hard and is very much fatigued at the close of the day. 
 He is smgle. 
 
 Until the present sickness the patient always enjoj^ed good 
 health, except that he suffered with headaches, which appeared 
 at the hot season of the year during field labor, and which 
 passed away accompanied by nasal hgemorrhages. A week 
 ago, November 21st, the patient became strongly chilled, and 
 in the evening he experienced chills, fever and pain in the 
 articulations; he took no tieatment, and until his admission 
 to the clinic, November 27th, he grew worse and worse. No- 
 vember 27th and 28th the patient was given seven ten-grain 
 powders of sodium salycilate in Ems-Kesselbrunnen water, 
 after which he had considerable tinnitus aurium, but the pains 
 were very much relieved and he was not given any more of the 
 salycilate. The painful articulations were rubbed with warm 
 olive oil and wrapped in cotton. 
 
 Status. — The appetite has reappeared, there is no dyspepsia, 
 stool regular. The urine, formerly red and quite saturated, 
 became limpid ; it contains neither sugar nor albumen. The 
 
— 210 — 
 
 liver and spleen are in a normal condition, as well as the organs 
 of respiration, circulation and the nervous system. His tem- 
 perature on admission was 38.2° R. (100.7° i^.) ; at present it is 
 36.8° R. (98.2° F.'). When admitted patient perspired freely, 
 now he perspires but little. On admission, all the joints (except 
 that of the hip) of the lower extremities were affected, also both 
 the elbow jouits : the pains were acute and the patient avoided 
 any movement ; a slight swelling onlj^ was noticed at the articu- 
 lations of the knees. At the present time all the pains are con- 
 siderably relieved, but they are felt as yet to some extent where- 
 ever they were before ; the swelling of the knee-jomts disap- 
 peared. The noise in the ears continues as yet, but to a very 
 much lesser degree. 
 
 Biagyiosis. — It is evident that our patient suffers from acute 
 articular rheumatism. This is shown, outside of the charac- 
 teristic picture of the disease, by the acute beginning of this 
 last in an organism previously healthy, in the presence of the 
 equally peculiar in this disease predisposmg conditions, as a warm 
 lodging, frequent hot baths, hot tea, proclivity to perspiration, 
 constant fatigue from physical labor, and finally a cold, and 
 also by the decided effect of the salycilate of sodium, which 
 serves in acute articular rheumatism as hardly less of a specific 
 remedy, than quinme does in malaria. We know of no other 
 disease, that would call out so suddenly such an agglomerate 
 of symptoms and which would so rapidlj^ yield to the salycilate 
 of sodium. 
 
 Prognosis, — The disease is slight and is already passing 
 away, but it is very liable to return, especially under the cir- 
 cumstances surrounding our patient and his mode of living. 
 
 Treatment. — The patient was given the most reliable remedy 
 against acute articular rheumatism, namely, sodium salycilate : 
 you have seen its effects. I usually administer sodium salyci- 
 late in a small quantity (in one or two glasses per day) of the 
 alkaline water Ems-Kesselbrunnen, or, to persons of a strong 
 constitution and with good nutrition and who are, moreover, 
 mclined to gout, m some Vichy-Celestins, because this remedy 
 is borne, if thus admmistered, in the best manner. The pa- 
 tients, who dislike the unpleasant taste of sodium salycilate. 
 
— 211 — 
 
 may take this last in cachets and wash them down with an 
 alkaline water. For acute articular rheumatism I never fail to 
 give sodium salycilate until tiunitus aurium is produced (just 
 as in the ease of quinine for malaria), at times quite strong, at 
 other times, in very severe cases, till very pronounced, watch- 
 ing of course carefully the action of the heart, in which large 
 doses of salycilate of sodium, especially if given for a long time 
 without an intermission, may induce a condition of collapse. 
 Experience taught me to regard such a mode of employing 
 sodium salycilate in acute articular rheumatism (just as quinine 
 is used for malaria) as giving the best results : the disease is 
 mterrupted rapidly and the interruption Ls lasting, the disease 
 is not protracted, and does not return, as in cases where the 
 remedy is given timidly and m small doses, without exerting 
 any positive effect ; this is very important, because the earlier 
 and the more completely the disease is interrupted, the more 
 certain may the patient be of avoidmg the development of 
 its dangerous complications, cardiac and otherwise. As soon as 
 the tinnitus appears to be sufficiently pronounced, as judged b}^ 
 the severity of the disease, I at once discontmue the use of the 
 salycilate. It happens frequently that with the appearance of 
 a sufficiently strong tinnitus aurium the articular pains and the 
 fever disappear not to return, so that the remedy is not given 
 any more. But if the tinnitus has markedly dimmished, but 
 the pains and the fever continue, although to a lesser extent, 
 then immediately prescribe again sodium salycilate. I begin m 
 adults with ten-grain doses every two hours ; but if the case is 
 very severe and this dose be well borne, I rapidly increase it. 
 givB fifteen and later twenty grains every two hours, carefully 
 watching, I repeat again, the condition of the pulse, so that in 
 case of necessity to administer stimulants, as tinctura valer. 
 gether. and liqu. anodyn. Hoffm. aa. 
 
 As I said before, the fever and the swelling of the knee-joints 
 left our patient, and the pains have very much diminished in 
 mtensity, but they are still felt to a slight degree wherever they 
 were formerly, while the tmnitus aurium, on the cessation of the 
 administration of the salycilate, has continually diminished and 
 is now very slight. In accord, therefore, with the above-men- 
 
.„ 212 
 
 tioned rule, we will ag^ain return to this remedy, but without iii- 
 'creasing its dose, because its effect is satisfactory as it is, and 
 the case is a light one. 
 
 Antipyrin is also valuable in the treatment of acute articular 
 rheumatism. There have even been described several cases of 
 the disease in which the salycilate failed, while antipyrin was, 
 successful. I have not met with such cases, and guided by the 
 number of my own observations and those of others, I still con- 
 sider the salycilate of soda as the most reliable drug in the treat- 
 ment of acute articular rheumatism ; besides, antipyrin in large 
 doses is even more dangerous for the heart than is salycilate of 
 soda. 
 
 The severity of some cases of acute articular rheumatism 
 with cardiac and other complications may, of course, be deter- 
 mined by the particularly severe effect of the disease-causing 
 agent, — very likely of a parasitic origin, because acute articu- 
 lar rheumatism is characterized by all the features of an infec- 
 tious and withal acute affection ; but, as I said before, such 
 cases are chiefly to be observed, when the treatment of the 
 disease has been long neglected, the disease not being interrupt- 
 ed at the beginning, and the patient continues to subject him- 
 self to colds (as, for instance, by living in cold rooms, or having 
 a cold water-closet), and to traumatic influences (can not obtain 
 sufficient rest, gets up, or generally moves around). In such 
 cases the sudden breaking up of the disease does not take place 
 and there is no immediate return to health, so that a chronic 
 affection of one or, more frequently, of several articulations is 
 established, which goes under the current name of " chronic 
 rheumatism,''^ — a name which is not correct, is vague and pre- 
 vents the formation of a positive diagnosis, and consequently 
 also treatment, of the various affections, which are all without 
 any differentiation embraced under this term (I shall have yet 
 occasion to return to this subject). The affection, usually of 
 one joint, which was left over, passes often into a condition of 
 severe inflammation, which eventuates into pus-formation ; this 
 last circumstance points to a superadded secondary infection by 
 pyogenic microorganisms. 
 
 Chronic affections of the jouits, remaining after acute articu- 
 
— 213 — 
 
 lar rheumatism, are often found also in cases in wliicli it attacked 
 not a healthy, but a previously diseased organism, as for instance 
 a tuberculous subject (thus in cases of acute articular rheuma- 
 tism in youthful " scrofulous " persons), or more frequently one 
 suffering with syphilis or gout, or even one with only a predis- 
 position to gout. In view of the coming lectures on " chronic 
 rheumatism " and gout, I wish to stop here to discuss the rela- 
 tion of acute articular rheumatism to the latter disease. 
 
 As proved by facts, gout is the result of an accumulation of 
 uric acid salts in the blood and their deposition — principally 
 that of the acid sodium urate — m various, or perhaps in all the 
 tissues and organs, most frequently in the articulations, in their 
 cartilages and other tissues ; this deposition is the cause of va- 
 rious affections, according to the variety of the affected organs. 
 Whence these uric acid salts accumulate is a debatable ques- 
 tion; but this fact is certain, that such an accumulation is 
 promoted by excessive eating and by the use of wine in the ab- 
 sence of active physical exercise, which means by conditions 
 which weaken in the organism the processes of oxidation. The 
 well-known clinician Ebstein assumes, not without ground, that 
 the deposition of uric acid salts in the joints is chiefly favored 
 by an abundant formation of uric acid in the organs adjacent 
 to the joints, in the bone-marrow and the muscles. Acute 
 articular rheumatism is accompanied by a febrile condition 
 (which causes an increased formation of uric acid) and by abun- 
 dant sweating, so that the urine is greatly diminished in quan- 
 tity, becomes very red and saturated, and gives on standing an 
 abundant sediment of sodium urate. It is well understood, that 
 if such a morbid process, which brings about an increase in the 
 formation and a decrease in the excretion of the uric acid — 
 through a decrease in the quantity of the urine — will affect 
 not only a gouty person, but even one with a predisposition to 
 gout, then this last is bound to make its appearance at once. 
 And as a matter of fact, we often observe the folio wmg : 
 
 A man, say, forty years old, of good constitution, with supera- 
 bundant nutrition and good digestion, a good eater, who imbibes 
 freely and is physically inactive, and who has for a long time 
 past observed that his urine was red, in short a candidate for 
 
— 214 — 
 
 gout, without, however, presenting a suigle local symptom of the 
 same, is suddenly affected by acute articular rheumatism, grows 
 feverish, sweats, and passes some red urine with an abundant 
 brick-dust sediment. Salycilate of sodium is administered cor- 
 rectly and the disease is rapidly interrupted ; the fever and the 
 pains disappear. The patient feels well, but in about two to 
 three days he returns complaining that the " rheumatism " re- 
 turned in the great toe of the right foot and has caused him excru- 
 ciating pam during the whole night. The painful spot turns out 
 to be swollen and red, but all the other joints of the body are en- 
 tirely free from pain and there is no fever ; in short the patient has 
 a typical attack of acute gout and not the least return of acute 
 rheumatism. In other cases of this last in persons suffering 
 with gout or predisposed to it, the fever and the greater number 
 of articular affections disappear on correct treatment, but in one 
 or more of the affected articulations there will remain a chronic 
 disease by this time of a gouty nature. 
 
 The further course of the disease. — The patient took six ten- 
 grain powders more of the sodium salycilate, after which the 
 tinnitus increased, but the pains disappeared and there remained 
 only the general weakness. With the aid of a good appetite 
 the patient improved rapidly, and December 11th left our clinic. 
 During the last days, before dismissal, his whole body was 
 sponged several times with water and brandy, and this strength- 
 ened him. On leaving, he was advised not to take any hot 
 baths during cold or damp weather, but instead to sponge 
 himself as above, and also to drink less of hot tea. 
 
TWELFTH CASE. 
 
 LECTURE OF FEBRUARY 19, J891. 
 
 The patient, a peasant woman, 58 years old, entered onr clinic 
 January 29tli, complaining of pains and swelling in the lower 
 and upper extremities, chiefly in the articulations of the wrist and 
 shoulder, the knee and the ankle, and also in the small articula- 
 tions of the hand and foot on either side. She has had the pains 
 there for the last year and a half ; they are aggravated by 
 movements and make these last extremely difficult. 
 
 Mode of living and anamnesis. — She has been living for the 
 last eighteen months in Moscow ; lived formerly in a village. 
 The lodgings are tolerable, the water-closet cold. Takes a hot 
 bath once a month. Drinks neither tea nor brandy now, nor did 
 she drink any before. Tlie food is that of an ordinary work- 
 ing woman. Was married and had several children ; no abor- 
 tions ; has been a widow for a long time. For the last year and 
 a half has been unable to work on account of sickness ; formerly 
 she did a great deal of very hard labor in orchards. Has always 
 enjoyed good health up to the appearance of the present illness. 
 In the autumn of 1889, while working durmg cold weather in the 
 orchard, she felt pains in the finger-joints of both hands ; she 
 contmued at her work, but the pains increased considerably and 
 to them was superadded swelling of the painful spots, so that 
 it became impossible for her to work. She consulted a phj^sician, 
 who gave her some ointment, and for internal use some sweet- 
 ish powders, evidently of sodium salycilate. She felt relieved, 
 but the disease did not disappear entirely, and prevented her 
 from working ; in such condition it was protracted until the 
 beginning of the last winter (1891), when, with the cold 
 weather, the former pains became worse, while fresh ones ap- 
 peared, accompanied by swelling in the remainder of the above- 
 enumerated affected joints. 
 
— 216 — 
 
 During the three weeks' sojourn of the patient in the clinic 
 ■she drank daily of Yessentucki water No. 17, — at first one and 
 a half, and later one glass per day ; she took several times salyci- 
 late of soda, at fu-st every other day and later every third day, in 
 quantities of twenty and later of forty grains daily, which caused 
 some tinnitus aurium ; and since February 6th, as soon as the 
 affected joints, thanks to rest, warmth and the above-mentioned 
 treatment^ became much less pamful, they were subjected to 
 massage, and later we applied the electric static current : the 
 patient felt much better. 
 
 Status to-day, February 19tJi. — The usual appetite is moder- 
 ate. The stomach, intestines, liver and spleen are m a normal 
 condition. The urine is reddish, without albumen and sugar. 
 Menopause established fifteen years ago. The organs of respir- 
 ation are normal (the slight bronchial catarrh, with which she 
 suffered on entering and which caused some cough, passed away), 
 as well as the organs of circulation, except that the arteries feel 
 somewhat stiff. The patient, somewhat spare for a long time 
 past, has not grown much thinner during the sickness. The 
 temperature on admission was slightly raised, 37.6° (99.7°^.), 
 but it soon became normal. The sleep is good. There are no 
 pains in the head, nor anywhere else outside of the above- 
 named articulations. In these last the pams have considerably 
 diminished and the movements become much more free. The 
 swelling, which was particularly considerable (there is also 
 noticeable some fluctuation) in the wrist and shoulder-joint, as 
 well as in the knee-joints of both sides, has diminished, while the 
 slight redness observed on her admission, and the higher tem- 
 perature in the last-named articulations, have disappeared. 
 
 Diagnosis. — The patient presents a type of what is usually 
 denoted m the text-books of special pathology, in literature 
 in general, as well as in practice, as chronic articular rheuma- 
 tism ; or, if besides the articulations there are also affected 
 other organs of locomotion, as the muscles, nerves and the 
 bones (i. e., all the portions of the bones, and not their articular 
 surfaces only), then it is simply designated as chronic rheuma- 
 tism. I had already occasion to ob3erve that I consider this 
 designation incorrect, vague, and one that prevents the for- 
 
— 217 — 
 
 mation of a positive diagnosis (and consequently treatment) 
 of the various affections, whicli are all, without any differen- 
 tiation, embraced under this name. I will take advantage of 
 the opportunity presented by this case, the only one of its kind 
 on hand at the present time (although there occur others, of 
 a more complicated nature and therefore more suitable for 
 my purpose) to elucidate the basis of my opinion. 
 
 The term rheumatism, having long lost its ancient definition, 
 has even at the present time no concise meaning : by it is 
 meant on the one hand an acute articular rheumatism, — which 
 is a sharply differentiated disease, no less definite than are 
 measles, variola, typhoid, typhus, etc., a disease which must 
 not be confounded with any other, — and on the other hand, 
 cases of the nature of the present one (of the importance of 
 which I shall speak later), as well as more complicated ones 
 that are diversified by the affected organs as well as, princi- 
 pally, by their etiology, and which are, besides, approaching 
 by their many interstitial (in the character of their symptoms) 
 manifestations the affection known as arthritis nodosa sive 
 deformans. Nomenclature must of course avoid unnecessary 
 destruction, it must not intrude on solidly based and univer- 
 sally intelligilDle defuiition.s, nor introduce unnecessarily, be- 
 fore explaining fully the nature of the subject, any new 
 terms; it should, however, strive for precision. If we must 
 preserve the name rheumatism, then it can only be attamed on 
 the condition that we give it a definite designation : and this 
 requisite is fully effected if we preserve this name solely 
 for acute articular rheumatism, a disease, as I said before, of 
 a definitely distinguishable character. The term rlieumatism, 
 as employed formerly in its old definition, will certainly not 
 correspond with exactness either to what we know already, 
 or to what we will probably learn in the future concerning the 
 nature of acute articular rheumatism ; we find the same facts 
 as regards the terms measles, small-pox, scarlatma, plague, etc.. 
 and in their correspondence to the relative diseases. Precise 
 definitions will be possible only when the nature of the enumerat- 
 ed diseases will be laiown with precision, but until that time the 
 hnplanted appellations have more rights to existence and they 
 
— 218 — 
 
 must therefore remain : the name rheumatism for the above 
 alluded to discussed (m the eleventh case) acute aifection of 
 manj articulations is no less firmly implanted than are the 
 names measles, small-pox, etc., for the diseases designated by 
 them, and, I must say again, it refers to a sharply differentiated, 
 definite disease, just as do these terms. 
 
 But if we were to preserve the name rheumatism for acute 
 articular rheumatism, may we then apply it, without depriving 
 it of a defuiite significance, to cases like the present one and to 
 others still more complicated, which I mentioned and of which 
 I shall yet have occasion to speak ? Evidently not — first, be- 
 cause these cases differ one from another, presenting, as we 
 shall see later, different affections origmating from various 
 causes, and secondly, because they are not in the least identi- 
 cal m their nature with acute articular rheumatism. Thus the 
 present case : at the beginning the jomts of the fingers were 
 affected and became swollen, and they have remained so until 
 now ; one yea7' later the other joints became affected, and they 
 remain thus now. Where is here the picture of acute articu- 
 lar rheumatism ? 
 
 Do we find here a contemporaneous affection of many articu- 
 lations of a changeable, jumping character, accompanied by a 
 febrile condition, by various complications, cardiac and other- 
 wise, which it would be so natural to expect, if the disease 
 were in reality what passes under the name of acute articular 
 rheumatism, and one withal of such long duration ? Fmally, the 
 salycilate of soda, which acts m such a specific manner, hreciking 
 up so decidedly an attack of acute articular rheumatism, acted 
 in this case — to judge by the history of the disease and by our 
 observations in the clinic — solelj^ as a symptomatic remedy, as 
 a slight pam-stilling agent, neither interrupting nor curing the 
 disease. 
 
 There occur, it is true, cases where an evident, typical, acute 
 articular rheumatism does not terminate in a rapid breakmg up 
 and cure of the disease (usually on account of the fact, that 
 the patient is surrounded by unfavorable circumstances, or is 
 not treated, or is treated wrongly and not sufficiently energetic- 
 ally), but leaves a chronic disease of the affected joints, which 
 
— 219 — 
 
 is dragged along through months and years, and is presented m 
 exactly the same form as the present case, namely, without any 
 characteristic peculiarities of acute articular rheumatism, un- 
 yieldmg to treatment by the salycilate, which fails to cure it. 
 To denommate such cases by the term of chronic articulai- 
 rheumatism, i. e., to consider them as cases of acute articu- 
 lar rheumatism — a disease havhig all the peculiarities of an acute 
 infectious process — which passed into a chronic condition, 
 would be the same, as if we were to consider chronic bronchial 
 catarrh, which is sometimes left after measles, as chronic measles, 
 or the diarrhoea left after an attack of typhoid fever, as chronic 
 typhoid. It is apparent, that in all these cases it was not the 
 acute infectious disease which passed mto a chronic condition, 
 but there were left local affections, which are caused by and, 
 under favorable conditions, disappear with the disease, and under 
 unfavorable circumstances become chronic. 
 
 In the chronic affection of the joints, which remams after an 
 attack of acute articular rheumatism, there take place at times 
 apparent recurrences of this last : thus there appears a febrile 
 condition, the affection of the jomts becomes aggravated and 
 takes on a migratmg character, and the salycilate of soda exerts 
 anew its beneficial effect. But such recurrences of acute artic 
 ular rheumatism, which are generally so very peculiar to this 
 disease and which occur frequentl}- also in cases where its attacks 
 leave no trace of any chronic affection of the joints, cannot go 
 to prove the fact, that the chronic articular affection, which in 
 the intervals between the attacks extended over months and 
 years, is identical with the acute infectious disease, which 
 passes under the name of acute articular rheumatism. 
 
 What then do these cases of chronic joint affection, of polyar- 
 thritis chronica, as our present one and others mentioned by me, 
 present ? Here it becomes particularly necessary to employ 
 careful clinical analysis : I usually make m such cases a dou])le 
 investigation and a double diagnosis — the anatomical, defining 
 the affected organs and tissues, and the etiological, referring to 
 the causation ; I resort to this j^rmcipally because the therapy 
 presents differences not only m accord with the causes, but als(j 
 with the affected organs, as joints, bones, muscles and nerves. 
 
— 220 — 
 
 The anatomical investigation gives the following : the most 
 frequently and preeminentl}' affected parts are the joints ; in 
 these we must determine the condition of the articulating ends 
 of the bones and of their cartilages, the condition of the articu- 
 lating capsule and of the soft parts outside of it. Less frequent- 
 ly are observed affections — usually with pain and swellmg — 
 of other parts, besides the jomts ; it then becomes necessary to 
 determine just what part is affected : the skin, as evidenced by a 
 hyperaesthetic condition, by dermatitis, etc., or the bones, most 
 frequently in the form of a periostitis, accompanied by pain, 
 which becomes aggravated on pressure, — and sometimes by 
 swelling ; or the cartilages, as seen, for mstance, in a perichon- 
 dritis of the costal, laryngeal and aural cartilages, — most fre- 
 quently m gout ; this condition also is accompanied by pain, 
 which becomes worse on pressure ; or it may be the muscles, as 
 proved by the existence of a myositis : a high temperature, ten- 
 sion and sensitiveness on pressure and motion, and, later on, 
 emaciation of the affected muscles, m which cirrhotic indura- 
 tions may form ; or the nerves, in the form of a neuritis : pains, 
 tenderness on pressure and various functional disturbances. 
 
 The investigation of the causes brings to surface most fre- 
 quently the following : acute articular rheumatism, and also, 
 although much less frequently, other acute mfectious diseases, 
 gonorrhoea (I cannot help observing, that the name polyar- 
 thritis gonorrhoica is much more preferable to the meaningless, 
 vague term " gonorrhoeal rheumatism"), syphilis, tuberculosis, 
 gout, a cold, traumatic influences, (of these last not so much 
 those of an acute nature, — contusions, wounds, etc., — as the less 
 severe, but constantly acting ones, as intense, fatiguing phj^sical 
 activity) and abuse of alcoholic drinks ; for although alcohol 
 does not cause directly any joint affections, it undoubtedl}^ 
 creates a predisposition to them. 
 
 Chronic affections of the joints, as I said once, are usually 
 not of a simple, but of a complicated origin, depending on the 
 effect not of one, but of several, even of many causative agen- 
 cies, as, for instance, of the conjoined action of a former acute 
 articular rheumatism and at the same time of gout, syphilis, of 
 a cold and of traumatic influences. 
 
— 221 — 
 
 What general name then is more suitable for those chronic 
 affections of which we are speaking at present ? If we desire 
 to preserve the briefness so essential in a term, then it is best 
 to call them i^oly arthritis chronica^ because the affections of the 
 joints are usually predominant, and such a name neither deter- 
 mines beforehand the concise diagnosis — and therefore the 
 treatment — of the given case, nor does it render it obscure, as 
 is the case with the term chronic " rheumatism." 
 
 We will turn now to the analysis of the present case. Per- 
 sons of our patient's age, — fifty-eight years, — living in the 
 midst of miserable conditions, full of privations, suffer often 
 from a particular form of gout, the so-called atonic gout, as 
 distinguished from the other, the ordinary form, to which we 
 alluded m our previous case. In our patient there are no 
 characteristic manifestations of gout, as, for instance, affections 
 of the joints of the great toes, neither the generally preeminent 
 affection of the small joints (both the small and the larger ones 
 are affected), nor any apparent gouty deposits around the artic- 
 ular ends of the bones ; but she presents indications of a pre- 
 disposition to gout — the constantly red urine and, as observa- 
 tion in the clinic made it evident, the favorable action on the 
 patient of an alkaline (Yessentucki) mineral water. This pre- 
 disposition to gout explams the fact, why the certain mfluences, 
 traumatism and cold, to which the patient subjected herself 
 with impunity during the whole of her laborious life, have at 
 last, in her old age, caused the appearance of an articular 
 disease. As regards the so much apparent influence of cold 
 (she was taken sick twice during the beginning of cold 
 weather), it is worth wliile noting, that precisely those joints 
 became affected, which were either uncovered — as those of 
 the fingers, and the wrist, or but insufficiently protected — as 
 those of the knee and of the ankle (as the patient wears neither 
 drawers nor a petticoat, while the soles were protected). As 
 mentioned above, in the diseased joints the affection is found 
 in the soft parts, located outside of the articular capsule, as 
 evidenced by the swelling and by the higher temperature and 
 slight redness on admission, and in the capsule itself (fluctua- 
 tion detected) ; there are no signs of any affection of the bones. 
 
Prognosis. — Judging- by the favorable course of tlie treat- 
 ■ment, we may hope for a satisfactory issue of the disease ; we 
 may expect a return to a considerable extent of freedom of 
 motion, in case, certainly, the patient succeeds in avoiding- m 
 the future any deleterious influences, which are liable to cause 
 a recurrence of the disease. 
 
 Treatment. — Wh}^ we prescribed for our patient, with her 
 predisposition to gout, an alkaline water, and, m view of her 
 ao-e and poor nutrition, a small quantity of the same, you 
 certainly understand well. I will only add that when atonic 
 gout be fomid in patients, who have been ailing for a long time 
 before with the usual form of gout, who drank a great deal 
 of mineral alkaline waters, and whose nutrition suffered con- 
 siderably, then we must admmister to them either the lightest 
 alkaline watere (Ems), or the earthy waters (Contrexeville). 
 To be sure, our patient's nutrition is not of the best, but still 
 we cannot call it very poor, and as she never drank any min- 
 eral waters, w^e therefore prescribed for her a very active 
 alkaline water (Yessentucki, No. 17), but, as I said before, 
 in a small quantity, and the course of the treatment justifies 
 completely this conduct of ours. The salycilate of soda, as 
 a pain-stilling agent, has relieved the patient sufficiently, 
 Massao'c and the constant electric current seem to exert a favor- 
 able influence by diminishing the articular swelling and by 
 making motion easier. "We will therefore continue the Yes- 
 sentucki water, a half-glass twice a day, the application of 
 massage and of electricity ; but there is no more need for the 
 salycilate. nor for any other pam-stilling drugs in general. 
 
 We limit ourselves to the above-named means, because they 
 seem to be sufficient. An excellent remedial agent for chronic 
 joint affections we have in the salt baths, warm or even, m the 
 absence of contra-mdications, hot : we do not resort to them 
 in the present case, because we can seemmgly get along 
 without them, but prmcipally because they are contra-indicated 
 by the season, it being wmter time : the patient, after leaving 
 our clinic, would subject herself to a greater risk in catching 
 cold. A good remedy for chronic articular affections is car- 
 
^ 'in — 
 
 bolic acid (in the form of fomentatious of a two to four per 
 cent solution and hypodermic injections) ; there is no need 
 for it in the present case, and, besides, injections of carbolic acid 
 cause severe pains. The iodine, as well as the mercurial 
 preparations, are undoubtedly useful m articular affections 
 when complicated by syphilis. 
 
 In prescribmg local treatment attention must be paid as to 
 what organs or tissues are affected. For muscles the best thing 
 is massage. For the articulations — Spanish fly, massage, elec- 
 tricity and carlx)lic acid. For affections of the periosteum 
 only general treatment, usually anti-syphilitic or anti-gouty, or 
 both together, as, for instance, iodine preparations m alkaline 
 mineral waters ; massage and electricity increase the pains and 
 aggravate the disease. For the neurites — rest, Spanish fly, 
 irritating and paiu-stilling salves, and, at the end of the acute 
 stage, a careful massage, not of the nerve itself, but with a 
 derivative aim m view, of the neighboring parts, chiefly of the 
 muscular masses ; the action of electricity is not certain. 
 Finally, I repeat again, salt baths, warm or hot, are useful in 
 all the affections. 
 
 FROM THE LECTURE OF MARCH I, 1 89 1. 
 
 The patient leaves the clinic to-day. All the functions are 
 normal, the nutrition as well as the strength has improved. 
 The swellmg remams, althoughjmuch less than it was before, 
 only in the wrist-joints, while from the others it has almost 
 passed away. There is an entire absence of any pains on 
 pressure, or on passive and short active movements. A pro- 
 longed walk gives rise to a feeling of fatigue, and later also 
 of pain in the knees, which, however, soon pass away after 
 rest. 
 
 Patient was advised to avoid certain harmful influences and 
 to continue massao-e. 
 
THIRTEENTH CASE. 
 
 LECTURE OF MARCH 3, 1892. 
 
 The patient, a widow of an official, is forty-seven years old, 
 and entered our clinic February 27tli complaining of severe 
 pains in the loins and in the thighs down to the knees ; the 
 pains are very much aggravated on motion, so that this last is 
 almost impossible ; she also complains of pains in the chest and 
 in the left half of the abdomen. 
 
 Mode of living and anamnesis. — The patient is an inhabitant 
 of one of the governments around Moscow, lives in a healthy 
 locality and occupies a good house, but the water-closet is cold. 
 Has not bathed in the river for the last five years, takes a hot 
 bath twice a month, perspires very freely. Drinks no coffee, 
 wine or whiskey, only some four glasses of hot tea per day ; 
 generally drinks but little: besides the tea only water, not 
 more than one glass during the whole day. She breakfasts and 
 dines at a good table, eats many sweets. Has been a widow 
 for the last five years ; was never pregnant. Goes out but little 
 mto fresh air, has but little exercise. Her occupations are 
 those of a small housekeeper. 
 
 Patient comes from a healthy family and is herself of a strong 
 constitution ; in her seventeenth year she passed through an 
 attack of typhoid, in her twenty-seventh had malaria. Has en- 
 joyed good health since, up to the climacteric period, which 
 began five years ago : the first three years the menstruation was 
 irregular, but two years ago it ceased entirely. With the 
 advance of the climacteric period there began to appear attacks 
 of heat in the head and pronounced perspiration all over the 
 body ; they were of frequent occurrence during the fii'st year, 
 several times daily ; since that time the quantity of the urine 
 dimmished, the urine became red and left frequently a reddish 
 224 
 
— 225 — 
 
 precipitate. Four years ago she had for the first time a very 
 severe attack of renal colic on the left side, as evidenced by 
 pains in the left loin transmitted to the left groin, which lasted, 
 with intervals, for four days. A year later she had another 
 attack of lesser severity, lasting two days. After that the 
 attacks of renal colic took place frequently, always on the left 
 side, but they were not of severe intensity. Since October 1891 
 there appeared a constant severe pam in the left loin and on the 
 corresponding side of the abdomen, and smce then began all 
 those pains with which the patient entered the clinic, and 
 which kept continually on the increase. The treatment was as 
 follows : at the beginnmg sodium salycilate until the production 
 of tmnitus aurium during one month, but without any success ; 
 then, for one month, potassium iodide (dose unknown) in solu- 
 tion, three spoonfuls per day ; no results whatever. Later, cool 
 spongings with a wet towel for one month, also without any 
 success ; finally, for two weeks before she entered the clinic, 
 the patient drank Vichy-Celestins (she never used any 
 mineral water before), about one glass and a half per day, and 
 felt slightly relieved. While in the clinic the patient continues 
 drinking the same water warmed to the temperature of freshly 
 drawn milk, three half-glasses during the day, each time one 
 hour before a meal. 
 
 Status. — The appetite is impaired. While observing a strict 
 diet and using Vichy in the clinic, she has no dyspeptic symp- 
 toms, but formerly she felt heaviness in the stomach and pyro- 
 sis almost constantly. The patient is usually constipated and 
 takes castor oil twice a month ; in the clinic the rectum is 
 sufficiently emptied with the aid of watery clysters. The liver 
 and the spleen are in normal condition. The pahis on the left 
 side of the abdomen are due to the considerable tenderness of 
 the kidney and the ureter ; on the right side the kidney and the 
 ureter are also tender on pressure, but much less so. For a few 
 days before her admission to the clinic, the patient discontinued 
 drinking Vichy and the quantity of urine on her admission was 
 small, — 500 to 700 c.c. in twenty-four hours, the urine very red, of 
 a strongly acid reaction, with a considerable deposit, principally 
 of sodium urate ; at present, when the patient resumed drinking 
 
— 226 — 
 
 Vich}^, and, as we advised, not verj hot tea (she thus perspires 
 less) and a greater quantity of ordinary water, the amount of 
 urine increased from 1000 to 1200 c.c. in the twenty-four hours, 
 the urme is not so red, and the sediment is much smaller. 
 Urine contains neither albumen, nor sugar. The organs of res- 
 piration are healthy. The dimensions of the heart are normal, 
 its tones clear, but the pulse is somewhat weak, which points 
 to an insufficient activity, and probably to the already affected 
 nutrition of the cardiac muscle, a condition so very natural in a 
 sick woman who takes so little exercise. The patient was former- 
 ly stout, but grew thin during the disease, and yet she cannot be 
 said to be emaciated. There is no fever. The pains prevent 
 sleep to some extent, but yet it is quite sound and sufficiently 
 prolonged. The pains in the chest of which the patient com- 
 plains, are proved by investigation to depend on the sensitive- 
 ness of the sternum, ribs and scapulae ; but most sensitive are the 
 pelvic bones (especially the sacrum) and both femurs ; the 
 movements of the acetabular articulations are extremely pain- 
 ful, which condition causes great difficulty in turning over in 
 bed, and makes getting up and walkhig about almost impossible : 
 the patient, as you saw, was carried mto the auditorium on a 
 chair. 
 
 Diagnosis. — It is evident, that we have here to deal with 
 a typical case of gout, arthritis urica. The patient, of strong 
 constitution, with a hitherto good digestion, lived always in 
 affiuence, ate more than was necessary, had but little exercise, 
 no children, grew stout, and with the approach of the climac- 
 teric period with its peculiar vasomotor disturbances (frequent 
 " bathing " of the whole body in sweat, which increased the 
 patient's usual tendency to perspiration), she began to excrete 
 a diminished quantity of red urine with an abundant uric-acid 
 deposit and began to suffer from renal colic, a disease to which 
 gouty persons are so liable to be subject, as it is connected 
 with the very nature of gout : then there appeared the above- 
 mentioned pains in the bones, gouty periostites. 
 
 Is not there also syphilis m the case, as the pains prevent 
 quiet sleepmg at times ? It is true that the pains interfere with 
 the sleep, but only when the patient while asleep makes 
 
— 227 — 
 
 a movement causing pain ; this last causes the patient to 
 start up, but after a rest the pain passes away and the patient 
 again goes fast asleep. But the nocturnal exacerbations of 
 syphilitic pains are of a different nature, they last longer, 
 for many an hour, and are not relieved by quiet posture ; on 
 the contrary, such patients at times get up and prefer to walk 
 about during the nocturnal attacks of these pains. I will not 
 stop here to discuss the point, that the bones which are most 
 frequently affected in syphilis, as for instance, the tibiee, the 
 bones of the forearm, of the skull, are not affected here ; nor 
 are there any, specially characteristic of gout, affections of the 
 small joints, and particularly of the great toes. But whereas 
 the anamnesis and the present condition point with such 
 positiveness to gout, they fail to give any indications of syphilis. 
 Finally, one month's treatment with potassium iodide brought 
 absolutely no improvement, while a two weeks' use of Vichy 
 water has produced an inconsiderable but nevertheless un- 
 doubted relief. As to what concerns the fact, that in our patient 
 it is the pelvic bones and the femur which are preeminently 
 affected by the gout, it is quiet possible, that this was aided by 
 a cold while sitting down in the water-closet m the beginning 
 of the cold weather, last October, when the buttocks and the 
 thighs were exposed to chilling blasts. 
 
 Prognosis. — Experience proves that patients like the one 
 before us become usually free from the severe symptoms of 
 gout and its recurrences, after an ordinarily repeated use 
 of mineral waters (at the beginning alkaline, later alkaline and 
 earthy) and a strict observance of hygienic regulations. 
 
 Treatment. — As a cause of failure of the former treatment 
 we must apparently consider the vagueness in the diagnosis. 
 The physician saw what he considered as " chi'onic rheuma- 
 tism," and during a whole month he was admmistermg sodium 
 salycilate till the production of tinnitus aurium, but without 
 any success ; salycilate of soda is perfectly inert in cases 
 of gouty affections proper, and especially in gouty periostites ; 
 it acts solely as a pain-stillmg agent, and then in connection 
 with alkaline mineral waters, only in gouty articular affections 
 complicated by acute or subacute articular rheumatism or by 
 
— 228 — 
 
 the affection of the joints consequent upon this, as well as 
 . by a catarrhal condition of these last. The failure of the 
 treatment and a suspicion of syphilis led to the employment 
 of potassium iodide, although it would have been more judi- 
 cious to administer at first an alkaline mineral water, because, 
 whereas the presence of syphilis was suspected, the presence of 
 gout was beyond doubt. An indication for the employment 
 of cool sponging could be found either in the nervousness of 
 the patient, who was harassed by pains, or again, in the vague 
 idea about " chronic rheumatism ; " but the nervousness could 
 certainly not be removed without setting aside its causes, 
 namely, the contmuous pains ; as for pains in general, and 
 particularly for those of renal origm, warm baths are more 
 suitable than the cool spongings (whether or not warm baths 
 are suitable m the present case, we shall see later on). 
 
 The patient was given Vichy, as experience proves that 
 the strong alkalme waters, as Vichy and Yessentucki, are the 
 best remedial, agents m such a typical gout, as found in our 
 patient (later on, in atonic gout. Ems or an earth}' water 
 like Contrexeville is more suitable). We administer Vichy 
 in a moderate quantity, although it would be desirable to give 
 it in a larger, because the patient is not only unable, in view 
 of the winter, to go out of doors, but she can not as yet even 
 walk about the room : such being the case, a considerable 
 quantity of an easily absorbable water, which has no tendency 
 to loosen the bowels, would increase the vaso-motor distur- 
 bances in our patient, the mfluxes of blood to the head, and 
 the perspiration, which last would diminish the secretion of the 
 urine. As we cannot administer any considerable quantity 
 of the mmeral water, we shall be compelled to give it for a 
 longer period of time. 
 
 What else shall we prescribe for our patient to hasten her 
 relief and improvement ? As was said once, and as proved by 
 experience, we have nothing to expect from the salycilate of 
 soda, of which the patient took so much. The same may be 
 said of antipyrin and other similar medical agencies, the action 
 of which is so similar to that of the salycilate. Besides, these 
 remedies are not only useless in the given case, but even harm- 
 
— 229 — 
 
 ful, as they increase the tendency to sweating, which prevents 
 the excretion of a sufficient quantity of urine, and weakens still 
 more the cardiac activity, weak as it is at present. 
 
 To give for the present case the preparations of opium for 
 the relief of the pains would be very erroneous, as they would 
 aggravate the above-mentioned vasomotor disturbances, which 
 so distress the patient (as the influxes of blood to the head), 
 and prevent sufficient urinary secretion (as the perspiration). 
 It were most desirable to diminish the pains in a radical manner 
 by removing their causes, which consist, namely, in those pecu- 
 liar gouty deposits of sodium urate in the painful parts. 
 
 Lithium, used for this purpose, is imdoubtedly effective, 
 but not to a particular extent. We will prescribe for our 
 patient piperazine recommended recently, which seems to pro- 
 mote solution and removal of uric acid deposits ; there exist ui- 
 vestigations w^hich speak much in favor of piperazine. We 
 will prescribe it in solution, (]J. piperazini 3], aquee destil. fvj) 
 in tablespoonful doses three times a day, consequent!}^ fifteen 
 grains a day, immediately before taking her Vichy water. 
 
 Of external means, in the present case with gouty periostites, 
 electricity is useless, while massage is even harmful, as it may 
 aggravate the pains. Warm baths are contraindicated by the 
 extreme sensitiveness on movmg about : the acts of undressmg, 
 getting mto the bath, emerging therefrom and di-essing anew, 
 would aggravate the pains to a greater extent, than they 
 would be relieved by a warm bath. ^loreover, for this case we 
 should have to employ, m view of the great tenderness of the 
 kidney and of the ureter in the left side, very warm baths, 
 which again would increase the tendency to perspiration so 
 harmful for our patient. 
 
 FROM THE LECTURE OF MARCH 27, 1892. 
 
 The patient continues to drink Yichy, and from March 4th to 
 25th she had been taking piperazme. Her condition has im- 
 proved considerabl3% all the pains in the bones as well as in the 
 kidneys have very much diminished: the patient walked with 
 
— 230 — 
 
 ease into the auditorium. All her functions are regular, the 
 urine is not red, gives no sediments and is of a weak acid re- 
 action, the sleep is sound, there are no nocturnal pains, as the 
 motions are painless. 
 
 As to what concerns the action of piperazine, it would seem, 
 that after it was administered the relief of the pains appeared 
 sooner, in fact much sooner ; however, we cannot be sure about 
 this, as the patient drank at the same time Vichy water, the 
 use of which we could not, to make the experiment clear, set 
 aside, on account of the patient's aggravated condition. The 
 stomach bore the piperazine well in the above-named dose, and 
 the drug has in general failed to cause any unpleasant signs.* 
 
 As we were unable, as said before, to give the mineral water 
 in large quantities, we must continue its use for as long a time 
 as possible. 
 
 The further history of the disease. — April 7th patient left the 
 clinic almost without suffering any pains. Until the time that 
 she left the clinic she drank Vichy in the former quantity : the 
 urine became pale and had at times a neutral reaction. Patient 
 was advised to discontinue drinking the mineral water, but 
 during the summer, in case of a recurrence of the pains, even if 
 they be not severe, to renew drinking Vichy, in the same quan- 
 tity, but for a shorter period, say three or four weeks, and also, 
 if possible, to take lukewarm baths of 27° R. (92.7° F.~) 
 with salt and soda, of the first some six, of the last some three 
 pounds per bath ; experience has shown the utility of such baths 
 for gouty persons ; she must certainlj- observe most carefully 
 her individual hygiene, as explained to her. She was advised 
 to take more exercise, but with due rest, never fatiguing her- 
 self, and especially avoid fatiguing the formerly diseased parts. 
 
 * Further observations proved tliat piperazine cannot be relied upon ; 
 that its action, if it has such, is insignificant and uncertain, and that it 
 belongs to the class of drugs, which have recently been pushed to the 
 front by speculation and advertised by pseudo-scientific methods. 
 
FOURTEENTH CASE. 
 
 LECTURE OF OCTOBER H, I89I. 
 
 The patient, the wife of a tradesman, is thirty-two years old ; 
 she entered our clinic October 2d, complaining of pains all over 
 the body, and particularly in the abdomen, in the right side, in 
 the chest, arms and legs ; of dyspnoea, palpitation, oedema of 
 the legs, poor sleep and general weakness. 
 
 Mode of living and anam^iesis. — Patient lives in one of 
 the governments around Moscow, m a good locality and in a 
 good house. Never bathed in the river much, and for the 
 last five years has not bathed at all, as it caused attacks of 
 severe dyspnoea. Visits once a week the public bath-house ; 
 is not subject to sweating. She drinks two to three cups 
 of tea and a glass of coffee; has never used any alcoholic 
 drinks. Her order of meals — breakfast, dinner and supper; 
 patient was always very intemperate in her eating, and is very 
 fond of fatt}^ starchy and particularly of sv/eet articles of food. 
 She was pregnant twice, last confinement nine years ago. She 
 has some trifling household occupation ; during the cold season 
 of the year patient almost never goes out-of-doors ; in summer 
 she is out-of-doors some, but on account of ill-health hardly 
 ever walks at all ; which, however, she did not do even while 
 well, because she never liked walking. 
 
 Patient comes from a healthy family and is herself of very 
 robust constitution. Has always lived in the above-described 
 manner, always ate much and exercised little ; with the cessation 
 of pregnancies she became very stout, and five years ago 
 began to suffer with biliary colic, in the form of character- 
 istic attacks of severe pains in the right side accompanied by 
 vomiting and jaundice. October 1886 she entered our clinic 
 the first time, and we found that besides general obesity and 
 
 231 
 
— 232 — 
 
 biliary calculi there was also a clearly pronounced gout, ex- 
 pressed in renal colic, the urine giving an abundant sediment 
 of sodium urate, and in gouty periostites of tUe various bones 
 and especially of the ribs (there was neither then, nor is there 
 now any sign of syphilis). The patient observed the diet, 
 drank Vichy, took several warm baths, and in the course of a 
 month left the clinic greatly improved ; but notwithstand- 
 ing the fact, that we pointed out to her clearly what her mode 
 of living would bring her to, she did not in the least alter 
 it, and in January 1887 was again compelled to reenter our 
 clmic, in which she remained for a month, was treated m a sim- 
 ilar manner and left the clinic again improved. But being of a 
 weak will-power, she returned to her former mode of livmg 
 again, and in October 1887 she applied to the clinic for the 
 third time, with all her former troubles, which became worse 
 this time, and were especially accompanied by a severe renal 
 colic. The treatment consisted in giving her calomel several 
 times, warm baths, and later on Karlsbad and Vichy. Patient 
 agam improved considerably, and notwithstanding her former 
 irregular mode of living, but little changed for the better, 
 she enjoyed comparatively good health durmg almost a whole 
 year, and only in October 1887 she was again compelled for the 
 fourth time to apply for treatment ; she was given calomel once, 
 and later drank, during a period of six weeks, Karlsbad-Miihl- 
 brunnen. two closes of one-half glass each m the morning, and 
 Vichy-Celestins, two doses of one-half glass each the latter part 
 of the day. She improved much, led a somewhat more regular 
 life and felt comfortable for about a year and a half; then 
 with her former disorderly habits of life there reajDpeared the 
 former affections, both kmds of colics and particularly the 
 gouty affections of the bones and articulations became much ag- 
 gravated, and nine days ago patient entered our clinic, three 
 years after her fourth sojourn in it. 
 
 Status. — Patient is very stout ; the color of the skin, for- 
 merly normal, is at present dark, olive-like. The appetite is 
 poor, there is no thirst; patient generally drinks sparingly. 
 Slight dyspeptic phenomena, as pyrosis, belching, nausea, appear 
 only when the diet is neglected, otherwise they are absent. 
 
— 233 — 
 
 She is costive ; has daily stools, but insufficient ones ; the excre- 
 tions are normally colored by bile. The abdomen is large — 
 from an evident deposition of fat as well as from intestinal me- 
 teorism. Menstruation appears in time, but is small in quantity, 
 lasting only one day. The urine, although small m quantity — 
 900 c. c. — is pale and turbid; the sediment contains a great many 
 crystals of oxalate of lime, epithelial cells from the renal pelvis, 
 and leucocytes ; albumen and sugar absent. The kidneys and 
 the ureters are very sensitive. The liver is enlarged, but of 
 normal consistency and form, and is not tender ; the region of 
 the gall-bladder is tender. There is considerable tenderness in 
 the sternum, ribs, scapulae and vertebrae ; dyspnoea. There occur 
 attacks of palpitation with slight signs of angina pectoris, as a 
 sensation of oppression at the side of the heart and simulta- 
 neously in the left scapula and left arm. The objective examin- 
 ation of the respiratory tracts elicits nothing abnormal. There 
 is no cough. The dimensions of the heart cannot be defined, on 
 account of the great thickness of the subcutaneous fat ; its tones 
 are clear, but very weak ; the pulse is regular, but very weak. 
 At present, as at other times, there is no fever ; but during a 
 cold all the pains become aggravated, and at such times the pa- 
 tient has some fever, but it is slight and of short duration. 
 There is no headache. Dizziness is of frequent occurrence, espe- 
 cially when she gets up suddenly or stands for some little time, 
 then the face becomes pale. 
 
 The sleep is always very poor on account of the general pains. 
 For the last year slight hysterical attacks began to appear : a 
 sensation of oppression in the chest and in the throat, and weep- 
 ing ; there are no convulsions or loss of consciousness. All the 
 bones and the joints of the extremities are more or less sensi- 
 tive ; in the lower ones it is especially the joints of the great 
 toes, in the upper ones it is the shoulder-joints. There is a pro- 
 nounced hyperaesthesia cutis. Hearing and sight are normal. 
 Extreme muscular weakness. The legs are oedematous up to 
 the middle. 
 
 Diagnosis — The greater part of the affections which are 
 observed in our patient were already discussed by us m con- 
 nection with the foregoing cases. The stomach is as yet in 
 
— 234 — 
 
 good condition. The costiveness and the intestinal meteorism 
 ■depend on the weakened condition of the muscular apparatus of 
 the intestines, so natural with the inactive mode of life and 
 the general muscular weakness of the patient. The urinary 
 tract presents signs of nephrolithiasis and of catarrhal pyelitis. 
 There are biliary calculi. The enlargement of the liver, in the 
 presence of insensitiveness and normal consistency, and also in 
 view of the general obesity, must be referred to a fatty condition 
 of this organ ; this is also evidenced by the olive color of the 
 skin, which points to some difficulty in the secretion of bile, 
 caused by a narrowing of the biliary passages through fatty de- 
 posits. The weak cardiac activity, as seen by the weak pulse, 
 dizziness in connection with a pale face and oedema of the legs, 
 in the presence of a pulse of normal frequency and of normal 
 rhythm, must be ascribed to the weakened activity of the cardiac 
 muscle, very likely due to a fatty condition of this last ; this con- 
 dition, in connection with the developed hysterical j)henomena, 
 may also be the cause of the slight attacks of angina pectoris 
 and of palpitation. The dyspnoea, in the presence of a normal 
 'condition of the respiratory tracts, depends evidently also on 
 cardiac weakness, and is jDartly due to the high position of the 
 diaphragm on account of the enlarged abdomen. The slight 
 hysteria developed in our patient under the influence of an in- 
 active life in confinement, contmuous insomnia and prolonged 
 severe pains. The cutaneous hypersesthesia may partly be due 
 to the hysteria ; however, it is of usual occurrence in severely 
 pamful affections of subcutaneous parts ; the hysteria in our pa- 
 tient is slight, whereas the cutaneous hypersesthesia is extremely 
 pronounced and is observed not over one-half of the body, as is 
 frequently the case in hysteria, but all over, and particularly 
 over the deep painful parts, as the gall-bladder, urinary passages 
 and over almost all the bones and cartilages. The disturbances 
 of nutrition are very typical in this case : under the influence 
 of the above depicted mode of life and with the cessation of 
 pregnancies, our patient developed general obesity, later typical 
 gout, arthritis urica, with the uric-acid nephrolithiasis, and later 
 still, under the influence of muscular inactivity and the su- 
 peradded functional nervous disturbances, thanks to a great 
 
— 235 — 
 
 quantity of sweet food, there appeared oxahiria. As is well 
 known, such a combination of disturbances of nutrition, or with 
 the addition yet of diabetes mellitus, is to be frequently met with. 
 
 Prognosis. — The condition of the patient is evidently very 
 serious : in the presence of so many and such great disturban- 
 ces of the organism, any accidental illness — of no consequence 
 in a healthy person — may take on a fatal significance. As to 
 what concerns the cure, or at least a considerable improvement 
 in health, even this, as we shall see later, is beset with great 
 difficulties, not to mention the patient's weak will, which para- 
 lyzes all our efforts in the direction of restoring her health on a 
 durable basis. 
 
 Treatment and course of disease. — Diet, watery clysters, in ac- 
 cord with the necessity of the case, and stimulants (a mixture of 
 the sether-valerianate drops with the Hoffman's di'ops with 
 coffee). At the beginning, in view of the great sensitiveness of 
 the gall-bladder, we gave calomel in eight one-grain powders, one 
 every hour ; this brought about considerable improvement, but 
 also a considerable, although only temporary, weakness,, so that 
 we had to give up the further use of calomel. For the same 
 reason, after the first warm bath, which relieved the abdominal 
 pams — those of the kidneys and of the gall-bladder — but which 
 has very much weakened the cardiac activity, we were also com- 
 pelled to give up warm baths. Massage of the affected joints 
 and general massage, as indicated by the oxaluria, even if very 
 slight, proved to be impossible, on account of the cutaneous 
 hypereesthesia. We had to limit ourselves to prescribing the 
 Contrexeville water — for the oxaluria — in half -glassful doses 
 three times a day, and to small doses (ten grains twice or three 
 times per day, but not every day) of sodium salycilate as a pam- 
 stillmg agent, and fifteen grains of sodium bromide at bed-time 
 (but not every night) as a somnifacient ; both drugs were ad- 
 ministered in the above-mentioned doses of Contrexeville water ; 
 but this relieved the patient but little ; while larger doses of 
 the salycilate were contra-indicated by the weak heart. Contmu- 
 ing the use of the mineral water we now took up antipyrine, in 
 five-grain doses twice a day ; this acted well and relieved the 
 pains to such an extent, that sleep became possible, without 
 weakening the cardiac activity. 
 
— 236 — 
 
 The patient left the clmic October 27th, markedly relieved in 
 all her sufferings. For further treatment she was given the 
 foUowmg advice : while resorting as far as necessary to watery 
 clysters, to stimulant and pain-stillmg drugs (as antipj'rme and, 
 later, if she become habituated to it, phenacetine in the same 
 dosage), she must drmk alternately Vichy-Celestins, for the 
 uric-acid deposits, and Contrexeville for oxaluria, — m small 
 quantity (one half-glassful twice a day) and mtermittently, 
 and also to drmk milk ; when possible to resort to massage, as 
 soon as the pains and the hypersesthesia diminish, and to warm 
 baths, when the weakness is diminished and durmg the warm 
 season of the year. 
 
 The treatment by milk was advised as follows : while continu- 
 ing the di^inkmg of the mentioned mineral waters, and while re- 
 sorting as far as necessary to the use of clysters, of stimulants 
 and anodynes, durmg the days of the milk treatment to use, be- 
 sides milk, only coffee with some sugar and a little tea without 
 sugar, and absolutely nothing more, no other food or drmk ; to 
 drink milk which is neither fat nor skimmed, one half-glassful 
 at a time, during the whole day, in such a quantity as not to 
 feel hungry, but not more than this ; it is ordinarily sufficient 
 to drink five to seven glasses per day ; to drink for several days 
 at a stretch, till there appears a feeling of weakness ; then to 
 leave off the milk, and to take up for a few days continuously 
 another food, in accord generally with the prescribed diet ; (va- 
 rious foods are recommended — meat, fish, eggs, and also starchy 
 articles ; excluded — sweet and very fatty food, as well as various 
 desserts, sauces, gravies, etc.) ; as soon as the sensation of weak- 
 ness will pass away after the use of such food, then return at once 
 to the sole use of milk for a few days, until a satisfactory result 
 is obtamed. For indications for this treatment by milk m such 
 cases, I refer to my article on syphilis of the heart. I will add, 
 that in cases of atonic gout similar to our present one, when 
 even the mmeral waters prove ineffective, or effective but to a 
 slight extent, good results are frequently obtamed by a continu- 
 ous use of a tea made of herbs and root of fragaria vesca (straw- 
 berry tea) ; for a pinch of this tea use a glass of boiling water, 
 let it steep well and drmk this quantity once or twice a day. 
 
DISEASES OF THE KIDNEYS, 
 
 SIXTEENTH AND SEVENTEENTH CASES. 
 
 LECTURE OF FEBRUARY 19, 1893. 
 
 The patient, a peasant, age thirtj-nine, entered the clinic one 
 week ago, complammg of swelling of the legs and face, difdcul- 
 tj in breathing, headache and general weakness. 
 
 Mode of living and (mamnesis. — Patient grew up in a village 
 of the Moscow Government, but has been living in Moscow for 
 a long time. His lodgmgs are rather cold, the water-closet 
 quite so. Takes a hot bath once a week. Is a hard smoker, 
 has been an intemperate alcoholist for a long time and is 
 addicted to drmking hot tea. His table is that of a working- 
 man. He is married, has children ; no history of syphilis. His 
 occupation is that of a machinist in a prmting establishment, 
 his work-day from 7 A. M. to 8 P. M. (with an interval of one 
 hour for dinner), has enough tune to sleep, but not much of an 
 out^door life. 
 
 Until ten years ago patient had nothing to complain of, but 
 later began to observe, after drmking heavily, swelling of the 
 legs and face, which would pass away within a few days with- 
 out treatment. Some six years ago, also after a debauch, he 
 spat considerable blood, but this passed without leaA'ing a trace 
 and never reappeared. In the beginning of this winter there 
 appeared the usual oedema of the face and of the legs, l^ut it 
 did not pass away ; and recently it increased and to it was 
 superadded a slight enlargement of the abdomen, diarrhoea, 
 dyspnoea, headache and general weakness, all of which com- 
 pelled him to seek medical aid in the clinic. 
 
 During a week's sojourn in the clinic, patient began to im- 
 prove markedly, thanks to the warm room and to the warm 
 
 237 
 
— 238 — 
 
 water-closet, to rest in a comfortable bed and to the use of 
 .strong wine (six tablespoonfuls per day), and of the stimulant 
 drops (tra. valer. seth. and liqu. anod. Hoffm. aa gttas. xxv, four 
 times a day), his food consisting of milk (boiled, in view of a 
 tendency to diarrhoea), milk soup of grits (semolino) and 
 chicken soup. 
 
 Status. — The appetite is better than it was on admission, the 
 former diarrhoea ceased. The liver and spleen present nothing 
 abnormal. The region of the kidneys is somewhat tender on 
 pressure. On admission to the clinic his urine amounted to 
 500 c.c. for the twenty-four hours, containing 0.3 per cent, of 
 albumen by Essbach's albuminometer, and a sediment consisting 
 of a few granular cylinders and red blood-corpuscles, and many 
 leucocytes; the quantity of urine is now 2000 c.c. with 0.2 per 
 cent, of albumen, a few leucocytes and with almost no cylinders 
 and red blood-corpuscles ; some accumulation of fluid can be ob- 
 served in the abdominal cavity. The dj^spncea, although easier, 
 is still considerable ; there is a slight cough with some expecto- 
 ration ; objective exammation of the respiratory tracts elicits 
 nothing abnormal, outside of some dry rales here and there. 
 The heart is enlarged : the apex beat is felt one finger's width 
 to the left of the left mammillary line, and the sound on the in- 
 ferior part of the sternum is markedly duller than on the superior; 
 the tones are clear. The pulse is 88, of regular rhythm, but 
 somewhat weak ; still it is already stronger than it was a week 
 ago. The oedema of the legs and of the face diminished some- 
 what. There is no fever. Sleep is prevented by pains in the 
 head which, although quite severe as yet, have abated some. 
 The general weakness is less at present. 
 
 Before we turn to the diagnosis and treatment of this case, 
 I will present to you another for a parallel investigation. This 
 patient, a peasant woman, thirtj^-nine years old, entered our 
 clinic October 31st, 1892, complaining of considerable swelling 
 in the face, legs and abdomen, of extreme dyspnoea, of cough, 
 constant headache, and extreme weakness. 
 
 Mode of living mid anamnesis. — The patient is a constant re- 
 sident of a village in the government of Moscow, situated in a 
 very damp locality. She lodges in an ordinary peasant's hut, with ' 
 
— 239 — 
 
 a water-closet in the barn. Patient takes a weekly steam-bath over 
 an oven, after which she clashes water over herself standing at 
 the front of the house, even in winter.* jS'ever drank any whiskey 
 or wine — drmks a great deal of tea ; food, ordmarj^ peasant's. 
 Patient is a widow, had neither children nor any miscarriages. 
 Judgmg from her anamnesis as well as her present condition, 
 sjiDhilis may be excluded. She does house-work and field-labor. 
 
 Until the last five j^ears our patient always enjoyed good 
 health. Five years ago there appeared for the first time swel- 
 ling of the legs and face, which passed away in the course of 
 two weeks without any treatment. Since then the eyelids would 
 swell occasionally. Last August the legs and face became 
 swollen ; during autuimi and winter the swelling continued in- 
 creasing and the abdomen began to enlarge very markedly ; to 
 this were soon added headaches, general weakness, dyspnoea 
 and cough, and at times a diarrhoea of abundant fluid evacua- 
 tions, accompanied now and then by slight pain in the abdomen. 
 
 Patient has beenm the clinic for the last three and a half 
 months. Her surroundings and diet were the same as m the 
 foregomg case, but on account of the diarrhoea, milk was given 
 in small quantities — two and a half glasses during the twenty- 
 four hours. The treatment was as follows : the looseness of 
 the bowels was kept under control, but not stopped suddenly, 
 first, because it could assist in decreasing the oedema and espe- 
 cially the abdommal dropsy, which was very considerable, as we 
 shall see later, and secondly, because the dyspnoea, caused b}^ 
 the oedema of the lungs and by uraemia, of which we will 
 speak later, would become intolerable if the patient were con- 
 stipated. To modify the diarrhoea, which took place occasion- 
 ally, and not to check it suddenly, fifteen drops of tra. coto, thi-ee 
 times a day, proved to be sufficient ; opium, which is generally 
 not indicated m cases of chronic, slightly painful diarrhoea, is ev- 
 idently contra-indicated in the present case by the general weak- 
 ness as well as by that of the heart, but especially by oedema 
 of the lungs. To strengthen the cardiac activity we gave the 
 same drops as in the foregoing case, twenty-five drops three 
 
 * A custom prevalent among a great iDart of the Paissian peasantry. — 
 Note of the translator. 
 
— 240 — 
 
 times per day ; we were compelled to discontinue the use of 
 wine, as it tended to aggravate greatly the pains in the head. 
 When the latter became very severe we resorted at times with 
 success to five-grain doses of phenacetine. As a diuretic we 
 tried at first diuretin (theobrominum natrobenzoicum, 3j in 3vj 
 of aqua destil., in tablespoonful doses), but had to give it up 
 after the fifth dose, as it increased the headache and caused 
 nausea and vomiting. For the same reason we left off caffeuium 
 nitrobenzoicum, which we prescribed after the diuretin in five- 
 grain doses three times per day. We then gave her calomel, 
 which was administered in one grain doses four times a day and 
 was well borne, without increasing the diarrhoea ; but it did not 
 in the least increase the quantity of the. urme nor relieve the 
 ursemic phenomena (the headaches), and it also was therefore 
 given up. We have had thus to limit ourselves, for purposes 
 of acting upon the kidnej^s, to the employment of baths since 
 the end of November. The patient, who has acquired of late a 
 susceptibility to cold, felt chilly in a bath at the temperature 
 of 30°i2. (99.5°i^.) and 31°i2. (101.7°i^.);but at 32°i?. (104°i^.) 
 and laterat 33°i?. (106.2° i^.) the bath mduced an agreeabl}^ warm 
 sensation. The patient had such baths, with slight interrup- 
 tions, from the time she entered the clinic until December 10th ; 
 they brought about a slight improvement, the quantity of urine 
 bemg increased temporarily and all the morbid phenomena hav- 
 ing diminished; but tills improvement was rather unstable and 
 passed off rapidly, so that by December 10th the average quanti- 
 ty of the urine was about the same as when she was admitted, 
 about 1200 c.c. in twenty-four hours, and the condition of the 
 patient improved but little. From that date on, we began the 
 employment of dry hot-air baths, from 4:5° E. (1SS.5°F.) to 60° J?. 
 (167°^.), in an apparatus conveniently applied, as you see, to 
 the bed ; these batlis called out profuse perspirations, and the 
 condition of the patient began to improve steadily smce ; by 
 January 10th the amount of urine was increased to 2000 c.c. in 
 twenty-four hours, by February 10th to 3000, which amount re- 
 mains at present ; the oedema and the ascites have also dimm- 
 ished greatly, and the patient has since enjoyed the good condi- 
 tion ui which you find her now. 
 
— 241 — 
 
 Status. — The appetite, which was poor on the patient's 
 admission to the clinic, is good now. Tlie dyspeptic phenom- 
 ena, as heaviness in the stomach and belching, also nausea and 
 vomiting accompanied by severe headache evidently of ursemic 
 origin, observed on her admission, have passed away ; so has, 
 since the middle of December, the diarrhoea. Ascites is not 
 apparent at present: the circumference of the abdomen on a 
 level with the umbilicus was 172 cm. before, but at present is 
 89 cm. The hver and the spleen, which did not admit of pal- 
 pation on patient's admission, present on examination notlimg 
 abnormal now. No menstruation smce August ; it was former- 
 ly regular and painless ; she never had any leucorrhoea ; the gy- 
 naecological examination shows that the climacteric period is 
 approaching. The quantity of urine on admission was 1,000 
 c.c. in the twenty-four hours, red, turbid, with an abundant sedi- 
 ment, consisting of a great quantity of renal epithelium, granular 
 hyaline cylinders, red blood-corpuscles and leucocytes; there was 
 0.6 per cent, of albumen ; the amount of urine is at present 3,000 
 c.c, it is pale, slightly turbid, with a trifling sediment, in which 
 the quantity of the above-named elements is much smaller, 
 while the red blood-corpuscles, the renal epithelium and the 
 epithelial cylinders are absent altogether; there is onl}^ 0.2 per 
 cent, of albumen. When admitted, patient was suffermg from 
 a severe dyspnoea, which would not allow of sleepmg in a re- 
 cumbent posture, and a severe cough, that would raise with con- 
 siderable difficulty a small quantity of expectorated matter, 
 accompanied by mucous rales in the inferior portions of the 
 lungs ; at present the rales, as well as the cough and dyspnoea, 
 have almost disappeared, and the patient is able to sleep in a 
 recumbent posture. The apex impulse, which could not be 
 palpated on her admission, is clearly felt now along the left 
 mammillary line ; at the same time the pulse, which was former- 
 ly very weak, although not quite frequent (80) and rhythmical, 
 became stronger and less frequent (72 to 76), the sound over the 
 sternum is everywhere clear, the tones of the heart clear. The 
 formerly enormous oedema has almost disappeared; there re- 
 mains yet some on the legs. Fever neither before nor now. 
 Patient, formerly very pale, is not so pale now. The sleep, 
 
— 242 — 
 
 which was formerly prevented by headaches and the patient's 
 inability to sleep in a recumbent position, is now good : the head- 
 aches are less frequent and milder, the general weakness is 
 much less. 
 
 These gathered data will certamly make it clear to you, that 
 it is the kidneys which are principally affected m both cases, 
 and that the morbid processes are of a chronic nature. Enter- 
 ing to-day on the discussion of diseases of the kidneys, namely, 
 chronic ones (as there do not happen to be in the clinic just at 
 present any pure cases of acute nephritis), I selected from among 
 the clinical patients the two whom I presented before you, be- 
 cause I considered their clinical analysis, conducted along paral- 
 lel lines, as particularly useful in acquamtmg you with the 
 chronic nephrites ; but before going any further, before consider- 
 ing the diagnosis and the treatment of both cases, I think it 
 necessary to take a brief survey of the varieties of chronic 
 nephritis recognized by modern pathology. 
 
 Pathological anatom}^ has proved that a chronic nephritis is 
 always the same in the sense, that there always takes place a 
 contemporaneous affection of the glandular element, — the urin- 
 ary tubules, — and of the interstitial substance, but that in a 
 great number of the cases one or the other of the affections is 
 more predominating. The clinical data prove, that the variety of 
 the disease and its course in cases in which the affection of the 
 glandular tissue predominates, are clearly distmct from the va- 
 riety and course of the disease with a predominance of the affec- 
 tion ofthe interstitial tissue, and the clinic therefore distinguishes 
 two varieties of chronic nephritis : the parenchymatous and the 
 interstitial. In the interstitial variety there is a great quantity 
 of pale and limpid urine with a trifling sediment, consisting 
 usually, although not constantly, of hyaline cylinders, the albu- 
 minuria is inconsiderable and inconstant ; the various oedemata 
 are either absent, or there ma}^ be some slight oedema of the 
 legs, while the left ventricle of the heart is hj^pertrophied and 
 usually dilated. In parenchymatous nephritis the urine is 
 scanty, very turbid, and gives a considerable sediment, contain- 
 ing leucocytes, frequently also red blood-corpuscles, renal epithe- 
 lium and epithelial, granular and hyaline cylinders ; the albu- 
 
— 243 — 
 
 minuria is considerable; with this there occur severe anasarca and 
 accumulations in the cavities, and a frequently recui'ring, ob- 
 stinate diarrhoea, while the left ventricle of the heart, although 
 enlarged (dilated), is not at all, or very little, hypertrophied, 
 probably because the nutrition of such patients fails rapidly, 
 whereas the nutrition of patients suffermg with mterstitial neph- 
 ritis may remain for a long time in a good condition. 
 
 In interstitial nephritis death is brought about either by apo- 
 plexy in the brain, caused by hypertrophy of the dilated left 
 ventricle in conjunction with a chronic arteritis, or even an 
 atheromatous condition of the arteries ; or by uraemia, or through 
 disturbances of compensation (when the heart is further affected) 
 or through inflammation of the mucous membranes, to which last 
 these patients are so predisposed. Parenchymatous nephritis 
 causes death through ascites and ui^aemia, as well as through the 
 above-named mflammations, to which such patients are even 
 more predisposed. Both varieties of the fully developed nephri- 
 tis are incurable; but patients with interstitial nepliiitis, enjoy- 
 ing moderately good health, may live for a long time, much over 
 ten years, while those with the parenchymatous variety will only 
 live a few years and that in a condition of great debility and 
 severe suffering. Prognosis is therefore worse for cases of pa- 
 renchymatous, than for those of mterstitial nephritis. In the 
 course of both varieties of chronic nephritis there take place 
 changes which point to their close relationship, to the fact, 
 that they belong to one process. 
 
 In interstitial nephritis the urine will frequently diminish in 
 quantity all of a sudden, become turbid, throwing down an abun- 
 dant sediment, containing the same formative elements, as it 
 does in parenchymatous nephritis, and show a great quantity 
 of albumen, and at the same time there will appear considerable 
 oedema ; but all these phenomena will pass away rapidly in a 
 few days under correct regimen and treatment (usually cardiac 
 stimulants and warm baths), and the physician — certainly, the 
 one who is very unexperienced or rather careless — who 
 first saw the patient in the above-depicted condition of exacer- 
 bation, will be compelled later on to change his diagnosis (and 
 consequenily also the prognosis), and instead of what seemed to 
 
— 244 — 
 
 him a parenchymatous nephritis, will recognize " an exacerba- 
 tion " of the interstitial variety. It is true, that this "exa- 
 cerbation " is in reality but a rapidly passing parenchymatous 
 inflammation, com plicating the original variety ; but this ori- 
 ginal variety, with all the peculiarities in its course and termina- 
 tion, and consequently in the prognosis, is in such cases after 
 all an interstitial nepliritis. Such " exacerbations " of intersti- 
 tial nephritis may pass away even if untreated, as is seen, for in- 
 stance, from the history of our first patient. 
 
 Parenchymatous nephritis terminates in the majority of cases 
 fatally ; but at times, rather rarely however, a more favorable 
 termination takes place, which is known as the " transition into 
 interstitial nephritis" : thus the amount of urine increases, its 
 turbidity, the sediment of abundant formative elements and the 
 considerable albuminuria, all these bemg the chief symptoms 
 of a severe affection of the renal parenchyma, decrease and 
 become insignificant. Alongside with these the various oede- 
 mata and exudations into the cavities disappear, the diarrhoea 
 ceases, while the nutrition improves, the patient gathers 
 strength, and there is developed a hypertrophy of the left 
 ventricle of the heart; thus the picture of a typical paren- 
 chymatous nephritis changes to that of a typical interstitial 
 variety with its more benign course. It becomes evident, that 
 this "transition of a parenchymatous nephritis into an in- 
 terstitial" is but the cessation or extreme diminution of the 
 more dangerous parenchymatous process, and a continuation, 
 in the form of a further extension, of the interstitial variety, 
 which always accompanies the parenchymatous form. 
 
 Diagnosis. — From the above it becomes apparent, that our 
 first patient suffers from a chronic interstitial nephritis (as 
 evidenced by the fact, that the disease had existed for ten 
 years, that the oedemata are of a slight and rapidly passing 
 character, and that the heart is enlarged) with an occasional 
 " exacerbation," i, e. complicated by a rapidly passing inflam- 
 mation of the renal parenchyma. That this last is of a rapidly 
 passing nature is seen by the rapid improvement m the patient's 
 condition : during the course of one week, with the aid of a 
 correct regimen and the emplojonent only of cardiac stimulants, 
 
— 245 — 
 
 even without warm baths, the quantity of urine was raised 
 from 500 c.e. in the twenty-four hours to 2000, and the forma- 
 tive elements in the urinary sediment began to disappear. For 
 the sake of completness in the diagnosis we must say a few 
 words on the condition of the heart ; its dilatation is indicated 
 by its enlargement: the dilatation of the left ventricle, as ap- 
 parent from the long duration of the disease, is of a permanent 
 nature, while the dilatation of the right one (as can be judged 
 by the dull sound on the inferior portion of the sternum) is 
 probably of a temporary character, dependent on the weakened 
 activity of the heart, and is likely to diminish with the improve- 
 ment of the latter. The rapid increase in the quantity of the 
 urine points to a hypertrophy of the left ventricle. The dys- 
 pnoea, headache and insonuiia, which appeared together with the 
 developed cedema and the diminished quantity of the urine, 
 and which decrease with the increase in the amount of this 
 last, are evidently of an ursemic character. 
 
 Our second patient, from what we are led to judge by the above- 
 mentioned two varieties of chronic nephritis, presents not a rapid- 
 ly passing inflammation of the renal parenchyma that occurs in- 
 cidentally during the course of a chronic interstitial nephritis, 
 but a firmly established parenchymatous nephritis ; this is in- 
 dicated not only by the characteristic picture of the disease, 
 as by obstinate dropsical phenomena of anasarca, ascites and 
 cedema pulmonum, by persistent diarrhoea, characteristic urine, 
 and the condition of the heart, but also by the unyielding nature 
 of the disease to treatment : warm, and even hot water-baths 
 at the temperature of 32° (104° F.) to 33° R. (106.2° i^.) 
 employed durmg a whole month, failed to bring about the 
 lea.st improvement in the patient's condition, and only ener- 
 getic application of air-baths at a high temperature induced a 
 decided turn for the better. 
 
 Prognosis. — As seen from the course of the disease and its 
 treatment, we may hope in the first case for a speedy disap- 
 pearence of the "exacerbation " and for the return of the patient 
 to his ordinary tolerable condition of health, while in the second 
 case we may expect the " transition " of the disease into a toler- 
 able condition of interstitial nephritis, i. e. the cessation of the 
 more dangerous~parenchymatous process. 
 
— 246 — 
 
 From the analj^sis of these two patients aud from their 
 further observation you will become acquainted with typical 
 cases of both varieties of chronic nephritis and with the most 
 important changes in their courses and also with the most effi- 
 cient means for their treatment. 
 
 Treatment. — We gave as yet no hot baths to our first patient 
 on account of his weakness, while internall}^ he was given stimu- 
 lant drops in view of the diarrhoea. At present the patient 
 is somewhat stronger and we will therefore order for him some 
 baths and internalh^, outside the above-mentioned stimulant 
 di'ops (for the diarrhoea stopped), also some caffeine, as a diuretic 
 which acts through the heart, by strengthening the latter's ac- 
 tivity ; as a diuretic agent on the kidneys, we have only milk : 
 the " strong" diuretics are contraindicated by the condition of the 
 kidneys, while the less irritating ones — as the alkaline mineral 
 waters, — cannot be used on account of the only recently ceased 
 diarrhoea. The mdication for prescribmg caffeine — in the con- 
 dition of cardiac activity as observed in the present case — for 
 its diuretic effect through the heart, and no other •■' cardiac " 
 drug, is certainly sufficiently clear to you now, but it will be- 
 come clearer still, when, m analj^zing clinically diseases of the 
 heart, we will discuss the comparative eff'ect of different cardiac 
 drugs. In the second case, after what was shown by its obser- 
 vation, we must continue the air-baths at a high temperature 
 and also the stimulatmg drops. For internal use, in view of 
 the patient's pallor, there is an indication for iron ; arsenic is 
 contra-indicated, outside of other considerations, by the former 
 obstinate diarrhoea. 
 
 The male patient left the clinic ^larch 11th. From February 
 19th to March 6th he was given seven baths at the temperature 
 of 31°it. (about 101.7°i^.) ; mternally he was given from Feb- 
 ruary 19th to the 2Tth caffeine natrobenzoate (in five-gram doses, 
 at first twice a day, and later three, four and five times), and 
 from February 27th to March 6th he had theobromine natroben- 
 zoate, in drachm quantities daily (3j in fij of water, in table- 
 spoonful doses). There was no appreciable difference in the 
 action of either of the drugs, but, as is well known, and as you 
 
— 247 — 
 
 may also judge by the present case, we have to give greater 
 quantities of theobromine than of caffeine ; and the first costs 
 more than the second. Already by March 6th the principal 
 morbid phenomena, as the oedemata, the dyspnoea, headache, 
 insomnia and weakness, disappeared, and the amount of urine 
 increased^ the patient left the clinic strengthened, suffering 
 with a trifling albuminuria and an enlarged, but functionally 
 efficient left ventricle of the heart ; the right ventricle has evi- 
 dently returned to its normal dimensions, as the sound on the 
 inferior part of the sternum became clear. Our advice to the pa- 
 tient when leaving : not to abuse brandy and hot tea, not to go 
 during the cold season of the year into a cold water-closet, nor 
 to take a steam-bath in winter, and to wear woolen undergar- 
 ments. 
 
 The female patient left the clinic April 17th. The very 
 small quantity of iron (tinctura tonico-nervina Bestujeff, * 
 five drops three times a day) which was prescribed for her Feb- 
 ruary 23d caused a diarrhoea on the very next day and it was 
 therefore discontinued. Under the use of tra. coto the diar- 
 rhfjea soon ceased. The treatment then consisted of the use of 
 air-baths at a high temperature, together with the use of stimu- 
 lating drops. By the begmning of April the baths became un- 
 necessary: the anasarca, ascites and the cedema of the lungs 
 passed away, there was no recurrence of the diarrhoea, the head- 
 ache and insomnia disappeared, the patient left the clinic with 
 an albuminuria (0.2 per cent), but very much strengthened and 
 with a functionally active heart. Our advice on taking her 
 leave : to take no steam-baths over the oven, nor dash any water 
 over the body during a frost, and to wear woolen undergarments 
 (with this last, being indigent, she was supplied from the 
 clinic). 
 
 * Solution of chloride of Iron (U.S.P) . . 850 min. 
 
 Stronger ether 4 fl. oz. 
 
 Alcohol, enough to make . . . . 16 fi. oz. 
 
 Each fluidrachm contains about Yz gr. of metallic Iron. 
 
 (U. S. D.) 
 
ANAEMIAE. 
 
 SEVENTEENTH CASE. 
 
 LECTURE OF MARCH 16, 1893. 
 
 The patient, a merchant's wife, age twenty, not desiring to 
 enter the clinic, is being treated at hoine and comes here only 
 for advice. She first applied here one week ago, complaining 
 of difficulty in breathing, palpitation of the heart and dizziness 
 on moving around, a constant noise in the head, general weak- 
 ness and a slight oedema of the face and lower extremities. 
 
 Mode of living and anajiinesis. — Patient moved two weeks ago 
 to Moscow, into a good residence, and before this she lived in a 
 healthy country locality, also in a good house. Is not used to 
 sea-bathing, but takes a bath (in the public bath-house) weekly. 
 Does not smoke, drinks neither wine nor coffee, and but a little 
 tea. Has good meals (fish on fast-days). Her occupation is 
 light, of a household nature, but fatiguing on account of her 
 weakness, this last also keeping her most of the time in-doors. 
 Was married two months ago. 
 
 The patient enjoyed good health until last summer, but on 
 account of the cholera epidemic she spent that summer in a 
 condition of great mental anxiety and suffered also a severe 
 shock from the loss, by cholera, of persons dear to her. Since 
 autumn the patient began to grow pale and weak ; and during 
 December the above-enumerated morbid phenomena made their 
 appearance and since her marriage have become particularly ag- 
 gravated. 
 
 Status. — The patient, as you see, is of average constitution 
 
 and very pale, while a week ago the pallor was striking and had 
 
 a greenish tint. The pallor, as well as the (jedema of the legs 
 
 and face, have decreased considerably for the last week, because 
 
 248 
 
— 249 — 
 
 the patient began taking iron, which we prescribed for her in the 
 clinic. Up to the time that she began taking iron her appetite 
 was poor and she suffered from nausea after meals ; the appetite 
 is now better and the nausea disappeared. She is costive, but 
 watery clysters empty the bowels sufficiently. The urine is 
 pale, of a specific gravity of 1007, but contains neither albumen 
 nor sugar, nor peptones. The liver, the spleen and the abdomen 
 in general present nothing abnormal. Menstruation appeared 
 first when she was seventeen years old and had been quite reg- 
 ular formerly, but since summer it began to appear once in 
 three months and very scantily, last time in December ; it was 
 always painless. Gynaecological examination shows the uterus 
 rather under-developed, considering patient's age. 
 
 Both the dyspnoea ' and palpitation are now less than they 
 were a week ago. The respiratory organs are in a normal con- 
 dition. The dimensions of the heart are normal. All over the 
 region of the heart there is heard a systolic murmur, while over 
 the veins of the neck the murmur is constant. The number 
 of the red blood-corpuscles is 50 per cent, of the normal, of 
 the haemoglobin but 12 per cent, of the normal quantity ; there is 
 neither poikilocytosis nor leucocytosis. The pulse is 80, as 
 yet weak, but already stronger than formerly. Patient is not 
 feverish. The sleep is fair. She complains less of noise in the 
 head, of dizziness and general debility. 
 
 Diagnosis. — We evidently have .here before us a typical ease 
 of chlorosis in its extreme development. No part of the 
 organism, outside of the blood and the sexual apparatus, pre- 
 sents any signs of a primary affection : the observed morbid 
 phenomena, which in their entirety form such a complete pic- 
 ture of chlorosis, depend apparently on a clearly pronounced 
 alteration in the blood ; the systolic murmur in the region of the 
 heart in the presence of normal dimensions of this last depends cer- 
 tainly on the same cause. Pernicious anaemia may be excluded 
 b}" the absence of any signs of increased disintegration of the red 
 blood-corpuscles, namely the absence of poikilocytosis, pepto- 
 nuria and urine of a high specific gravity ; against leukaemia 
 speaks the absence of leucocytosis and of symptoms of any 
 affection of the spleen and of the lymphatic glands ; this last 
 
— 250 -^ 
 
 also excludes pseudo-leuksemia ; that the disease is not an anae- 
 mia resultmg from failure in nutrition and hsemotopoiesis as 
 due to unfavorable conditions of life, is evidenced by the fact, 
 that the disease developed under the identical material con- 
 ditions, under which her health was formerly satisfactory, while 
 a depressed mental state — as in the present case — is shown by 
 experience to favor the development of just the condition of 
 chlorosis. 
 
 What is the nature of chlorosis ? The investigation of this 
 question lies outside of the domain of clinical exercises proper, 
 as conducted for beginners, but I consider it important to take 
 it up now, so that we may define the disease more fully and 
 consequently be able to distinguish it with greater precision 
 from other cases of ansemia that we may run across later 
 on. 
 
 In the text-books of internal pathology chlorosis is described in 
 the part treating of diseases of the blood ; but this part forms 
 one of the weakest features of every text-book. Let us take, 
 for example, the well-known German text-book of Eichhorst, 
 translated into the most important European languages : 
 ." Chapter VIII. Diseases of the blood and of the hlood forming 
 organs. Part first. Diseases of the blood.''"' And now, without 
 any explanatory introduction, there follow one after the other 
 descriptions of leuksemia, pseudo-leukgemia, pernicious anaemia, 
 chlorosis, melansemia, purpura simplex, purpura rheumatica, 
 purpura hcemorrhagica, scorbutus, hsemoglobinuria and heemo- 
 philia. What a variegated collection ! How can we consider 
 as belonging to one class such affections as purpura simplex — a 
 but insignificant symptom to be met with in a great many differ- 
 ent diseases, and Werlhoff's disease, which, when fully developed, 
 presents all the symptoms of an independent affection, of a disease 
 sui generis^ in all probability of an infectious nature. On the 
 other hand, if we place among diseases of the blood purpura 
 hsemorrhagica, in which the primary affection of the blood is 
 perhaps probable, but has not been proved as yet, then why not 
 describe in the same chapter also malaria, in which disease the 
 affection of the blood is so apparent, and very probably of a 
 primary origin? If the chapter of the diseases of the blood 
 
— 251 — 
 
 treats of leukgemia and melana;mia, in wiiich the alterations of 
 the blood are but consequent on affections of the other parts of 
 of the organism and on other diseases, then why not place there 
 also urpemia, cholsemia, etc. ? To treat thus of diseases of the 
 blood tends to produce a vague idea about them in the begin- 
 ner's mind and puts them within narrow limits. A short in- 
 troduction should at least delineate fully the limits of this 
 department of diseases, should distinguish the primary affections 
 of the blood from the changes consequent thereon, and should 
 keep it prominently before the beginner's mind, that it was only 
 for the greater convenience of exposition, that either has been 
 described in other parts of the text-book. 
 
 It is evident, that placing chlorosis in the chapter that treats 
 of diseases of the blood, will assist but little in explaining the 
 nature of this disease, especially if we consider the modern ac- 
 count of the same. 
 
 The changes in the blood in chlorosis and their consequences 
 are evident, and to judge by the present case, may be very great : 
 but what produces them? We do not observe in oui' patient 
 any signs of an insufficient development of the general circula- 
 tory system, as the presence of a narrow calibre of the vessels, 
 etc., to which Virchow called attention m cases of chlorosis, 
 though they occur very rarely. The influence of unfavorable 
 material conditions and of disturbances of digestion on the. nu- 
 trition and hsematopoiesis have to be excluded by the very fact 
 of their absence in the present case. One thing is certain — 
 the presence of a disease-causing influence on the nervous sys- 
 tem, namely, the depressing mental condition. Influences of 
 such a nature play an important part in the setiology of chloro- 
 sis\ Some physicians, as for instance, the late Prof. Botkin, in 
 his clinical lectures on chlorosis, are even inclined to classify 
 chlorosis with nervous affections. While I recognize fully, from 
 my own experience, the truth of his observations as well as of 
 those of others, — observations of which the present case may 
 serve as an example, — I still think that the morbid influence 
 on the nervous system serves but as the exciting cause, which 
 calls to the surface the hidden, but nevertheless already existing 
 disease. 
 
— 252 — 
 
 I base my opinion, first, on the fact, that in many cases chloro- 
 sis is developed without any such influences on the nervous 
 system ; secondly, because such influences on the nervous sys- 
 tem cause chlorosis only at the age when sexual maturity is 
 in the process of being formed, while at any other age no such 
 effect takes place; and thirdly, because even at this age 
 they may call out the existence of the disease in some, and 
 fail to do so in others. It is reasonable to assume that the im- 
 mediate cause of the disease lies in the process of development 
 of sexual maturity, and in the condition and functions of the 
 sexual organs at this period of life. The signs of incomplete 
 development of the sexual sphere and the anomalies of men- 
 struation, usually observed in chlorosis, as well as the remark- 
 able facts which have become known lately, all tend to streng- 
 then this assumption still further. 
 
 The well-known physiologist Brown-Sequard promulgated the 
 idea that the glandular organs of our body secrete not only ex- 
 ternally, but also internally, thus exerting an influence on the 
 life of the organism. As a particular confirmation of his idea, 
 he pointed to the inter-relation between the activity of the male 
 generative organs and the general condition of the organism, and 
 on this fact he based the application, with a therapeutic aim, of 
 his well-known injections. These injections were at first com- 
 promised by being thoughtlessly applied, and partly also through 
 invidious exploitation, but at present they are considered as 
 worthy of experimentation by serious investigators. Similar 
 observations were at the same time made known, which tended 
 to prove the hitherto unsuspected connection between the condi- 
 tion of certain parts of the body and that of the body as a 
 whole : I refer to the investigations, which prove a relation of 
 the thyroid gland to myxoedema, of the suprarenal bodies to Ad- 
 dison's disease, probably of the pituitary bodies to acromegaly, 
 of the pancreas to diabetes. One cannot help thinking that 
 there may be a similar relation between some special condition 
 of the sexual apparatus during the period of the formation of 
 sexual maturity and chlorosis ; this condition being such, that 
 only in its presence may influences on the nervous system cause 
 the development of chlorosis, while the other circumstances, as 
 
— 253 — 
 
 failure in nutrition and blood-formation from various reasons, 
 may favor this development.* 
 
 I must say here a few words on the relation of chlorosis to 
 hysteria, in the aetiology of which morbid conditions of the 
 genital sphere also play such an important part. The combi- 
 nation of chlorosis and hysteria is seen, according to my experi- 
 ence, not only infrequently, but rather rarely. The influence of 
 marriage in chlorosis and hysteria is as follows : other condi- 
 ditions being equal, for example, with a similar and withal 
 good constitution, amidst similar and withal favorable con- 
 ditions of life, hysteria, even if strongly developed, often passes 
 away completely after marriage, or is at least considerably 
 diminished; while chlorosis, if slight, becomes neither better 
 nor worse after marriage and requires treatment ; but if con- 
 siderable, it always becomes worse, so that for chlorotic girls 
 late marriage is more advisable, for the phenomena of chlorosis 
 will then cease to recur and will finally disappear, and sexual 
 maturity as well as that of the whole organism, will be fully 
 established. 
 
 The prognosis in the present case is favorable, considering the 
 patient's fair constitution, her good conditions of life, and also 
 
 * A later addition [from the article of the well-known (by his works 
 in the domain of pathology of metabolism) Prof . Noorden : "Altesund 
 Neues liber Pathologie nnd Therapie der Chlorose." — Berliner Klinische 
 Wochenschrift, iS'os. 9 and 10, 1895]. What causes the diminution of hae- 
 moglobin in chlorosis,- — the increased disintegration of the blood, or the 
 weakened power of haematopoiesis ? The bilirubin of the bile is formed 
 from the hsematin. From the bilirubin there is formed hydrobilirubin of 
 the feces and urobilin, identical with hydrobilirubin ; this urobilin is ab- 
 sorbed by the intestines and passes into the urine, of which it forms the 
 principal coloring matter. Thei'efore, the general quantity of urobilin in 
 the urine and of hydrobilirubin in the feces may serve as an index of 
 the disintegration of the haemoglobin. Not only the pale urine and the 
 usually pale color of the feces in chlorosis, but also direct measurements 
 of the quantity of urobilin in the urine and of hydi'obilirubin in the feces, 
 which measurements show their diminution in this disease, — go to prove 
 that the disintegration of the haemoglobin is not increased in chlorosis, 
 but diminished, and that consequently the decrease of this body in 
 the blood depends on the weakened power of haematopoiesis. On the con- 
 trary, in other anaemiae, — as in the pernicious, leukaemic, febrile, ma- 
 larial, — where the existence of an increased disintegration of the blood 
 is too certain, there are constantly found greater quantities of urobilin in 
 the urine and of hydrobilirubin in the feces. 
 
— 254 — 
 
 in view of the fact that she has hardly been subjected to 
 any treatment. The prognosis would certainly be less favor- 
 able, if her constitution and mode of living were poor and if we 
 had found in her such an extreme development of the disease 
 after a considerable and frequent use of iron and arsenic ; and 
 such a thing does occur. Whereas now, especially in view of 
 the fact that iron is well borne and is evidently effective, we 
 may well hope to bring the patient soon out of her chlorotic 
 condition. It is true, that this last is liable to recur and seldom 
 yields to treatment instituted the first time ; but with the aid 
 of a good constitution and favorable conditions of life repeated 
 treatment is usually successful in preventmg a recurrence and in 
 establishing the health on a firm basis. Otherwise the con- 
 dition of health is liable to undergo different changes, while the 
 organism may acquire a predisposition to various diseases, espe- 
 cially to pulmonary tuberculosis. 
 
 Treatment — First of all, be sure to create as favorable hy- 
 gienic conditions as possible; the principal therapeutic means 
 are iron and arsenic. 
 
 Before prescribing these drugs you must carefully investigate 
 the condition of the stomach : it is just as erroneous to consider 
 the dyspeptic phenomena due to chlorosis as caused by a gas- 
 tric catarrh and to hesitate in prescribing iron and arsenic, as it 
 would be, on the contrary, to prescribe at once these remedies 
 without previously removing such a catarrh, in case this last 
 condition were present. The dyspeptic symptoms, as seen in 
 our patient with extreme chlorosis, were trifling, (vomiting 
 after meals) and appeared only during the course of the chloro- 
 sis ; we therefore prescribed iron at once, and, to judge by the 
 course of the disease, rightly so. Eight pills a day (the well- 
 known Blaud's pills : iron sulphate, potassium carbonate aa, 
 tragac. q. s.), four after dinner and four after supper, each of 
 them containing one and a half grain of iron sulphate, dimin- 
 ished the phenomena of chlorosis, improved the appetite, while 
 the nausea after the meals disappeared. If, on the contrary, 
 with a moderate chlorosis there were present considerable dys- 
 peptic symptoms which had existed prior to the appearance of 
 the chlorosis, then it would have become necessary at fhst to 
 
— 255 — 
 
 remove them (most frequently by the use of alkaline mineral 
 water and of bitter remedies). 
 
 When shall we administer iron and when arsenic in cases of 
 chlorosis ? In proportion as the phenomena of chlorosis are 
 more prominent and the condition of nutrition favorable, the 
 sooner must we give iron, and that in large, frequently even in 
 very large doses, beginning with moderate ones and increasing 
 them gradually ; the best form is that of pil. Blaud. On the 
 contrary, 'if the character of the chlorosis is less prominent, 
 and if the nutrition has suffered greatl}-, and the more evidence 
 there is of the case being one of simple ansemia, as a result of 
 failure of general nutrition and that of hsematopoiesis in par- 
 ticular, — then it is better to administer in the beginning arse- 
 nic, especially if the appetite be poor, thus : ^. acidi arsenicosi 
 gr. j, extr. trifolii q. s. ut f . 1. a. pillulse thirty or forty — one 
 twice a day, after a meal ; and later arsenic combined with a small 
 quantity of iron, as : IJ. acidi arsenicosi gr. j, ferri hydi'ogenio 
 reducti grana xxx extr. trifolii q. s. ut f. 1. a. pil, xxx, in 
 the same dosage. Still, there occur also cases of pure chloro- 
 sis with fair nutrition, but of a very obstinate frequently re- 
 curring nature, when the patients become habituated to the use 
 of iron, this latter ceasing to exert any effect (so that it is un- 
 able to prevent a recurrence of chlorosis) ; in such cases the 
 administration of arsenic — -as mentioned above — instead of 
 the iron, usually prevents the recurrence of the disease, after 
 which iron, in case of another recurrence, will again act favorably. 
 
 There is no need of interrupting the administration of arsenic 
 itself, or in combination with some iron, during the menstrual 
 periods ; but we must certainly interrupt the administration of 
 large quantities of iron during these periods. We frequently 
 have to stop the iron even a few days before the appearance of 
 menstruation, otherwise tliis latter will be very profuse, thus 
 weakening the patient. The attempt to continue the adminis- 
 tration of iron up to the very time of the appearance of the 
 menstrual flow (so as to avoid the necessity for delaying the 
 treatment), and then, by using egortine, tra. hydrastis and such 
 like, to diminish this flow, usually miscarries ; and it is better 
 not to hurry on with the treatment and interrupt it a few days 
 
— 256 — 
 
 before the menstruation appears. The condition of tlie diges- 
 tive apparatus may also require mtermissions during the treat- 
 ment by iron and arsenic. But in a general way the treatment 
 is continued until a complete and certain removal of chlorosis 
 is effected. 
 
 I consider it also necessary to remind you of the fact, which 
 is unfortunately liable to be easily forgotten, that while taking 
 arsenic every sour article of food is to be forbidden, as meals 
 with vinegar, lemon, and all sour or soured fruits and berries, 
 sour sauces, as well as horse-radish and mustard, which are usual- 
 ly prepared with vinegar ; otherwise a diarrhoea may start up, 
 usually of a painful and lasting nature, delaying the success of 
 the treatment. 
 
 The iron mineral waters play but a subordinate part in the 
 treatment of chlorosis, principally because they do not stand 
 transportation as well, for instance, as the alkaline waters, and 
 can be successfully used only on the spot ; but the treatment of 
 chlorosis and of aneemiae in general by the aid of ferrous min- 
 eral waters is not more successful than the treatment by medi- 
 cinal preparations of iron, but is in fact less so. 
 
 The treatment of chlorosis and of ansemise in general by import- 
 ed arsenical and arseno-ferrous mineral waters, so widely adver- 
 tised of late (Bourboule, Levico, Roncegno) does not, from 
 my observations, present any advantage over the treatment by 
 the above-named correctly prepared medicinal preparations of 
 arsenic or of arsenic with iron. 
 
 The constipation is easily overcome in our patient by watery 
 clysters. These are eificient in the majority of cases ; in ex- 
 ceptional cases we have to administer, and that rarely, light 
 laxatives. There seems to be no reason for any other symp- 
 tomatic treatment in the present case ; m some cases we do 
 resort to it; but the more the physician refrains from such 
 treatment, and particularly from the use of the various nervines, 
 as, for instance, the bromides, and the more he insists on the 
 radical treatment, the more successful will he be in establishing 
 a condition of sound health. I cannot help telling you that 
 a predominating palliative therapy in practice is a sure sign 
 of a poor physician. 
 
— 257 — 
 
 The condition of the nervous system in chlorosis requires 
 certainly the greatest attention on the part of the physician, as 
 is apparent from what we said concerning the Eetiology of the 
 disease : it is necessary to strengthen this system as much as 
 possible ; but to effect this purpose we must not direct our 
 efforts against individual nervous symptoms, but we must act 
 on the whole system. It is true that both iron, by improving 
 the condition of the blood, and arsenic directly, improve the 
 state of the nervous system as a whole ; but the application of 
 hydi'otherapeutic and of balneotherapeutic means in general is 
 also very beneficial in this connection. If the patients are not 
 predisposed to chills, then bathing in the river, or, better still, 
 in the sea, is the simplest means. Unfortunately, in cases of 
 considerable chlorosis, patients are usually chilly and become 
 weak after bathing ; for such cases we must order baths at the 
 temperature of 27° it. (92.8° F.") and lower, so that the patients 
 while m the bath, would feel refreshed, but not chilled, and 
 after the bath would become quickly warmed and feel vigorous. 
 ,Such baths are best prepared with table-salt and soda. Warm 
 baths (29° R, and over; 97.2° F?) tend to weaken such pa- 
 tients. 
 
 As our patient is not habituated to bathing in the river 
 it will be more suitable to advise her to take the above-named 
 baths for the coming summer season. 
 
 The patient was treated under the supervision of one of our 
 clinical assistants : the result of the treatment was entirely 
 successful. 
 
EIGHTEENTH CASE. 
 
 LECTURE OF MARCH 5, 1893. 
 
 The patient, a young girl nineteen years old, entered our 
 clinic March 2d, complaining of dyspnoea, palpitation and 
 dizziness on moving around, and of general weakness. 
 
 Mode of living and anamnesis. — Up to within two years ago 
 the patient lived in a small country town in a healthy locality 
 and in favorable circumstances ; but since then she has been 
 living constantly, summer and winter, in Moscow. Her resi- 
 dence is fair. She bathes outside, but during the last j-ear 
 bathing tended to weaken her and cause dizziness. She neither 
 smokes, nor drinks coffee or wine ; drinks some four glasses 
 of tea daily, sweetened and with lemon. Has three meals a 
 daj^ but they frequently consist of lunches onlj^, as bologna, 
 cheese, etc. She is a student of midwifery and attends her 
 lectures from nine o'clock m the morning to three o'clock in 
 the afternoon ; her evenmgs are spent m sewing and reading ; 
 she has sufficient time for sleep ; goes out for about an hour 
 and a half in the fresh air, but during her service as mterne in 
 the lying-in hospital (six days every month) she is entirely con- 
 fined to the house. Durmg the last year she is becoming very 
 much fatigued from her studies. 
 
 In her childhood patient passed through attacks of mea- 
 sles, scarlatina and mflammation of the lymphatic glands on 
 the right cheek, which suppurated and left a scar. Since then 
 and up to the time she moved to Moscow, she enjoyed good health, 
 with the exception of an attack of malaria, which was of short 
 duration and yielded to qumine. During the first winter 
 that the patient spent at Moscow, she began to feel weak- 
 ness, dyspnoea and palpitation ; the appetite became impaired, 
 there appeared dyspepsia and an inclination to costiveness, 
 258 
 
— 259 — 
 
 ana menstruation became verj irregular ; later on, in May of last 
 year, during laborious preparations for the examinations, there 
 appeared considerable hEemoptysis. During the summer the 
 patient remained at Moscow, and the condition of weakness, 
 the dyspnoea, palpitation and dizzmess kept increasing. In 
 October patient, havmg caught cold, began to cough, and at this 
 time she also had haemoptysis for two days, felt some pain in the 
 left side of the chest, and was feverish. In the course of a 
 month all these phenomena disappeared but the weakness, 
 dyspncea, palpitation and dizziness became aggravated. In 
 January patient was takmg, during two weeks, tra. nervina 
 Best, without any appreciable results. 
 
 Status. — Patient is of a weakly constitution, of tall stature, 
 but with an insufficiently developed somewhat flat chest, and 
 pale. The appetite is poor. Eating is accompanied by belch- 
 ing, pyrosis, nausea and by a sensation of heavmess m the 
 stomach. She is usually costive, but there occur at times 
 loose stools ; thus, during the last twenty-four hours she had 
 . three loose stools, accompanied by pains in the abdomen. The 
 urine contains neither albumen nor sugar, its specific gravity 
 is 1021. The liver and spleen present nothing abnormal. 
 The menstruation, which, previous to her coming to Moscow, 
 was regular and painless, has become very irregular since, 
 appears only once every two or three months, and is accom- 
 panied by abdominal pains ; she menstruated last time six 
 weeks ago. The heart is not enlarged, its tones are clear, there 
 are no murmurs, pulse is very variable, between 60 and 84, and 
 weak. Movement causes palpitation and dyspnoea. The number 
 of the red-blood corpuscles is 50 per cent., that of the heemoglo- 
 biii 35 per cent, of the normal. Leucocytosis and poikilocytosis 
 absent. There is a slight enlargement of the thyroid gland. 
 Patient does not cough, but has at times pams in the left side 
 of the chest, especially after she has been sitting for a long 
 time in a stooping position. Careful objective uivestigation of 
 the lungs elicits nothing abnormal. Patient grew thin ; she is 
 slightly feverish — 36.4.°/iJ. (97.5° F.) in the mornmg, 37.4 R. 
 (99.5° i^.) in the evening. Sleeps poorly; is dizzy; has at 
 times attacks of migraine with vomitmg. After sitting for a long 
 
— 260 — 
 
 time, experiences heaviness in the head and pain in the loins. 
 There is considerable general debility. 
 
 Diagnosis. — The simultaneous appearance, about a year and 
 a half ago, of general weakness, dyspnoea, palpitation, dizziness, 
 of a sensation of noise in the head, and of the irregularity of 
 menstruation, and the occurrence of changes in the blood, and the 
 enlargement of the thyroid gland, all point to chlorosis ; but 
 we have here evidently something more to deal with than 
 chlorosis only. The hsemoptysis during last May and especially 
 the above-described disease of last autumn point to tuberculosis 
 of the lungs. The absence of pronounced objective signs in 
 the 'chest, as well as of cough and expectoration, do not certain- 
 ly speak agamst it. Not to speak of the literature of the 
 subject, even a limited personal experience is sufficient to 
 prove the fact, that such rapidly passing, incidental illnesses, 
 as that from which our patient suffered last autumn, are of 
 frequent occurrence during the mcipient stage of pulmonary 
 tuberculosis ; they pass away apparently, but usually precede 
 the development of the real disease and serve therefore as a 
 true indication of the presence of this last. It would be an 
 unpardonable mistake to hesitate in such cases in taking the 
 necessary measures against pulmonary tuberculosis and to wait 
 for local symptoms — beginning with the cough and objective 
 data to the finding of bacilli inclusive. For the rest, our pa- 
 tient presents also some local symptoms, as pains in the left 
 half of the chest, and general indications, as slight fever, the 
 most probable cause of which m the present case is tuberculosis 
 of the lungs. 
 
 A question may arise as to whether the group of symptoms 
 presented by our patient, so peculiar to chlorosis and appearing 
 at the beginnuig, did not depend also on an incipient tuberculo- 
 sis of the lungs, i. e., whether our patient had before and has 
 now chlorosis, or only pulmonary tuberculosis. Against the 
 last supposition speaks experience which proves that, although at 
 the beginning of pulmonary tuberculosis emaciation, pallor and 
 weakness are apt to occur, such a simultaneous collection of symp- 
 toms peculiar to chlorosis, as observed in our patient, does not 
 take place ; besides, we note considerable alterations in the blood 
 
— 261 — 
 
 and an enlargement of the thyroid gland. We must, however, 
 take into account the fact, that the above-mentioned signs of an- 
 £emia are due not to chlorosis alone, but depend certainly on fail- 
 ure in nutrition and haematopoiesis amidst the unfavorable con- 
 ditions under which our patient lived while in Moscow, and, later 
 on, also because of the incipient tuberculosis pulmonum ; so that 
 we may call the disease chloranaemia, which, having attacked 
 a weak constitution, created a predisposition to pulmonary 
 tuberculosis. 
 
 Prognosis. — It will be more convenient for us to discuss the 
 prognosis of chronic tuberculosis of the lungs after we will have 
 analyzed a few cases of this disease ; as far as the present case 
 is concerned, I can only say that it is curable. 
 
 Treatment. — We will first of all advise our patient to give 
 up her studies and to return to the former favorable conditions 
 of life, until she is well again. 
 
 As regards treatment, we must certainly first of all remove 
 the dyspeptic symptoms. The patient is already taking Ems 
 water — one-half glassful twice a day, warmed, one hour before 
 a meal — and bitter drops (extr. fluidi condurango guttas xxx 
 and trae. nucis vomicae guttas v, twice a day after a meal), and 
 for overcoming constipation she resorts to the use of watery 
 clysters. In view of the diarrhoea of the last few days we will 
 prescribe ten grains of bismuth once or twice a day pro re nata 
 
 What shall we give her after the dyspeptic symptoms will 
 have been removed? Shall we treat the chlorosis or the tuber- 
 culosis ? We must certainly treat the tuberculosis, — first, 
 because of the greater danger it presents, and secondly, because 
 the principal remedy for chlorosis, namely iron, especially in 
 large doses, is clearly contraindicated in the present case, as it 
 may give rise to haemoptysis, to which the patient is so much pre- 
 disposed, and which may favor the further development of the 
 pulmonary trouble. Perhaps later on, after this last will have 
 been completely and securely interrupted, we may be able, if 
 necessary, to prescribe iron, certainly not in large doses, and 
 with due care. Concerning arsenic, it is, firstly, contraindicated 
 partly by the long-standing dyspepsia and the frequently occur- 
 ring attacks of diarrhoea ; and secondly, although it is used in the 
 
— 262 — 
 
 treatment of tuberculosis, it is much inferior in its effects in 
 this disease to creosote and guaiacol. Of all the apothecary 
 drugs at our disposal, these last two, in the present condition of 
 our knowledge, are the most successful ones in the treatment 
 of tuberculosis. I shall discuss these and the treatment of tu- 
 berculosis in general when we come to analyze some cases of 
 this disease ; but I will only state here, that not only in incipi- 
 ent tuberculosis, but also in cases presenting a failure in nutri- 
 tion or anaemia, or slight chlorosis with only a predisposition 
 to tuberculosis (on account of heredity, or of a poorly developed 
 chest), I have frequently witnessed much more benefit from 
 the use of these remedies, than from the employment of arsenic 
 alone or in combination with iron. 
 
 In vicAv of all this we will prescribe for our patient, after the 
 dyspeptic symptoms will have been removed, guaiacol carbon- 
 ate, it being borne by the stomach readily, in five-grain doses, 
 after each meal, at other times in a half-glass of milk ; we will 
 constantly increase the number of the doses, and administer the 
 drug for a long time, but with interruptions, till we will have 
 secured a complete and lasting cessation of the pulmonary 
 trouble. 
 
 FROM^,THE ILECTURE OF MARCH 16, 1893. 
 
 Until March 12th we continued the above-outlined treat- 
 ment of the digestive troubles ; and we were enabled since then 
 to leave off this treatment and to prescribe guaiacol carbonate, 
 in five-grain doses, the first two days one dose a day. and later 
 two doses daily. The condition of the patient at present is 
 as follows : the appetite is better ; there is no dyspepsia, stools 
 regular ; during the period of menstruation that occurred 
 recently after a prolonged absence of the same, there was an 
 evening rise in the temperature (as is frequently to be seen in 
 tuberculous women during their menstruation) up to 37.6° R. 
 (99.7° #.), and now it is 36.6° R. (97.5°) ; the dizziness, heavi- 
 ness in the head and the general weakness have diminished 
 considerably. Patient leaves our clinic to-morrow and will 
 continue the treatment with guaiacol in constantly increasing 
 doses, guided by the results of the treatment and the condition 
 of the stomach. 
 
THORACIC AND INFECTIOUS 
 DISEASES. 
 
 NINETEENTH CASE. 
 
 LECTURE OF JANUARY 29, 1893. 
 
 The patient, a merchant's clerk, thirty-seven years of age, en- 
 tered our clinic yesterday, complaining of severe pain in the 
 left side, of dyspnoea, cough and general debility. 
 
 Mode of living and anamnesis. — Patient has lived for the 
 last twenty-two years constantly in Moscow ; formerly lived in 
 the country. His lodging-rooms are good, with a warm water- 
 closet ; but he spends the day m a cold store. He takes a hot 
 bath once a week; does not bathe during the summer; drmks 
 as many as fifteen glasses of hot tea per day ; is subject to 
 sweating. Has been drmking whiskey, half a bottle daily, 
 for a long time; somewhat less for the last two months. Does 
 not smoke. Has a good board. Is married and has a few chil- 
 dren. Never had syphilis. 
 
 Four years ago, after a blow over the nape of the neck, on 
 which dropped a bale of goods, there appeared on the injured 
 part a small swelling, which soon disappeared, accompanied by 
 pain, which was also relieved in the course of time, but which, 
 on his catching cold, reappears even now (periostitis of the occi- 
 pital bone). Outside of this and of some slight colds, which, 
 as he claims, were relieved by hot baths, patient has no recollec- 
 tion of any other diseases. The present trouble began six days 
 ago : patient was severely chilled by a draught and in the even- 
 ing felt pain in the head and weakness, but this notwith- 
 standing he went out to take a hot bath ; on his return he 
 began to shiver and felt a pain in the left side. On the next 
 day he grew worse still, the pain was aggravated, there ap- 
 peared a cough, patient was compelled to take to his bed, and 
 
 263 
 
— 264 — 
 
 remained in a condition which was growing worse all the time, 
 till his admission to the clinic ; for the last five days he has been 
 taking quinine powders, one in the morning and one in the 
 evening. Yesterday he was given in the clmic a watery in- 
 jection, the painful side was rubbed with butter and chloroform 
 and wrapped in cotton and flannel, and internally we began 
 to administer the mixture of Hoffman and Valeriana drops, 
 twenty-five at a dose, and also some wine ; besides, he was 
 given in the evening one-fourth grain of codeine. 
 
 Status. — Patient is spare and of weakly constitution ; his 
 chest is flat and narrow. Until the advent of the disease his 
 appetite was good, he sufi^ered from no dyspeptic symptoms, 
 and had regular movements of the bowels. At present he has 
 almost no appetite at all ; a meal, even if light, causes difficulty 
 in breathing ; he had no movements of the bowels for four days 
 previous to his admission to the clinic, but yesterday a clyster 
 brought on a sufiicient evacuation. The urine flows freely, is 
 red, and contains neither albumen nor sugar. No abdominal 
 pains. The regions of the liver, spleen and kidneys present 
 nothing abnormal. There is dyspnoea of the same character as 
 yesterday, thirty -six respirations per minute, much more frequent 
 on moving around; the pains in the side are somewhat quieter, 
 and so is the cough ; there is very little expectoration (twice 
 during twenty-four hours). Objective investigation on the right 
 side elicits nothing abnormal ; on the left side posteriorly, from 
 the middle of the scapula downward, there is dullness, as 
 well as over the lateral surface ; the vocal fremitus is very much 
 weakened ; on auscultation, all over the left half of the chest, 
 the respiratory murmur is weaker than on the right ride and 
 non-vesicular, but of an indefinite character ; the respiratory 
 murmur is especially weak at the area of the dull sound ; besides 
 this, posteriorly, over the surface of the dull-sound area there 
 are heard along a narrow zone some rales of an atelectatic char- 
 acter, while anteriorly, almost on the same level, there can be 
 perceived a pleuritic rubbing sound. The intercostal spaces on 
 the left side of the chest are sensitive to pressure. The heart 
 is neither displaced nor enlarged, its tones are clear ; the pulse 
 is 110, regular, of fair volume (patient gets through the day 
 
— 265 — 
 
 four tablespoonfuls of wine and seventy-five drops) ; it was 
 weak yesterday. The temperature yesterday morning, 38.1°i^. 
 (100.5°^.)' ill the evening 39.6° J?. (103.3°i^.), this morning 
 again S8.1°E. (100.5°i^.). Patient slept somewhat better 
 than he did while at home, but still poorly, and was slightly de- 
 lirious. The whole head aches, but especially the injured spot. 
 There is slight dizziness on getting up ; the weakness as for- 
 merly. 
 
 Diagnosis. — We have apparently to do here with an acute tho- 
 racic disease, which causes the febrile condition and, through 
 this, some disturbance in the organs of digestion and in the ner- 
 vous system. The disease itself is evidently not located in the 
 thoracic wall, which, outside of the sensitiveness of the intercostal 
 spaces, presents a healthy condition, but within the chest, in the 
 pleura or iu the lung. What is it then — pleuritis or pneumonia ? 
 All the symptoms speak against pneumonia and for pleuritis : 
 the severe pains, the weakened respiratory murmur in connection 
 with a considerable area of a dull sound (if there were pneu- 
 monia in the case we would have, according to the period of the 
 disease, either pronounced bronchial respiration, or, in the begin- 
 ning, crepitation, and, at the end, subcrepitation), the pleuritic 
 friction sound, weakened vocal fremitus and a dry cough; the 
 expectoration is triflmg in quantity and does not have the pneu- 
 monic character. The considerable difference between the 
 morning and evening temperature — 38.1°it. (100.5° i^.) and 
 39.6° R. (103.2° i^.) — is not usually peculiar to pneumonia. 
 Thus the case is one of pleuritis, and to judge by the consid- 
 erable area and intensity of the dull sound, by the weakened 
 respiratory murmur and vocal fremitus, and partly also by the 
 degree of the dyspnoea, there must be a considerable effusion. 
 
 With this the diagnosis is, however, not at an end. Pleuritis 
 may be of variable origin : it maybe due only to a cold, and al- 
 though this causative agency is disputed by many, my observations 
 lead me to think that its existence can hardly be denied ; it is fre- 
 quently due to tuberculosis, to pyogenic microbes (the strepto- 
 cocci and the staphylococci), to acute articular rheumatism, to in- 
 flammatory conditions of the kidneys, sometimes to syphilis, ac- 
 tinomycosis and other diseases. What is the origin of the pleu- 
 
— 266 — 
 
 ritis in the present case ? To attempt to prove that the disease 
 in the present case is not due to acute articular rheumatism, be- 
 cause this last is absent, or to nephritis, on account of the ab- 
 sence of this disease, or to syphilis, because of its absence, etc., 
 as would be attempted by a clinician who zealously believes in 
 " the usefulness of exercises in differential diagnostication" 
 (and there are such), would be but a profitless task, which, 
 moreover, lowers the utility of a method really useful in certain 
 cases and to a certain extent. From the collection of data re- 
 ferring to the case before us it becomes apparent, first, that cold 
 has played undoubtedly an important part in the aetiology of 
 the pleuritis, and secondly, that notwithstanding the absence 
 of indisputable symptoms of jDulmonary tuberculosis, it would 
 be rather rash on our part to conclude, in view of the patient's 
 weak constitution and poor nutrition, as well as because of the 
 long-continued abuse of whiskey so ruinous to health, and with- 
 out further observation and examination of the sputum, that 
 the pleuritis was entirely due to cold, and that the patient was 
 free from tuberculosis. 
 
 What is the character of the effusion in our patient ? In 
 cases of pleuritis caused by cold only, and also in pleuritis of 
 this nature in tuberculous persons, the effusion is usually, at 
 least at the beginning, of a serous character. To decide the 
 question of the nature of the pleuritic exudate we have to resort to 
 a trial aspiration ; but this procedure has to be adopted only 
 when the disease yields to no other treatment, whereas our treat- 
 ment is only just begun. 
 
 Prognosis. — Pleuritis caused by a cold, as well as pleuritis with 
 pulmonary tuberculosis, may eventuate in a complete return to 
 health ; but the condition of our patient must nevertheless be 
 recognized as serious, namely, as such, which, without present- 
 ing any immediate danger, may lead to it in the future, as we 
 learn from the pathology of the disease. 
 
 Treatment. — ■ Before discussing the treatment of our patient, 
 I must make a few general remarks concerning my treatment 
 of pleurisy, as it differs from the treatment recommended by the 
 most widely read text-books on internal pathology and thera- 
 peutics. 
 
— 267 — 
 
 Thus we find in Eichhorst's Handbuch d. speciell. Pathol, u. 
 Therapie ( fourth edition, vol. I, p. 590) : 
 
 " In a recent and uncomplicated serous pleuritis we must, in 
 the beginning, quietly wait " (Bei einer frischen, nicht complicir- 
 ten serosen Pleuritis, warte man zuniichst ruhig zu). Later on, 
 if during the second and third week the disease presents no 
 changes, we are to employ internal remedies to aid in the absorp- 
 tion of the exudate ; but if by the fourth or fifth week we were 
 unable to achieve any success, and the effusion is considerable 
 or is even increasing in quantity, then we must resort to thora- 
 centesis to effect its removal. Of internal drugs to aid absorp- 
 tion, Eichhorst recommends iodine (with due care also exter- 
 nally, over the painful side of the chest), diuretics, seldom 
 laxatives, rather strong diaphoretics (subcutaneous injections 
 of pilocarpine hydrochlorate and per os salycilic acid and so- 
 dium salycilate), while for debilitated and anaemic patients, 
 nutritious food and strengthening measures. 
 
 But I, on the contrary, consider it erroneous to " wait quiet- 
 ly " until the second or third week, limiting one-self to hygiene 
 and palliative measures. My observations teach me that the 
 sooner we succeed in breakuig up the acute stage of the pleu- 
 risy, the more favorable will be the further course of the dis- 
 ease, and the sooner will occur absorption of the effusion and 
 the possibility of aiding it by therapeutic measures. Even in 
 those cases, as for instance, in acute pleurisy in syphilitic or 
 tuberculous patients, in which, later on, the cure of the pleurisy 
 and the return to health in general will be effected by other 
 treatment, having a particular, special relation to the principal 
 disease, as iodide and mercury in syphilis, creosote and its pre- 
 parations in tuberculosis, — even in such cases the acute stage 
 of pleurisy, if pronounced clearly, requires a preliminary treat- 
 ment of a particular character for itself. 
 
 The principal symptoms which characterize the acute stage 
 of pleurisy, and which form an indication for such a treatment 
 are fever and pain in the chest ; with these there are, of course, 
 dyspnoea and a dry cough, which are the more embarrassing 
 the more prominent the first two symptoms : until these last 
 are removed, or at least consider-ably relieved, we cannot hope 
 for the absorption of the effusion to take place. 
 
— 268 — 
 
 For the treatment of the acute stage of pleuritis, for the re- 
 moval of the above-named symptoms, I resort to the following : 
 To relieve the pains I employ blood-letting;* certainly in 
 patients who are not anaemic, but in those with good nutrition 
 and strength, and consequently, as we can see by the aetiology 
 of the disease, in cases of rather unfrequent occurrence. Next 
 to blood-lettmg, or, if this be contra-indicated, then at once, 
 keep the painful side warm, as in the present case, or in case of 
 necessity, give hypodermic injections of morphine, and internally 
 codeine, Dover's powder, or again morphine to quiet the cough 
 that tends to aggravate the pains m the chest. 
 
 The best remedy against the fever I consider to be sodium 
 salycilate ; at the same time I administer stimulants (to guard 
 against collapse), which are, moreover, generally indicated m 
 pleuritis. It is here, in the acute stage of pleuritis, that the 
 great usefulness of this drug becomes apparent, as it causes a 
 fall in the temperature and at the same time induces a pro- 
 nounced relief of the pains, of the dyspnoea and cough. I ad- 
 minister the drug in ten-grain doses, and during twenty-four 
 hours I begin with thirty or forty grains and increase the 
 quantity as required ; m moderately severe cases, as the present 
 one, three or four days of such treatment are sufficient to bring 
 about the desired result. 
 
 I will not stop to discuss here the various drugs, the effect of 
 which is similar to that of the salycilate of soda (as antipyrin, 
 antifebrine, phenacetine), to which, in pleurisy, I prefer this 
 last, but will say a few words on the use of calomel and qui- 
 nine in this disease. 
 
 I administer calomel in pleurisy only in those very rare cases, 
 in which this disease is complicated by certain morbid condi- 
 tions in the abdomen, which form an indication for calomel 
 (of this I spoke before) ; consequently calomel is given not 
 against the pleuritis itself, but with a view of meeting such 
 indications. 
 
 Quinme does not have even a shadow of the effect produced 
 by the salycilate of soda in pleurisy. While speaking of the 
 comparative effects of quinine and sodium salycilate in pleurisy, 
 
 * Vide article on ''blood-letting." 
 
— 269 — 
 
 I will mark down the following difference between them, as 
 observed in my experience : quinine acts well in febrile affec- 
 tion of the respiratory tract (of the nose, pharynx, larynx, tra- 
 chea, bronchi} of a catarrhal nature caused by colds, better than 
 the sodium salycilate ; this last acts well in febrile diseases of the 
 organs of locomotion due to colds, and especially of the muscles, 
 aponeuroses and articulations (in the healthy organism, as well 
 also as in the gouty, syphiKtic, and in the one generally dis- 
 eased), in which quinine exerts almost no effect whatever. 
 
 I will take up now the further treatment of pleuritis. Hav- 
 ing removed the above-mentioned acute symptoms so as to 
 further absorption of the effusion, I take particular care to 
 establish a regular functional activit}^ of all parts of the organism, 
 a good nutrition and a favorable condition of the nervous sys- 
 tem ; as what concerns therapy, I apply flying blisters, so as 
 not to keep up the irritation later on, over the pamful half of 
 the chest. With the exceiDtion of in syphilitics, I do not use 
 iodine internally m pleuritis, as I did not obtain any benefit 
 from it, but on the contrary harm, the general condition be- 
 coming worse ; iodine externally fails to produce any marked 
 effect, while it annoys the patient and hmders the application 
 of the blisters. Except when necessary laxatives are certainly 
 harmful, as they tend to weaken the patient. The diuretics can 
 not be relied upon to a great extent. The strong diaphoretics 
 are very risky, and may be used only for exceptional cases, and 
 even then they can hardly be preferred to the operative method 
 for removing the effusion. 
 
 As what concerns this last procedure I resort to it, first, 
 when the exudation, if considerable, is not undergoing any ab- 
 sorption for a long time ; but still I do not hasten, and do not 
 limit myself to the four or five weeks' period recommended by 
 the text-books ; I had occasion to observe that a considerable 
 effusion which had existed longer than this period, and which 
 in the opinion of some physicians required operative abstraction, 
 but which was not thus removed at the advice of other physi- 
 cians, imderwent absorption with the improvement in the gen- 
 eral condition of the patient, thanks to better hygienic condi- 
 tions and to a more careful surveillance over the regularitias of 
 
— 270 — 
 
 .functional activity and over the condition of nutrition and of 
 the nervous system of the patient ; secondly, in case of rapid 
 mcrease in the effusion, and of the danger to life accompany- 
 mg this mcrease because of the pressure on and displacement 
 of the neighboring organs ; thirdly, in cases of purulent and pu- 
 trid effusion, which tends to keep up the exhausting fever. 
 
 I turn now to the treatment of our patient. Blood-letting is 
 contra-indicated by his debilitated constitution and nutrition, 
 and we therefore had to limit ourselves to keeping warm the 
 painful side of the chest and to quieting the cough. As the 
 temperatm^e w-as high last night, d9.6°E. (103.3°^.), we will 
 prescribe to-day sodium salycilate, begimiing with four ten- 
 grain doses per day, each dose in one-fourth glass of warm Ems 
 water. The stimulants, which were indicated even yesterday by 
 the weakness of his pulse, it is the more necessary to continue 
 giving to-day, in view of the fact that we are administering so- 
 dium salycilate, as far as necessary and in a larger dose. 
 
 As what concerns hygienic conditions, the prmcipal ones in 
 pleuritis are rest and warmth. The '' ambulance " treatment of 
 pleuritis, even if this last be inconsiderable, will lead, particularl}^ 
 in the cold season of the year, to a more dangerous aggravation 
 of the disease. 
 
 FROM THE LECTURE OF FEBRUARY 3, 1893. 
 
 The course of the disease. — January 29th we gave him forty 
 grains of the salycilate, the evening temperature was 38.4° i^. 
 (101.1°-F.) ; the night of January 30th was spent somewhat 
 better. The 30th he was given fifty grains of the salt, the 
 evening temperature was 37.5°i^. (99.o°i^.) ; had a very good 
 night the 31st ; January 31st and February 1st he was given 
 forty grains of the drug each day, and the temperature fell 
 then for good, while the condition of the patient improved at 
 once. Yesterday, February 2d, he w^as not given any of the 
 salt at all. 
 
 Status. — He feels very well; has an appetite. Had regular 
 stools for the last two days without clysters. The urine in- 
 creased in quantity, and is not red. The pain on the left side 
 
— 271 — 
 
 of the chest is much relieved and he can breathe more freely ; 
 the number of respirations is twenty-four per minute, instead of 
 thirty-six as formerly. He coughs much less. The quantity 
 of expectoration has not dimmished, and it contains tuberculous 
 bacilli. The pleuritic friction murmur disappeared. The area 
 of dullness has dimmished. In the area of dullness,, as well as 
 all over the left side of the chest in general, the respiratory 
 murmur, which was formerly weak and of an indefinite quality, 
 became much clearer, while in the region of the apex of the 
 left lung, in front, under the clavicle, as well as behind, there 
 appeared moist rales. The pulse is 80 and of fair volume. 
 Last evening's temperature, S6.6°B. (97.9°i^.). This morning, 
 36.5°^. (97.6°^.). His sleep is good. There is neither headache 
 nor dizziness on getting up. He is gathering more strength. 
 
 The presence of the tubercle bacilli in the sputum and of 
 the rales in the superior apex of the left lung, which could 
 not be heard when the patient was unable to fully expand the 
 left lung, as he could not breathe sufficiently deep, and which 
 became noticeable now when breathing became free, speak 
 for tuberculosis of the lungs. 
 
 The beneficial effect of the sodium salycilate is but too 
 evident in the present case. After the first few days of the 
 patient's sojourn in the clinic under entirely normal circum- 
 stances, which were more favorable than duiing the first six 
 days of the disease before his admission to the clinic, and with 
 the aid of the necessary symptomatic treatment, the improve- 
 ment in the patient's condition was but triflmg ; but from the very 
 first day that we began the use of the salycilate of soda the 
 temperature began to decline rapidly, and in four days a 
 complete breaking up of the disease took place: the tempera- 
 ture fell finally to the normal and the local symptoms de- 
 creased very markedly. 
 
 At present, while keeping continually the left half of the 
 chest warm, we will apply a blister, the size of the palm of the 
 hand, under the left scapula, and for internal use we will give 
 him creosote, beginning with five drops three times a day, and 
 increasing the dose gradually. 
 
272 — 
 
 FROM THE LECTURE OF FEBRUARY 17, 1893. 
 
 The course of the disease. — Febuary 3d we applied the first 
 blister under the left scapula ; the 9th, the second one on the 
 lateral surface of the left side of the chest. Since February 
 14th, patient is treated by inhalations of compressed air. He 
 takes creosote in eight-drop doses, three times a day. 
 
 Status. — The appetite is good, there is no dyspepsia, the 
 stools are regular, the urine normal. At times patient experi- 
 ences a trifling pain in the left side. The breathing is free. 
 There is almost no cough, and there is but very little expectora- 
 tion, which appears at times, and is absent at others. Objec- 
 tive examination shows that there is only under the scapulse a 
 slight difference in the percussion sound and that the respira- 
 tory murmur is but slightly weaker on the left side. In the 
 region of the apex of the left lung there are sometimes heard 
 a few rales, at other times they are absent. The temperature 
 is normal, the sleep quiet ; he gathers strength. 
 
 Treatment. — The blisters are not necessary any more. The 
 creosote must certainly be continued. The benefit derived 
 from inhalations of compressed air during the period of the 
 absorption of the pleuritic exudate, is but too well known. 
 The patient asserts, that after the inhalation of compressed 
 air breathing became easier and the sensation felt by him 
 heretofore, outside of the pain, of tightness in the left side, 
 was relieved (as the patient expresses it, " the side was 
 loosened "). Our patient, however, presents some contra-indi- 
 cation to this treatment, in view of the tuberculous nest in 
 the left lung, and it was only because of the inconsiderable 
 size of this nest that I ordered, three days ago, previous to the 
 absorption of the exudate, the inhalation of compressed air. 
 In the presence of more or less considerable tuberculous nests 
 such inhalations are not only not beneficial, but, on the contrary, 
 rather harmful, probably because they assist in aspiration of 
 tuberculous expectoration by the healthy portions of the lungs. 
 In our apparatus (Waldenburg's) for inhalation of compressed 
 air, the air is conducted, as you see, from outside through a win- 
 
— :273 — 
 
 dow-frame and is warmed in a special apparatus. The air for our 
 patient, conducted from the outside and warmed before being ad- 
 mitted to a Waldenburg apparatus, is passed through a Wolff 
 jar containmg eucalyptus oil. 
 
 The patient, considerably strengthened, left the clinic Febru- 
 ary 22d. He was mstructed as to the necessary regimen, and 
 was advised to continue the creosote treatment. 
 
TWENTIETH AND TWENTY-FIRST CASES. 
 
 LECTURES OF APRIL % 13 AND 14, J893, 
 
 Patient, a sergeant-major of the reserve army, age 37, en- 
 tered our clinic, March 8, 189S, complaining of dyspnoea, 
 cough with expectoration, pain in the left side and general 
 weakness. 
 
 Mode of living and ariamnesis: — Patient resides in a damp, 
 marshy,, woody locality. His rooms are very small, damp and 
 cold ; the water-closet is cold. For the last three years he 
 has almost never taken a hot bath, although he washes himself 
 at times at home ; does not smoke or drink whiskej' (he drank 
 and smoked much formerly), drinks only a little warm tea. 
 
 His food is that of an ordinarj^ workingman. He is single, 
 never had syphilis. Our patient is a clerk in a country house, 
 is much occupied, does not sleep sufhciently, is often fatigued. 
 and subjected to colds, as he is compelled to talk much and 
 loudly out-of-doors in every season of the year. 
 
 Patient comes from a healthy family. Since his nineteenth, 
 year, he was addicted to the abuse of whiskey. During his 
 twentieth year he passed through an attack of malaria, which, 
 lasted nine months. On his twenty -second year he entered the 
 military service, in which he spent five years, during which time 
 he did not drink any liquor, and enjoyed excellent health, 
 liecoming a reserve, he began to drink again, and seven years 
 ago, while employed m rafting, he began to cough, at first only 
 slightly, but later on much more. Two and one-half years 
 later, in the autumn of 1888, he suffered for the first time 
 from haemoptysis, which lasted for about one month (about one 
 half-glassful of blood daily) and weakened the patient consid- 
 erably : he grew thin, and began to complain of dyspncpa. Dur- 
 
— -275 ^ 
 
 mg the autumn of 1889 there occurred another attack of 
 hsemoptysis, which lasted a week ; patient at the same time be- 
 gan to grow feverish and to feel a pain in the left side* 
 Then, at the advice of his physician, he gave up whiskey 
 drinking and smoking, and subjected himself to treatment. Of 
 the drugs employed for treatment he remembers that creosote 
 was of the greatest benefit of all, and he had been takmg it 
 during the winter of 1891-1892, up to forty drops a day, in 
 milk; as a result of this treatment he gathered considerable 
 strength, and became somewhat stout, while the fever, cough 
 and the pain in the side diminished. Last January all the mor- 
 bid symptoms reappeared again, as the result of a cold. Pa- 
 tient has been taking since cod-liver oil (three tablespoonfuls 
 a day), at times powders of codeine, and applied blisters, but 
 there was no improvement. 
 
 During the month that the patient resided in the clinic, the 
 treatment was as follows ; as he was costive, he was given, when 
 necessary, watery clysters ; during the mornmg cough, which 
 was most embarrassing, as the expectoration was then brought 
 up with great difficulty, patient sipped about one glass of a mix- 
 ture of Obersalzbrunnen water and warm milk ; this assisted ma- 
 terially in loosening the secretion ; at bed-time, in case the 
 cough prevented sleep, patient was given one-quarter grain of 
 codeme ; the left side of the chest was kept warm ; as the pulse 
 was somewhat weak, he was given four tablespoonfuls of wme 
 dail}^ 
 
 From the very first day of the patient's sojourn m the clinic, 
 he has been taking creosote, commencing with five drops up to 
 thirty drops a day. Besides this, patient took, March 29th 
 and^SOth, some ipecacuanha (mfusi rad. ipecac, e gr. vj fvj, 
 altogether twice this quantity) which was indicated by the diffi- 
 cult expectoration with the aggravated djspncea and rales, and 
 also with the rise in temperature, up to 38.8'' it; (101. 9°i^.), 
 while before this the temperature was below 38°i?. (100.5°i^.) ; 
 after having taken the ipecac, patient expectorated very freely, 
 the dj^spnoea was relieved, the rales diminished and the temper- 
 ature reached its previous height. 
 
 Status. — Patient is of average constitution. The appetite, 
 
— 276 — 
 
 which was poor on admission, is good no\A'. Tliere was no dys- 
 pepsia before, nor is there any now. The stools are regular 
 at present. The urine flows freely, contains neither sugar nor 
 albumen, was reddish on admission, but is of a normal color 
 now. The pams in the left side of the chest, not severe before, 
 are trifling now. The dyspnoea and cough are much better at 
 present than they were when the patient was admitted to the 
 clinic. 
 
 There are no pains in the abdomen, nor does objective exam- 
 mation discover anythmg abnormal in it. At the time of 
 admission he had a muco-purulent expectoration, of about one- 
 half-glassful per day, mixed with blood ; at present it is just 
 half of what it was formerly. Repeated examinations of the 
 expectoration always showed the presence of tubercle bacilli. 
 On percussion the sound over the left side anteriorly from the 
 clavicle to the fourth rib, as well as posteriorly from above 
 down to the middle of the scapula, is duller than from the mid- 
 dle of the scapula downwards and on the right side, where the 
 percussion sound is normal ; on auscultating the left side, over 
 the area of dullness, we hear bronchial breathing and abundant 
 moist rales ; on the right side, under the clavicle, there are also 
 at times heard a few rales ; at the other parts of both the left 
 and the right sides of the chest we hear the normal respiratory 
 murmur, either vesicular or indefinite, in accordance with the 
 depth of the respiratory movements. The heart is neither en- 
 larged nor displaced, its tones are clear, the pulse was at the 
 begmning 100 and somewhat weak, but is now 88 and of fair 
 volume. When admitted, his evening temperature was about 
 ^S°R. (100.5°^.), and the morning below S1°E. (98.6°i^.) ; now 
 in the evenmg it is 37.6°i?. (99.7°-F.) or SLb^E. (99.5.°i^.) and 
 in the morning below Sl°Il. (98.6°^.). Patient is very thin : 
 his weight when admitted was 147 pounds, it is now 119. His 
 sleep is good now ; it was prevented formerly by cough and 
 dyspnoea. There is no headache. He has become markedly 
 stronger than he was on admission. 
 
 Diagnosis. — It is evident, that we have here before us a 
 pure case of chronic tuberculosis of the lungs, which causes all 
 the morbid symptoms observed in our patient, the local as well 
 
— 277 — 
 
 as the general ones, as fever, emaciation, and weakness ; the other 
 organs seem to be unaffected. The lungs may become affected 
 by tuberculosis, first, from the neighboring organs ; such cases 
 are of comparatively unfrequent occurrence generally, and are 
 particularly rarely seen in the clinic for internal diseases ; they 
 are more frequently met with, as tuberculosis of the vertebrae. 
 in surgieial and peediatric clinics ; besides, they pla}^ but a sec- 
 ondary part m the principal affection ; secondly, through the 
 blood, when there is a general infection of this last ; these are 
 also, comparatively speaking, rare cases of miliar}- tuberculosis of 
 the lungs ; and, thirdly, most frequently, through the respira- 
 tory passages, when the apices of the lungs become first affected* 
 (either both at once or at the beginnmg one, and then the 
 other), and later when the affection spreads by contiguity or 
 through aspiration of the tuberculous expectoration b}- the hith- 
 erto healthy portions of the Imigs ; these are the cases, which are 
 known in pathological anatomy as broncho-pneumonia tuberculosa 
 chronica, and which are called in common parlance consump- 
 tion of the lungs, and in the clmics, hospitals and by physicians 
 chronic tuberculosis of the lungs. The present case belongs 
 evidently to this last class : the tubercular affection of the Imigs, 
 in view of the other unaffected organs, is present beyond doubt 
 and to a considerable extent : both the superior lobe of the left 
 lung and the apex of the right one are affected : the anamnesis 
 gives sufficient proofs of its chronic course, ^^'hile the absence 
 
 * This is, however, a disputed question. Thus Volland (Zeitschrift 
 fiir clinische Medicin, 1893), denying that the presence of the tubercle 
 bacilli in the air was ever proved, assumes, that infection by tuberculosis 
 takes place in infancy, when the children are not on the arms of the 
 mother or nurse, but unable as yet to walk, they crawl about, rub their 
 hands over the floor, on which there may be some tuberculous expecto- 
 ration, and then over their faces, and thus infect themselves through 
 accidental lesions of continuity, so frequent around the mouth and nose. 
 The infection by tuberculous and other microbes gives at first rise tu 
 eruptions ("scrofulous"), and later to an affection of the lymphatic 
 glands ; then in the presence of a predisposition to tuberculosis, be it 
 hereditary or acquired, the disease will sooner or later spread from the 
 primary focus in a general way, but most frequently along the lymphatic 
 vessels and the glands of the neck andpleui-a, the apices of the lungs, etc. 
 Kesting on these grounds and on some other data, which he cites, 
 Volland insists upon prophylactic measures consistent with these last. 
 
— -278 — 
 
 of the exhaustive fever (namelv, chills, constant and consider- 
 able rises and falls of the temperature as well as abundant 
 sweating) shows, that the period of consumption, phthisis 
 proper, has not as yet arrived. 
 
 The prognosis will be more conveniently discussed, when we 
 speak of the prognosis in chronic pulmonary tuberculosis in 
 general ; while the treatment, in view of the success attained by 
 it, will of course remain the same. 
 
 Patient left the clinic by the end of April, considerably 
 strengthened and markedly grown, his weight being one hun- 
 dred and fifty-six pounds, as against one hundred and forty- 
 seven on admission ; he had no fever, no pains in the side, 
 almost no dyspnoea, and a slight cough with about one-fourth 
 of a glass of expectorated matter per day; he was advised to 
 continue the creosote in constantly increased doses. 
 
 This patient is a woman, forty-six years old, who entered the 
 clinic April 2, 1893, complaining of dyspnoea, cough, and 
 general weakness. 
 
 Mode of living and anamnesis. — Patient has been livmg for a 
 long time, during both winter and summer, in jMoscow. Her 
 residence was always a poor one, of late she lived in the base- 
 ment of a stone building, which was cold and damp, the water- 
 closet cold. Takes a hot bath every week. For the last half- 
 year patient gave up smokmg and whiske}' drinkmg, but used 
 to smoke before, and drank a wineglassful of whiskey with both 
 dinner and supper ; drinks but little tea ; her board is that of 
 a working-woman. Her occupation — in the line of house- 
 keeping — ■ is burdensome, so that patient frequently does not 
 sleep enough and is overworked. Goes but rarely out-of-doors. 
 Has been married for twenty-six years, has had eleven deliveries, 
 all normal, last time eight years ago ; has five children living ; 
 presents no indications of syphilis. 
 
 Patient comes from a healthy family, and enjoyed during her 
 childhood fair health. When fifteen years old she passed 
 through an attack of typhoid fever. Later on she caught fre- 
 
— 279 — 
 
 qiient colds and coughed at times. Twelve years ago she had 
 a slight attack of acute articular rheumatism. Eight years ago 
 a pleurisy on the right side, after which the cough became con- 
 stant, more severe in the winter than in the summer, accom- 
 panied at times by fever and pain in the right side. Last 
 January (1893) the patient's condition became considerably 
 aggravated, as a result of vexatious troubles and of a cold : the 
 cough became very severe ; there appeared considerable dysp- 
 noea and a feverish condition, the patient grew thin and lost 
 strength, and her voice became very hoarse and weak. As far 
 as treatment is concerned, patient resorted lately, as well as be- 
 fore, to the use of Dover's powders, and at rare times to ipeca- 
 cuanha ; she never took any creosote. 
 
 Durmg her residence in the clinic patient was given, when 
 necessary, a watery clyster, and every morning a glassful of 
 Obersalzbrunnen water with milk, to be sipped during the 
 cough ; at bed-time a powder containing one-fourth grain of 
 codeine, and durmg the day twentj^ drops three times a day 
 of the mixture of liq. anod. Hofmanni and liq. ammoniianisati* 
 aa. Besides this, patient took, on her admission, ^vj of mfu- 
 sion of ipecac (e gr. vj), then terpine hydrate, five grains 
 per dose, at the beginning twice, and later on three times 
 per day, and for the laryngeal catarrh she inhaled atomized 
 silesian water. 
 
 Status to-day, April 9th. — The aj)petite, which was poor on 
 her admission, is better now. There is no dyspepsia. The 
 former costiveness is somewhat relieved. The urine, which 
 was reddish formerly, is almost of normal color, without al- 
 bumen or sugar. The abdomen in general and the regions of the 
 liver, spleen and kidneys present nothing abnormal. Menstruation 
 is unfrequent — once in two or more months (last time one 
 month ago) — quite abundant, but painless ; no leucorrhoea. 
 
 When admitted, she had considerable dyspnoea, pains all 
 over the chest, and especially in the right side, severe cough, 
 some expectoration, mostly of a muco-purulent character, partly 
 foamy and tinged with blood, more than a glassful during 
 
 * Liq. ammon. anisatus is a mixture consisting of liq. amnion. 19.5 per 
 cent., anise oil 2.4 per cent, and alcohol (90 per cent.), 78 per cent. 
 
— 280 -- 
 
 twenty-four hours ; the expectoration shows, at times, the pres- 
 ence of the tubercle bacilli; percussion elicits nothing abnormal 
 anywhere in the chest, on auscultation we hear everywhere a great 
 number of rales, dry and moist, and over the apex of the right 
 lung, in front and in the back, some slight bronchial breathing 
 (the percussion sound is not altered in those places). At pres- 
 ent the dyspnoea, cough and expectoration, as well as the rales, 
 are much less prominent, the pain m the chest is greatly re- 
 lieved. The voice, which was very hoarse and weak on her ad- 
 mission (laryngoscopic examination showed the presence of a 
 laryngeal catarrh), is clearer and stronger now. The heart is 
 neither displaced nor enlarged, its tones are clear, the pulse, 100 
 and weak on admission, is now 84 and stronger. 
 
 The highest temperature the patient reached during her stay in 
 the clinic, took place the day before yesterday : namely, 37.8°i^. 
 (100°^.) in the mornmg, 38.2°i?. (100.7°^.) in the evenmg ; 
 this morning the temperature was 37.6° i^. (99.6°i<'.), last even- 
 ing, 37.8°i?. (100° J^.) Her sleep, which was formerly pre- 
 vented by the cough, is at present much more quiet. At rare in- 
 tervals patient suffers from migraine, and, when fatigued, from 
 dizziness. She is much stronger than she was when admitted. 
 
 Diagnosis. — The presence of tubercle bacilli m the expectora- 
 tion is an undisputable proof that the patient has pulmonary 
 tuberculosis, while the other data, concernmg both her present 
 condition and her past history, as the bronchial breathing and 
 the rales in the region of the apex of the right lung, the pains 
 m the right side of the chest, and the chronic course of the disease, 
 strengthen this supposition and point to that form of tuber- 
 culosis from which our previous patient also suffers, namely, 
 chronic tuberculous broncho-pneumonia. But the two cases 
 differ from each other hy the great variance in the local, as well 
 as in the general symptoms, and by the course of the disease. 
 
 Let us take the local data first. Our male patient presents 
 pronounced symptoms of a complete affection of the whole 
 upper half of the left lung, as evidenced by dulhiess in this 
 region, by bronchial breathing and abundant rales, while the 
 other parts of the chest, with the exception of the few rales 
 heard at times on the right side, under the very clavicle, pre- 
 
— 281 — 
 
 sent nothing morbid, as evidenced by a normal percussion 
 sound, and a normal respiratory murmur ; in our female patient 
 the percussion sound is everywhere normal and there are rales 
 in abundance all over the chest. The male patient has evident- 
 ly a complete tubercular affection of a considerable extent of 
 the upper portion of the left lung, while the remaining parts of 
 the lungs, outside of the right apex, are unaffected either by 
 tuberculosis, or by a simple bronchial catarrh ; in the female pa- 
 tient, if we consider the bronchial breathmg and the rales in the 
 region of the right apex as a sign indicating the presence of a 
 tuberculous nest (which is shown loj the presence of bacilli in 
 the sputum) in this region, what then must be the condition of 
 the remaining parts of the bronchi and of the lungs ? We may 
 suppose in this connection two morbid conditions : first, an or- 
 dinary bronchial catarrh, secondly, a chronic tubercular broncho- 
 pneumonia diffused all over the lungs, not, however, as a com- 
 plete process, but in small islands surrounded by pulmonary 
 tissue containing air, and which do not therefore cause any dull- 
 ness nor bronchial breathing ; such cases are usually observed 
 during the further course of the disease (as their development 
 requires some time), at its very termmation, at the period of phthi- 
 sis, when the exhaustive fever and the extreme emaciation of the 
 organism foretell the approach of the fatal issue ; but even at 
 this time, when the aspect of the patient itself is a clear indica- 
 tion of the diagnosis and of the prognosis, even then the physi- 
 cian can only hear rales on auscultation, but can nowhere obtain 
 a sure alteration in the precussion sound, nor generally any 
 positively certain symptoms of a compact thickening of the pul- 
 monary tissue. 
 
 Before we decide as to which of the two diseases our female 
 patient suffers from, whether it is a chronic, at times exacer- 
 bated, bronchial catarrh, or a chronic tubercular broncho-pneu- 
 monia diffused all over the lungs in its last stage, let us compare 
 the course of the disease and the general condition of both 
 patients. The male patient is thirty-seven years old, he comes 
 from a healthy family, lived under unfavorable conditions of life 
 and abused alcoholic drinks, but for the last three years he has 
 not been drinking or smoking, and has subjected himself to 
 
— 282 — 
 
 quite a radical treatment ; but this notwithstanding, having 
 been ill only seven years, he loses his health steadily. 
 
 The female patient is forty-six years old, she comes from a 
 healthy family, has been surrounded by similar poor circum- 
 stances, has also been a drinker (although a rather moderate 
 one, as she asserts) and a smoker, has had eleven children, has 
 been ailing for eight years, had never subjected herself to radi- 
 cal treatment, and still her health is not failing as rapidly as it 
 does in the male patient ; on the contrary it is rather in a con- 
 dition of a tolerable statu quo, worse in the winter as regards 
 the cough and the dyspnoea, and better during the summer, but 
 it is not accompanied by such periods of fever and such a con- 
 tinuous emaciation, as we find in our male patient. Let me 
 add, that while in the clinic, the woman improves more rapidly 
 than the man (thus, the fever, generally trifling and without 
 having the slightest symptom of an " exhaustive" nature, dis- 
 appears itself without any resort to antifebrile remedies) ; still 
 we did not as yet give her any creosote, while the man began to 
 take it from the very day of his admission to the clinic. 
 
 We are justified then in concluding from the above state- 
 ments, that our female patient has a moderately developed 
 broncho-pneumonia tuberculosa chronica and a diffuse chronic 
 bronchial catarrh, but not a broncho-pneumonia tuberculosa 
 chronica disseminated over the whole lungs, in its last stage. 
 This conclusion is strengthened also by the fact, that the 
 muco-purulent expectoration, peculiar to bronchial catarrh, as 
 observed in our patient, contained only at rare intervals the 
 tubercle bacilli, whereas the sputum of phthisical patients 
 contains them usually in abundance. 
 
 Prognosis. — The chronic bronchial catarrh, as well as the 
 broncho-pneumonia tuberculosa chronica as developed in our 
 patient, are both yielding to treatment, which is the more en- 
 couraging, as the patient up to this time was treated solely in 
 a palliative way. 
 
 Treatment. — To explain why we gave the patient Obersalz- 
 brunnen mixed with milk in the morning, codeine at bedtime, 
 the mixture of liq. anod. Hofmanni and liq. ammonii anis., 
 as a cardiac stimulant and as a means to promote expectoration, 
 
— 283 — 
 
 during the day, and why we gave on her admission ipecac ; to 
 explain all these after what was said in connection with the treat- 
 ment of the foregoing case, appears to me superfluous ; as re- 
 gards terpine hydrate, I will say, that on a par with the alka- 
 line mineral waters, it forms the best remedy, of those for 
 internal use, for the treatment of chronic bronchial catarrh ; as 
 soon as the exacerbation of the disease, which compelled the 
 patient to come to the clinic, has quieted down, we will begin 
 the treatment by creosote. 
 
 (The female patient continued the above outlined treatment 
 up to the time she left the clinic, April 23d ; when she left 
 her condition was as follows : appetite normal, stool regu- 
 lar, the dyspnoea, cough, expectoration and rales have dimin- 
 ished greatly, there are no pains in the right side, nor is there 
 any fever ; the sleep is sound, the patient gathered strength 
 and became somewhat stout; she weighs 133 pounds as against 
 129 she weighed when admitted. She was prescribed creosote 
 treatment.) 
 
 GENERAL REMARKS CONCERNING THE DIAGNOSIS 
 OF CHRONIC TUBERCULOSIS OF THE LUNGS. 
 
 We have analyzed four cases of chronic pulmonary tubercu- 
 losis. 
 
 First, episodic, transient affections of the lungs by tuberculo- 
 sis, which precede the development of the permanent disease 
 in a person predisposed to tuberculosis because of a weakly 
 constitution and the presence of chloraneemia. 
 
 Second, a small tuberculous focus in the apex of the left 
 lung, complicated by pleurisy of the left side. 
 
 Third, a complete considerable affection of the left lung 
 and an incipient affection of the right one, without any compli- 
 cations. 
 
 Fourth, a moderate affection of the lungs (apparently, to a 
 greater extent, of the right one), complicated by a chronic 
 bronchial catarrh, which at times becomes greatly exacerbated. 
 
 The cases of pulmonary tuberculosis, which are to be seen 
 at this time in the clinic, present, outside of the two last 
 
— 284 — 
 
 discussed cases, the same condition as tlie third case ana- 
 lyzed by us, namely, chronic tuberculous broncho-pneumonia in 
 various stages of development, but without any complications 
 and in general without any pronounced peculiarities, and there 
 appears therefore no reason for taking them up for discussion. 
 There is one case of chronic pulmonary tuberculosis in its last 
 stage, in that of phthisis declarata, but the patient is so exhaust- 
 ed, and the final issue is so near at hand, that it is impossible to 
 transfer him from his small ward into the auditorium for dem- 
 onstration before the class. 
 
 However, the four cases discussed by us represent practically 
 the most important clinical forms of chronic pulmonary tubercu- 
 losis — those which are particularly accessible to treatment, and 
 in which treatment is of the greatest benefit. The complications 
 which occurred with them — chloransemia, pleurisy and bron- 
 chial catarrh — are also very important, as they are observed 
 particularly often. 
 
 It is true, that the multiplicity of forms of chronic tuberculo- 
 sis of the lungs, which is to be seen in medical practice and 
 which depends on the peculiarities in the course and develop- 
 ment of the tuberculosis itself, and on the complicating diseases 
 and the peculiarities of the affected organs, is far from being 
 exhausted by the cases we discussed ; but not only in the clinic, 
 not even in a systematic text-book of internal diseases, un- 
 less it be in a special monograph, can this multiplicity be ex- 
 hausted, or a complete picture of all the various forms of chronic 
 tuberculosis of the lungs to be seen in medical practice, be pre- 
 sented. 
 
 I consider it, however, useful to outline before you now, after 
 we have discussed the previous cases, a clinical picture of those 
 varieties of the disease, which we had no opportunity to bring 
 before you, at least the most important ones ; my aim in doing 
 this is, that the cases presented to you alongside with these 
 forms, as well as these last side by side with the presented 
 cases, might become more salient, and might be better and more 
 strongly impressed on your memory, than is usually the case 
 when pathology is studied systematically, but without the aid 
 of a clinic. 
 
- 285 — 
 
 The last stage of chronic tuberculosis of the lungs is pulmon- 
 ary phthisis, phthisis declarata. You had occasion to see a suffi- 
 cient number of such patients both in our clinic and in the 
 propsedeutic clinic when you were engaged in studying the ob- 
 jective examination of the diseases of the organs of respiration ; 
 you are familiar with the sharp local changes, with the charac- 
 teristic abundant expectoration, containing great numbers of 
 tuberculous and other bacteria and elastic fibres of the broken- 
 down pulmonary tissue, and also with the characteristic habitus 
 of such patients : their extreme emaciation, their great debility 
 (the patients, when seen, are always in the recumbent posture), 
 the high jumps and the low falls of the temperature, the ex- 
 hausting sweats. How great is the difference between these 
 and the cases of chronic tuberculosis of the lungs in its in- 
 cipient, or frequently even in its advanced development, 
 when the patients, only slightly or not at all emaciated, with 
 but a slight cough, without a constant or considerable fever 
 (only a trifling rise of the temperature toward the evening 
 without QMj considerable fall in the morning), — are not only 
 not confined to bed, but are actively occupied with their affairs, 
 and look simply like men whose health is not quite up to the or- 
 dinary, but by no means like pronouncedly sick people. I will 
 stop here to discuss the importance of the exhaustive fever — 
 the febris hectica — seen in phthisical patients, which is so 
 characteristic by the high jumps and the low falls of the tem- 
 perature, and also by the sweatings which accompany these 
 last. As is well known, the expectoration of phthisical patients 
 contains, besides the tubercle bacilli, also numbers of other 
 micro-organisms to which is ascribed the pernicious influence 
 on the organism of the patient, and which are considered as 
 the cause of the last, phthisical stage of chronic pulmonary 
 tuberculosis ; but until recently the nature of the special micro- 
 organism, which is accountable for this pernicious influence, 
 has not been thoroughly mvestigated. Exact investigations 
 touching upon this subject have lately appeared from the Insti- 
 tute for Contagious Diseases under the supervision of Prof. Koch 
 at Berlin. (Petrushky, Tuberculose und Septiccemie, Deutsche 
 med.Wochenschrift, 1893, No. 14.) 
 
^ 286 — 
 
 In the expectoration, which was subjected to a certain process, 
 ■ by which everything that was mixed with it in the cavity of 
 the mouth was removed, there were found much smaller num- 
 bers of bacteria, than in the expectoration which was mixed 
 with the saliva ; it was found that this expectoration, free from 
 saliva, contains principally tubercle bacilli, and of the others 
 the most constant and the most abundant were the pyogenic or- 
 ganisms, namely, the streptococci. They were also found in 
 the tissue of the lungs and other organs, and also in the blood 
 of dead phthisical persons, so that, according to Koch, the last 
 stage of chronic pulmonary tuberculosis presents already a com- 
 plication of this last by a secondary infection of the organism 
 through streptococci, which enter the body through the ulcer- 
 ated spaces (the cavernse) in the lungs, in a way very similar to 
 that in which they infect the organism when entering through 
 wounds. It thus becomes clear, why the fever in the last stage 
 of chronic tuberculosis of the lungs has the identical features of 
 that seen in septic wound mfections. Koch calls the tempera- 
 ture curve in this fever, for brevity's sake, streptococcus curve 
 (Streptococcencurve.) * 
 
 Pneumoyiice complicating chronic ful'monary tuberculosis. — Fi- 
 brinous (croupous^ pneuononia occurs, although very rarely, in 
 chronic tuberculosis of the lungs and is easily diagnosticated, 
 especially if it affects a patient whom the physician knew be- 
 fore : in such a case the physician will be able to detect, beside 
 the old, well-known tuberculous focus in the apex, say, of the 
 right lung, also an affection of the whole of the inferior lobe of 
 the same or of the other lung, as evidenced by the dull percus- 
 sion sound, by crepitation, bronchial breathing, subcrepitation ; 
 the expectoration will be tmged with blood and will contain 
 along with the tubercle bacilli, pneumonic diplococci, while 
 
 * iSTot all, however, entertain a similar view on this subject: Leyden 
 does not believe that other micro-organisms, besides the tubercle bacilli, 
 play any part in the phthisical period ; he points out the fact that in 
 miliary tuberculosis and in tubercular caseous pneumonia the fever is 
 very high, and still we find only tubercle bacilli, and no other micro-or- 
 ganisms in these cases ; Frankel states, that in many cases of tuberculous 
 pneumothorax the pus contains only tubercle bacilli {Berlin. Klinische 
 Wochenschrift, 1893, :N'o. 42, pp. 1029-1030). 
 
— 287 — 
 
 the temperature will rmi the course so peculiar to croupous 
 pneumonia. The disease may terminate in recovery or death, 
 but if recovery takes place, there is usually observed an aggra- 
 vation in the course of the tuberculous process. 
 
 But more frequently chronic pulmonary tuberculosis is com- 
 plicated by catarrhal and caseous pneumoyiice, which are emi- 
 nently peculiar to it. Here also the diagnosis is easier, if the 
 patient was known before. The physician then observes simulta- 
 neously with the sudden rise and the further pneumonic course of 
 the temperature, a rapid increase of the local changes : the well- 
 known sign of tuberculous affection, for instance, of the apex 
 of the right lung, the slight dullness under the very clavicle, 
 with prolonged expiration and in the presence of rales, is ob- 
 served to be spreading to a greater distance down to the third, 
 and then to the fourth rib, and later on further, becoming more 
 intense all the while ; the same is observed in the posterior sur- 
 face of the chest ; with this there are heard over the area of the 
 dull percussion sound rales and bronchial breathing. A whole 
 lung may thus become affected in a short time ; but generally the 
 affection spreads at a slower rate than in the case of croupous 
 pneumonia, and, besides, usually from above dowTiward, and not 
 in the opposite direction, as ordmarily occurs in croupous pneu- 
 monia. Concerning the termination of the disease, there are 
 cases in which the pneumonic fever keeps on but for a short 
 time, the affection of the lung is not considerable and passes 
 away with the fall of the temperature, leaving traces of the 
 former tuberculous focus, at times slightly increased ; in such 
 cases the pneumonia is very likely of a catarrhal nature. In 
 other cases the affection of the lungs spreads to a considerable 
 extent and does not become limited, the high temperature of a 
 pneumonic character, with its slight difference between morning 
 and evening does not fall, and the patient succumbs after a few 
 weeks (four to eight) from the commencement of the pneumonia. 
 Autopsy shows in these cases a considerable caseous pneumonia, 
 which terminated in the destruction of pulmonary tissue and 
 the formation of cavities. These are the cases of what the 
 Frenchmen call galloping pulmonary phthisis. 
 
 There was one such case that has left a particularly strong 
 
— 288 — 
 
 impression on my mind. The patient, whom I have known for 
 •several years, had small tubercular foci in both pulmonary 
 apices, at times expectorated blood and was feverish, but had 
 nevertheless enjoyed fair health and was very active. After 
 one certain period of time, unfavorable to his health (after a fa- 
 tigue and a cold), his temperature rose suddenly and the area of 
 dullness under the right clavicle began to spread downward 
 and also on the posterior surface of the right half of the 
 chest. During six weeks, until the patient's death, the tempera- 
 ture vacillated constantly between S9°B. (102°F.) and 39.5° i^. 
 (10SA°F.') m the mornmg and 39.5°i^. (103.1°!^.) to 4:0°R. 
 (104°J^'.) in the evening, while the right lung was almost com- 
 pletely affected. 
 
 It is thus evident that the clinical pictures j^i'esenting the 
 pneumonic complications of pulmonarj^ tuberculosis, the or- 
 dinary course of this last and its last phthisical stage, differ one 
 from the other, and enable one to recognize these various mor- 
 bid conditions. 
 
 Acute miliar^/ tuberculosis of the lungs may also be superadded 
 to chronic tuberculosis (i. e. to chronic tubercular broncho-pneu- 
 monia), and its clinical picture differs also from the clinical pic- 
 tures of the usual course, of the last stage and of the pneumonic 
 complications of this last ; it is rather similar in its clinical as- 
 pects to an irregular typhoid fever ; but it is more opportune 
 to discuss acute miliary tuberculosis in general and that 
 of the lungs in particular when we chance to come across, if not 
 a case of this comparatively rare disease, then one of typhoid 
 fever. 
 
 The most important complications of chronic tuberculosis of 
 the lungs by affections of other organs, outside of those we dis- 
 cussed above, are pneumothorax and pyopneumothorax, tubercu- 
 losis of the larynx, and intestinal tuberculosis. Clinical pictures 
 of these diseases enable one to fully recognize their presence. 
 
 As regards the peculiarities in the clinical picture and in the 
 course of chronic pulmonary tuberculosis, which are determined 
 by the peculiarities of the affected organs, I will only note the 
 following. Persons who fall victims to chronic tuberculosis of 
 the lungs may be subdivided into three classes : there are those 
 
— 289 — 
 
 who are by nature of a weak constitution, with a narrow and 
 flat, under-developed chest (in proportion to their height) ; 
 they frequently come from as weak and even tuberculous par- 
 ents, and present but too evident a predisposition to tubercu- 
 losis of the lungs ; others, on the contrary, who were formerly 
 of a strong constitution, robust, and enjoyed the best of health, 
 become affected by pulmonary tuberculosis after their health 
 had been previously undermined, most frequently by syphilis, 
 alcoholism, prolonged and severe malaria, or diabetes mellitus ; 
 quite often these persons succumb sooner than those belonging 
 to the other categories (m those previously affected with dia- 
 betes mellitus the course of pulmonary tuberculosis is always 
 liable to be unusually rapid, more so than in any other case) ; 
 lastly, persons of the third class do not present the character- 
 istic peculiarities of either of the above two classes. 
 
 Prognosis of chronic tuberculosis of the lungs. — I must repeat 
 what I took occasion to say two years ag-o while comparing the 
 treatment of pulmonary tuberculosis by injections of Koch's 
 tuberculin (discussed at that time) with the treatment of this 
 disease by the usual method, with the aid of creosote, arsenic, 
 koumyss and cod-liver oil, in connection with the necessary symp- 
 tomatic treatment, for the removal of difficult and exhausting 
 symptoms, and with correct hygienic measures, including, of 
 course, the climate. I said then : " What results did we obtain 
 from this treatment ? What experienced physician has not ob- 
 served, even in the advanced — but certainly not in the last — 
 stage of pulmonary tuberculosis a considerable improvement 
 for a period of years, and in the incipient period, a complete 
 recovery of the general health ad integrum, while all the local 
 symptoms, subjective and objective, disappear unless there re- 
 mains only a slight difference between the respiratory murmur 
 over the apex of the healthy lung and that of the affected one ? 
 What experienced physician has not noticed that such a re- 
 covery of health, such a cure, may last for years ? I had occa- 
 sion to keep under observation such recovered patients for pe- 
 riods of from five to ten years, before I lost track of them. It 
 is true, that at times, after several years of such a favorable 
 condition, the patient will reappear again with symptoms of pul- 
 
— 290 — 
 
 monary tuberculosis ; but it can usually be proved that this 
 .fresh reappearance of the symptoms has been preceded by a 
 weakening in the general condition of health, because of an ir- 
 regular mode of living, unsatisfactory circumstances, or an attack 
 of some painful disorder; it thus remains, in such cases, to decide 
 whether all this was due to the lighting up of the old focus, or 
 to the appearance of a fresh infection. Finally, such a method 
 of treatment, whether it result in the above-outlined favorable 
 issue or not, is neither risky nor fraught with any danger, as is 
 so frequently the case during the treatment by injections of 
 tuberculin." 
 
 The slighter the local, i. e. the pulmonary affection, and the 
 better the general condition of health, and the less the number 
 of complications, — the better is, of course, the prognosis, and 
 contrariwise (although there are exceptions to this). 
 
 As to what concerns the influence on the prognosis of diseases 
 developed before the occurrence of the chronic pulmonary 
 tuberculosis, we may say that it is particularly unfavorable 
 in cases where the pulmonary tuberculosis seizes upon an 
 organism previously affected by diabetes mellitus, and also by 
 syphilis. However, in the last case, in persons of a strong 
 constitution, we may sometimes succeed, after having influenced 
 the syphilis effectively by the iodides or less frequently by mer- 
 cury, in obtaining some good results by the usual treatment 
 of the pulmonary tuberculosis. (Vide article on "•' Syphilis of the 
 Lungs.") 
 
 TREATMENT OF CHRONIC PULMONARY TUBER- 
 CULOSIS, 
 
 Do we possess a remedy against chronic pulmonary tubercu- 
 losis, which may be called specific? Before we present an 
 answer to this question, we must say that the nature of a 
 specific has not been, as yet, clearly defined. Thus, as the most 
 typical specific remedy, we consider quinine in malaria, which 
 last is an infectious disease ; whereas modern medicaliescn ce 
 searches for specific remedies against infectious diseases in 
 the products of the vital activity of the micro-organisms, which 
 
— 291 — 
 
 are considered as the causative agencies of these diseases; 
 consequently these remedies are of a nature totally different 
 from that of quinine.* 
 
 Such being the condition of things, I can only define the 
 nature of a specific remedy in the words I spoke while dis- 
 cussing the treatment of cholera : " a specific remedy is not 
 one which exerts its effect upon one certain symptom of the 
 disease, but one that strikes, so to say, the very centre of this 
 last, and by acting at once on all the symptoms, breaks them 
 up, causing a cessation of the disease, as quinine does in 
 malaria, and sodium salycilate in acute articular rheumatism." 
 If we are to regard a specific drug from such a point of view, 
 then there is no doubt that we have no drug whose effect 
 in tuberculosis could be comparable to the action of quinine 
 in malaria ; but the effect produced by creosote in tuberculosis 
 is such that it cannot be called symptomatic only ; its action is, 
 besides, evident only in tuberculosis or in cases of predisposi- 
 tion to the same, and, as far as I know, in no other disease. 
 - Let us now turn to the treatment of tuberculous patients 
 as based upon facts. 
 
 Symptomatic treatment^ by which we mean the removal of all 
 the distressing and debilitating symptoms, plays an important 
 part. During the discussion of the previously presented cases 
 of chronic tuberculosis of the lungs I had occasion to speak 
 of the treatment of all the symptoms of this nature, except 
 haemoptysis and fever, which I will take up presently. 
 
 During haemoptysis the patient must preserve quietude 
 and be silent. If there are no contra-indications, in the form 
 of a diarrhoea or extreme debility of the patient or in the degree 
 of the haemoptysis, we must first of all administer a laxative 
 (an eccoprotic, not a drastic) and then secale cornutum, an 
 
 * Let me recommend you an interesting, altliougii somewhat verbose 
 and lengthy (a common fault of the majority of modern writers) article 
 of Behring's (Prof. Behring, " Die atiologisch-therapeutische Bestre- 
 bungen der Gegenwart," Deitisc/ze med. Wocftenschrift, 1893), in which the 
 author, being a partisan of Koch's, criticises sharply, but nevertheless 
 judiciously, the general pathological and therapeutic positions of Vir- 
 chow, which once played an important role, and discusses the question 
 of the specific treatment in its past and present condition. 
 
— 292 — 
 
 infusion of 3ij to 3vj, a tablespoonful every hour; to quiet the 
 ■cough codeiae or morphine. For habitual, repeated haemop- 
 tysis two to three leeches to ' the coccyx (vide article on 
 '' Blood-letting "). 
 
 If the fever is not considerable and the rise of temperature does 
 not exceed 38° (100.4° i^.), then there is usually no necessity 
 for the employment of special measures in combattmg it : the 
 creosote treatment, by causing a general improvement, causes 
 also a cessation of the fever. But in case the fever is more 
 considerable, then, at the commencement of the creosote treat- 
 ment, before it has as yet an opportunity to exert its effects, I 
 prescribe for the mornmg, during the fall of the temperature, five 
 to ten grains of quinine, and in the evening, during the rise of the 
 temperature, four to eight grains of phenacetine, less frequently 
 three to five grams of antifebrine, and still less so ten to twenty 
 grains of sodium salycilate, and very rarely antipyrin. Most 
 frequently we have to admmister antipyretic drugs in the last 
 stage of chronic tuberculosis of the lungs and during its 
 pneumonic complications, to administer them of course until 
 a marked lowering of the temperature is effected, but not until 
 it be brought down to the normal ; this last is frequently im- 
 possible, always useless, and besides risky, as it requires large 
 doses of the mentioned antipyretics, and may thus cause a 
 dangerous weakening of the heart. 
 
 The most important part is played by improvement in 
 the nutrition (and this is usually accompanied by an increase 
 of patient's strength), whether it result, in connection with the 
 successful employment of the symptomatic treatment, from 
 the application of hygienic measures only or from them and the 
 additional use for this purpose of various remedial agencies, 
 the most important of which are koumyss and creosote. It is 
 only with the aid of improved nutrition and strength, that we 
 obtain the good results to which we alluded in discussing the 
 prognosis. 
 
 Koumyss. — Until the time when large doses of creosote 
 were introduced into medical practice for the treatment of 
 chronic pulmonary tuberculosis, koumyss was considered the 
 best means for improving, in a very short time, the nutrition 
 
— 293 — 
 
 and strength, and also the local symptoms. But since then, 
 koumyss has become less important. First, because creosote, al- 
 though somewhat slower, gives the same results ; and whereas 
 the koumyss treatment is only possible during the three sum- 
 mer months (from the middle of May till the middle of August) 
 after which it must be interrupted for nine months, during 
 which time the obtained results are either partly or entirely 
 lost, the treatment with creosote can be continued constantly, 
 only with those short (about one month) interruptions, which 
 are required by the peculiarities of the creosote treatment itself. 
 
 Secondly, the treatment with creosote is incomparably more 
 accessible than a trip to the koumyss sanatarium, which in- 
 volves considerable expense, worry, and finally the risk of not 
 being able to obtaui good koumyss, or good board, lodging, 
 etc. 
 
 It would, however, be erroneous to assume that koumyss has 
 entirely lost its importance. There may occur many cases in 
 which the koumyss treatment is both more convenient for the 
 patient and indicated either during the interruption in the cre- 
 osote treatment or when this last is not well borne or does not 
 give the expected result, which last circumstance occurs, how- 
 ever, only in the minority of cases treated by creosote. Moreover, 
 koumyss is beneficial in the treatment of other diseases, out- 
 side of chronic pulmonary tuberculosis. It constitutes an unre- 
 placeable medicinal agency for effecting a rapid recovery of 
 health which has suffered from serious maladies or from a pro- 
 longed residence under unfavorable hygienic conditions. Fi- 
 nally, koumyss is useful not only for improving the health, but, 
 by causing a sound and prolonged sleep, for its strong effect up- 
 on the nervous system : koumyss is an excellent remedial agent 
 in neurasthenia. If the neurasthenic patient is not thin, the 
 more so if he be stout, then the best thing for him is bathing in 
 the river, and, even better still, in the sea (up to a certain age, 
 after which baths at the temperature of 27°i?. (92.8° i^.) are 
 more suitable ; of this we shall speak in due time) ; but if the nu- 
 trition of the neurasthenic patient has failed considerably, then 
 bathing may become very harmful to him, while the baths at 
 21° R. (92.8°#.), even if harmless, will be but of little benefit 
 
— 294 — 
 
 and but for a short time, during the employment of these baths ; 
 whereas koumyss in such cases, by improving the nutrition and 
 by exerting a powerful influence on the nervous system, may 
 bring about a complete recovery of health. In the same cases of 
 neurasthenia, which are accompanied by a failure of nutrition, 
 koumyss by its effects is superior to the best apothecary drugs 
 used against neurasthenia, as arsenic and silver nitrate ; (these 
 last are preferred to koumyss only because they may be used 
 at any time of the year). I will add here, that we meet very 
 often cases of neurasthenia complicating chronic pulmonary 
 tuberculosis. 
 
 While speaking of the koumyss treatment, I mentioned trips to 
 the koumyss sanatoria. This must be explained. The fame 
 of koumyss as a curative agency, a fame which is fully merited, 
 as I can testify also by my own practical experience, has origi- 
 nated in the locality between the Volga and the Oural. There 
 existed before, and there exist to an extent now, vast feeding 
 grounds, which make it possible to breed horses in great herds ; 
 the summer there is mostly dry and warm, even hot. Only 
 during such a summer can the patients use the considerable 
 quantities of koumyss, so necessary for obtaining good curative 
 results ; only at such localities, from such an abundance of young 
 healthy mares, which are not used for labor, but feed on the 
 abundant pasture-grounds, will the patients obtain good kou- 
 myss in a sufficient quantity. The attempts to resort to 
 koumyss treatment in the absence of such conditions, even in 
 the cities (compare the air of the city with that of the field) 
 or even during the winter (!) months, give, of course, miserable 
 results, and are usually harmful (as the koumyss is not borne 
 well and causes a diarrhoea), and has surely no claim to be re- 
 garded as koumyss treatment.* 
 
 Treatment with cod-liver oil (during the cold season of the 
 year), with keffir, less frequently with milk and the farinaceous 
 preparations, may serve as a good aid, in improving the nutrition, 
 to the other treatment, but it certainly cannot be compared to 
 the genuine koumyss treatment. 
 
 * Prof. IST. F. Goluboif has written a great deal on the subject of kou- 
 myss treatment. 
 
— 296 — 
 
 The treatment with arsenic was spoken of before, and particu- 
 larly its use in chlorosis and chloransemia with a predisposi- 
 tion to pulmonary tuberculosis. 
 
 Creosote^ guaiacol^ OA'idi guaiacol carhonate. — How these reme- 
 dies exert their effects — whether directly on the tuberculous 
 bacilli (which is denied by some) or only by strengthening the 
 organism, and thus diminishing the predisposition to the devel- 
 opment of these last — is not known ; but the fact that they 
 are effective is beyond any doubt, and is recognized as such by 
 a majority of most competent practitioners. My own practical 
 experience speaks in favor of the subject in a similar manner. 
 There are also heard dissenting opinions, which are due partly 
 to insufficient observations, and partly to the fact that the creo- 
 sote, guaiacol and its carbonate are not always of the best 
 quality, and do not always have the same constituents. The 
 effect itself of these remedies consists in this, that as a result 
 of their prolonged and gradually increased use, the appetite is 
 improved, the former slight dyspeptic symptoms disappear, the 
 nutrition and strength improve considerably, at times strikingly 
 so, and together with these, also the local symptoms. 
 
 The above-named remedies are used at the beginning in small 
 and later on in gradually increasing doses, as, for mstance, creo- 
 sote or guaiacol at first five drops (guaiacol carbonate five 
 grains), once a day, and later, more and more frequently, alwaj^s 
 after a meal, and, when taking frequent doses, if not after a 
 meal, then in a half-glassful of milk ; if they are taken in ca- 
 chets or capsules, then one-fourth of a glass of milk is taken 
 before the capsule and another one-fourth after it. The ra- 
 pidity with which the dose is to be increased depends on how 
 well the remedies are borne and on theii" effects ; if, after taking 
 them, there is felt an unpleasant heaviness in the stomach and 
 the appetite is not improved, then the dose remains the same ; 
 but if, as usually happens, the appetite is improved, and there 
 is no heaviness in the stomach, but on the contrary even the 
 formerly present — before the beginning of the treatment — 
 dyspeptic symptoms disappear, then the dose is increased up to 
 thirty, sixty, and more drops in the twenty-four hours. At 
 times the treatment must be interrupted, say, for two to four 
 
— 296 — 
 
 weeks after two months of treatment; we must, of course, in 
 doing so, take into consideration the patient's individuality and 
 the successful results of the treatment : the more considerable 
 these last, the less necessity there is for hurrying on with the 
 treatment. The interruptions are made with the aim in view of 
 not injurmg the stomach and the kidneys ; at times, although 
 it may be rarely, during the treatment with the above-named 
 remedies, there is observed the appearance of albuminuria, which 
 usually passes away after the cessation — in such cases necessary 
 — of their employment. 
 
 Creosote and guaiacol do not present any notable difference 
 in their effects : the guaiacol carbonate is at times better borne 
 by the stomach, but it is high-priced and evidently exerts a 
 weaker effect than creosote or guaiacol ; such is at least my im- 
 pression, received from its use in several cases. 
 
 We are rarely compelled to mtroduce creosote or guaiacol in- 
 to the system through other ways than the stomach. The 
 slight dyspeptic symptoms, so frequently seen in patients with 
 chronic pulmonary tuberculosis, depend usually upon the gene- 
 ral weakening of nutrition, of the function of hgematopoiesis 
 and of the nervous system, and are not due to a chronic gas- 
 tric catarrh ; a gradual and carefully conducted treatment with 
 guaiacol or creosote not only usually ameliorates these, but 
 with the improvement in the general condition, the symptoms 
 pass away entirely. But if these dyspeptic symptoms be con- 
 siderable, then we can usually succeed in removing them by 
 preliminary treatment, and bring the stomach into a condition 
 which would enable it to bear well creosote, guaiacol, or at least 
 guaiacol carbonate, as was the case with our patient who suffered 
 with chloraucemia and incipient tuberculosis (vide 18th case). 
 But still I had occasion to observe a case of chronic pulmonary 
 tuberculosis complicated by a very obstinate chronic gastric ca- 
 tarrh of an independent origm, not due to the pulmonary trouble, 
 in which creosote was not borne by the stomach, even after the 
 latter had been subjected to a preliminary treatment, and the 
 patient improved only after a prolonged introduction of great 
 quantities of creosote — dissolved in olive oil — by subcutane- 
 ous injections, usually into the buttocks. 
 
— 297 — 
 
 The introduction of creosote through the respiratory tract is 
 usually badly borne (it causes severe coughing), and does not 
 produce even a shadow of the effect which is obtained by the 
 continuous and gradually mcreasing administration of the drug- 
 through the stomach. The inhalations of small quantities 
 of creosote are sometimes well borne, but outside of a slight 
 relief in loosening the expectoration and some improvement of 
 this last (patients sometimes find that the expectoration, dur- 
 ing the inhalation of creosote, is of a less disgusting taste and 
 odor), it induces no marked change for the better in the local 
 symptoms and in the condition of the affected portions of the 
 lungs. I may add that the same may l^e said also regarding 
 the other remedies of the inhalation therapy, as eucalyptus 
 oil, ol. terebenth. rectific, — which is more beneficial in bronchial 
 catarrh complicating chronic pulmonary tuberculosis, and cer- 
 tainly also m a plain bronchitis, — menthol, Peruvian balsam and 
 others. 
 
 All that was said of the use of koumyss, creosote and other 
 remedies in chronic pulmonary tuberculosis, does not refer to 
 the last stage of this disease : at this stage these, as well as all 
 other, remedies are but little effective; we have as yet no reli- 
 able means for the treatment of the disease at this period. 
 When chronic pulmonary tuberculosis is complicated by catarrh- 
 al and caseous pneumonia, then koumyss is of course of no 
 avail ; of the use of creosote in cases of these pneumonic com- 
 plications I can say nothing : since I am using creosote m con- 
 siderable doses, I observed such complications of chronic 
 pulmonary tuberculosis but rarely ; there are no sufficient data 
 in the literature on the subject. 
 
 The tendency, so peculiar to modern medical bacteriology 
 and which promises so much for the future, of searching in the 
 pathogenic micro-organisms themselves, in the products of their 
 life-activity, for means for immunization against the diseases 
 produced by these micro-organisms, and also for the treatment 
 of these diseases, has not resulted as yet, as far as tuberculosis 
 is concerned, in anythmg of practical importance. I have spok- 
 en elsewhere (in an article entitled " Treatment of tuberculosis 
 by Koch's tuberculin" appended to the Russian edition of the 
 
— 298 — 
 
 lectures) of the thoughtless, I may say precipitous treatment 
 •of tuberculosis by tuberculin — ■ an attempt the failure of which 
 can only be measured by the world-wide hopes its appearance 
 has excited. 
 
 In passing from the therapy of the patients suffering with 
 chi'onic pulmonary tuberculosis to their hygienic treatment, we 
 must principally take up their climatic hygiene, which is usu- 
 ally, but less correctly, called climatic therapy ; but the import- 
 ance of this subject and the approaching close of the lecture 
 hour compel us to postpone it till the next lecture. 
 
 THE CLIMATIC THERAPY OF CHRONIC 
 PULMONARY TUBERCULOSIS. 
 
 LECTURE OF APRIL 16, 1893. 
 
 For a long time I have made it the business of my clinical 
 instruction to discuss this subject not only in view of its im- 
 portance and the entire ignorance on the part of the students 
 about it, but also because it cannot be denied, that the majority 
 of the practitioners are but slightly acquamted with the sub- 
 ject, and do not therefore prescribe the climatic treatment 
 correctly. On the contrary, as we very frequently see by the 
 physicians' advices, the climatic therapy is expected to yield 
 what it cannot, and no advantage is taken of what it can give. 
 
 Later on I shall illustrate my assertions by sufficiently con- 
 clusive examples. 
 
 Before we speak of the climatic therapy of chronic pulmo- 
 nary tuberculosis, we must say a few words regardmg climate 
 and climatic therapy in general. Climate (Gr. KXt7xa[T-], a region, 
 zone) denotes, properly speaking, a distance between two cir- 
 cles parallel to the equator. In connection with climatic therapy, 
 climate is considered as the sum total of all the influences of the 
 given place, which include its quantity of sunlight, its tempera- 
 ture, air, waters, soil and vegetation ; besides these, in choosing a 
 certain locality with a climato-therapeutic aim in view, we must 
 also take into account the various changes in the above-named 
 influences which take place during the various seasons of the 
 
— 299 — 
 
 year, and also the conditions of life in the given locality, — 
 the peculiar traits of its population, the residence, the diet, etc. 
 You thus comprehend that climate is something of a very 
 complex and changeable nature ; neither climatotherapy, nor 
 even climatology are therefore much advanced. Thus, for in- 
 stance, meteorology (the most important basis of climatology) 
 can foretell the condition of the weather for the next twenty- 
 four hours, but is unable to predict its condition, for the given 
 locality, for the approaching season of the year, for instance, for 
 the winter, which would be a matter of great importance for 
 climatotherapy, because the climate differs not only during the 
 various seasons of- the year, but during one and the same sea- 
 son of the year it is liable to be variable in different years : one 
 year, for instance, the winter is cold, the next year it is warm, 
 or with a clear and quiet weather, or rainy, snowy, windy, etc. 
 The complexity and inconstancy of the climatic influences, 
 in the undeveloped state of climatology, make it impossible to 
 establish any satisfactory climatotherapeutic classification of the 
 climates. Webber, the author of the article on climatotherapy in 
 the well-known collective edition of Ziemssens Hayidhueh der all- 
 gemeinen The^-apie^ states that he was tempted to describe the 
 climatic sanatoria in alphabetical order, but the necessity of 
 avoiding repetitions so inconvenient in a text-book prevented 
 him from domg this. As a great many others, he divides the 
 climatic sanatoria into those situated near the seashore (these 
 again being subdivided'into warm, cool, damp and dry ones), and 
 those situated inland (with subdivisions into mountainous and 
 low) ; but this subdivision certainly does not do away with 
 the necessity, while selecting any climatic sanatorium, for care- 
 fully considering not only its seaside or inland position, its 
 high or low altitude, its warmth or coohiess, but also all the 
 remaining numerous climatic and life peculiarities and the 
 manner of their combination, by availing oneself of the aid 
 found in literature, or better still, if possible, of the opportunity 
 of a personal acquaintance with such places. 
 
 Such being the condition of climatology and of climatother- 
 apy, in discussing the special climatotherapeutic question, 
 namely, that of the climatic treatment of chronic pulmonary 
 
— 300 — 
 
 tuberculosis, I consider it best, without touching upon the 
 unsatisfactory division and the characteristics of the climates, 
 and giving a short review of the elements of climate and its 
 therapeutic, or, rather, hygienic, effect in general, to give an his- 
 torical exposition touching at least the last decades of the cli- 
 matic treatment of chronic pulmonary tuberculosis. I am led to 
 think that this will be the best method for explaining the 
 nature of the climatic treatment not only of this disease, but of 
 the whole idea in a general way, in so far as we can at least 
 judge of this subject in the present condition of our knowledge ; 
 I think thus, because, although the question of the climatic 
 treatment of chronic pulmonary tuberculosis is but a special 
 one in the domain of climatotherapy, it is undoubtedly the 
 most important one.* 
 
 THE ELEMENTS OF CLIMATE, 
 
 The temiJerature of the locality. — Heat weakens the nervous 
 system (causing fatigue, disinclination to work, sleepiness), 
 the appetite and nutrition. Cold excites the appetite keen- 
 ly ; it is therefore unsuitable for debilitated persons with poor 
 digestive powers, who also evince an inclination to colds and to 
 diseases dependant thereon. Such patients are best beneiited by 
 localities with a moderate temperature, one which is neither 
 hot nor cold, and withal as constant as possible, undergoing but 
 few changes, because a rapidly and pronouncedl}- changeable 
 temperature tends to aggravate and to cause in such patients 
 cold and diseases resultmg therefrom. On the contrary, for 
 neurasthenics a moderately changeable temperature is suitable, 
 with moderate winds, as, for instance, the temperature of sea- 
 side localities ; of this we shall speak when discussing balneo- 
 therapy. 
 
 * The hand- and text-books of climatotherapy, besides the climatic ther- 
 apy of chronic pulmonary tuberculosis, usually mention this therapy for 
 the following diseases: catarrhal and "rheumatic," gout, scrofulosis, 
 various anaemic and nervous diseases (neurasthenia, hypochondriasis, 
 etc.) ; however, there are certainly but few diseases in which correct 
 climatic conditions would not be of importance. 
 
— 301 — 
 
 2. Moderate sunlight acts beneficially on the mental condition, 
 on tlie nervous system, and on nutrition. For winter, therefore, 
 the localities where the day is mostly clear are particularly 
 suitable ; during summer, on the contrary, when there is a su- 
 perabundance of sunlight, shady, woody places are preferable. 
 
 3. The air. — Moisture in the air. — Damp air is generally de- . 
 leterious : damp and hot air increases the noxious effect of 
 heat ; damp and cold air has even a greater tendency to cause 
 cold and diseases due to it, than cold air which is not damp. 
 Very dry air, either warm or cold, irritates the mucous mem- 
 branes and increases the tendency to cough and hsemoptysis. 
 An average degree of moisture in the air is therefore a necessary 
 attribute of a good climatic sanatorium. Considerable cloudi- 
 ness of the sky and severe rains are harmful, as they increase 
 the amount of moisture in the air and in the soil, and tend to 
 decrease the amount of sunlight, which last is generally slight 
 during the winter ; but moderate rains are useful because they 
 purify the atmosphere. Snow is beneficial for the same reason, 
 
 'and also because the covermg of snow prevents the air from be- 
 coming contaminated by the various kinds of dust which rise 
 from the ground. 
 
 The density of the air, the pressure of the air. — It is thought 
 that the air of the seaside localities, under the greatest 
 pressure and therefore the densest and the richest in oxygen, 
 excites the appetite more readily than the rarefied air of moun- 
 tainous localities at high altitudes ; but this circumstance is 
 usually counterbalanced b}^ the necessity of a greater amount 
 of physical exertion, of greater muscular labor as spent in fre- 
 quent ascensions in a mountainous locality. The considerable 
 alterations in respiration and circulation observed on ascending 
 very high mountains or on ascending in a balloon have no sig- 
 nificance for climatic therapy, because the climatic sanatoria are 
 mostly located at altitudes between 500 and 1500 meters; 
 the rarefaction of the au- peculiar to such altitudes does not 
 produce to any marked extent such influence on respira- 
 tion and circulation, and on the organism in general, as is pro- 
 duced by the rarefied air of the high mountains. The great 
 development of the chest, so frequently observed in inhabitants 
 
— 302 — 
 
 of the mountains, must be ascribed not to the rarefaction of the 
 mountainous air and the increased respiratory movements conse- 
 quent thereon, but rather to increased depth of the same move- 
 ments as necessitated by frequent ascensions. 
 
 The motions of the air, the winds, are of enormous importance 
 climatically : some winds carry with them warmth, moisten the 
 dry air, and clear the atmosphere of dust ; others bring with 
 them cold or heat, superfluous moisture (dampness), or, on the 
 contrary, dryness, dust. A good climatic sanatorium must be 
 protected from noxious winds by an elevation of the land, or by 
 a forest. 
 
 The dem-ness of the air, the freedom from all kinds of dust, 
 inorganic, organic dead and living (as micro-organisms), is the 
 highest, most necessary requisite of a climatic sanatorium. 
 
 The presence of ozone in the air is beneficial. 
 
 4. The soil. — The relief of the soil, in the shape of eleva- 
 tions or mountain ranges, which^ serve as a protection against 
 noxious winds, is directly important' in determining the value of 
 a climatic sanatorium. A damp soil predisposes to malaria, is 
 deleterious to those suffering from catarrhal and " rheumatic " 
 affections, as well as for those afflicted with chronic pulmonary 
 tuberculosis, and for many other patients. A dry but bare 
 soil, only sparsely covered with vegetation, which fills the air 
 with dust, is^particularly harmful for patients with chest troubles, 
 for whom the best is a dry soil, but one covered with vegeta- 
 tion, or, during the cold season of the year, with snow. 
 
 5. Waters. — A good water for drinking purposes is certainly 
 a necessity at a climatic sanatorium. The neighborhood of the 
 sea, which moistens the atmosphere, purifies it by the aid of an 
 almost constant wind, modifies the extremes of temperature, at 
 times warms the locality, as by warm sea-currents, and presents 
 frequently the possibility of profiting by the beneficial — as for 
 neurasthenics — sea-bathing — through all these influences forms 
 a very important preference for a climatic sanatorium. 
 
 6. The vegetation, by covering the soil, prevents the forma- 
 tion of dust, and by absorbing the carbonic acid and yielding 
 up the oxygen, purifies the air and assists in the formation of 
 ozone. Forests form an excellent protection against the winds 
 
— 303 — 
 
 and, during the summer, against tlie excessive heat of the 
 sun. 
 
 7. The heauty of the locality (the view on the sea, moun- 
 tains, etc.) exerts a favorable psychical influence and plaj^s by 
 no means an unimportant part in the selection of a sanatorium. 
 
 8. The value of a trip to a sanatorium, that is, the import- 
 ance of removing the patient from the habitual conditions of 
 life (at times unfavorable, as, for instance, an unhealthy locality, 
 excessive occupation, worries, etc.) and of a change in the 
 mode of living, by instituting exercises in the open air, and also 
 the importance of the conditions surrounding the life at a cli- 
 matic sanatorium — partly needs no explanation, and was, to 
 some extent, already spoken of when we discussed the internal 
 use of mineral waters ; we shall also touch upon the subject 
 later on, as well as when we come to discuss the subject of bal- 
 neotherapy. 
 
 We will now take up the climatic treatment of chronic pul- 
 monary tuberculosis. 
 
 Up to within the fifties of the present century its treatment 
 consisted chiefly in this, that the patients, during the cold season 
 of the year, were sent away to localities with a prevailing warm 
 climate, at first to places on the shore of the Mediterranean Sea 
 protected by the Alps from the cold winds (the Riviera), as 
 Cannes, Nice, Mentone, San Remo, etc., and later on to neigh- 
 boring places around Cairo (Heluan), Algeria and to the 
 Madeiras. In these localities, besides the warmth and the protec- 
 tion from the cold winds, there was greatly appreciated the 
 absence of sharp variations in the temperature. Finally patients 
 with a dry cough and with an inclination to haemoptysis were 
 advised to avoid localities with dry air, as, for example, the en- 
 vironments of Cairo, and to go to places where the air is suffi- 
 ciently moist (as, for instance, Madeira), while for patients with 
 abundant expectoration, on the contrary. 
 
 Some thirty-five years ago, the physicians of Europe turned 
 their attention to the treatment of chronic pulmonary tubercu- 
 losis by residence in the mountains. Observations in mountain- 
 ous localities induced them to do so: thus it was found that 
 
— 304 — 
 
 in Peru, where at the seaside localities the above-named 
 disease is seen frequently, and where it rapidly brings on 
 a fatal termination, a residence for the patients during a long 
 period in the mountainous plains — at the altitude of 3000 
 meters — in the neighboring Andes has been considered since a 
 long time as the ordinary and only successful treatment. 
 
 Meeting with scarcely any cases of chronic pulmonary tuber- 
 culosis at such high altitudes, observers came to the conclusion 
 that the success of this treatment, consisting of a prolonged res- 
 idence in plains situated at high altitudes, depends on the pres- 
 ence m such localities of a peculiar " immunity " as regards 
 the above-named disease. The principal element, which was 
 considered as exerting a favorable influence on the patients 
 suffering from chronic pulmonary tuberculosis during their resi- 
 dence on high altitudes, was the rarefaction of the air, which, as 
 it were, excited increased respiratory movements, brought about 
 a better ventilation of the air, and tended to develop the chest, 
 etc. But neither supposition was found to be true. It was 
 proved that pulmonary tuberculosis is also met with in moun- 
 tainous localities, although there it is of much rarer occurrence 
 thanks to the absence of factory life and similar conditions, the 
 population not being huddled together, as in localities with a 
 dense population, under unfavorable conditions of life ; while at 
 the same time it was found, that even in Switzerland, in the 
 factory districts, situated as they are on high altitudes, there is 
 quite a number of consumptives. The importance of rarefied 
 air in climatic mountain sanatoria has been spoken of before. 
 
 The German physician Brehmer, deeply convinced of the 
 curative properties of the climate of mountainous localities for 
 tuberculous patients, was the first to establish, or he thought 
 he established, such a sanatorium ; I said he thought because the 
 place selected by him, in the vicinity of the village of Gorbers- 
 dorf, in Silesia, at an altitude of hardly 550 meters, can not be 
 called a truly mountainous locality. But even without the 
 features of a really mountainous place, Gorbersdorf is distin- 
 guished by its excellent climate during summer, which is not 
 hot, but cool, almost without rains, and is protected from noxious 
 winds ; in connection with this the air is remarkably pure, free 
 
— 305 — 
 
 from dust and rich in ozone, thanks to the abundance of trees, 
 especially of firs : it abounds therefore in many pleasant, shady 
 walks ; the soil is hard. 
 
 Brehmer was convinced of both the " immunity" of mountain- 
 ous localities as regards tuberculosis and of the beneficial influ- 
 ence of the rarefied air of the mountains on tuberculous pa- 
 tients, although the environs of Gorbersdorf present cases of 
 consumption ; and as regards the rarefaction of the air — not 
 to repeat what was said before, that there was no foundation 
 for ascribing to it any special benefit for the consumptives — 
 we can not speak of the presence of any considerable rarefaction 
 of the air on such but slightly elevated locality as Gorbersdorf. 
 Besides that, Brehmer entertained a theory of his own regard- 
 ing the beneficial influence of mountainous localities on tuber- 
 culous patients, namely: tuberculosis attacks persons whose 
 lungs are large, but whose hearts are of small dimensions, and 
 in whom therefore the lungs are not sufficiently supplied with 
 blood and are poorly nourished, and who through such conditions 
 become predisposed to tuberculous affections ; on the mountains 
 the pulse becomes more frequent, which means that the activity 
 of the heart is increased, the lungs receive a greater supply of 
 blood, they are better nourished, and therefore are better able 
 to withstand tuberculosis and can sooner be cured of it. This 
 theory was of course proved to be without any patho logo-anatom- 
 ical foundation in fact, not to speak of the insignificant influ- 
 ence of such a slightly elevated locality as Gorbersdorf on 
 the increase of the frequency of the pulse. 
 
 But all this notwithstanding, Brehmer achieved a greater suc- 
 cess in the treatment of patients afflicted with chronic pulmonary 
 tuberculosis, than was obtained by the ordinary, at that time, 
 treatment of such patients. This fact was recognized by com- 
 petent German physicians and clinicists and has led to the es- 
 tablishment of sanatoria after that of Gorbersdorf, with the 
 application of Brehmer's method of treatment. This " method 
 of treatment," to which Brehmer is so much indebted for his 
 successes, consists properly speaking of a strict observance of 
 hygiene. Thus, in the other climatic sanatoria patients, under 
 the impression that the climate will do everything and that every- 
 
— 306 — 
 
 thing is possible in such a climate, neglected the necessaiy hy- 
 giene as much as they did in their own homes, permitted them- 
 selves to smoke, to drink too much wine, did not observe the 
 diet regularly, spent the nights in playing cards, in visitmg 
 the theatre, etc., and therefore took no advantage of the pleasant 
 hours during the day while the sun is up, nor of the fresh air 
 and out-door exercises. Brehmer was remorseless in requiring 
 of his patients the strictest observance of hygiene ; he insisted 
 upon the avoidance of pernicious habits in the mode of living, 
 upon going to bed in due time, upon as prolonged out-door life 
 as possible, upon exercise compatible with the patient's strength ; 
 he required a correct diet (in the form of frequent administra- 
 tion of . nutritious food) and the use of wine ; and, besides all 
 these, he ventured to introduce hydrotherapy into the treatment 
 of tuberculous patients. It is true, that both the use of wine and 
 the application of hydrotherapy w^ere conducted without a plan 
 and with too great impulsiveness (thus, for instance, the patients 
 were given too strong douches) and at times they were produc- 
 tive of harm ; but it was nevertheless shown, that wine and such 
 moderate hydrotherapeutic procedures as sponging, when not 
 prescribed aimlessly but by observing the individual peculiari- 
 ties of every patient, are of benefit to many suffering with 
 chronic pulmonary tuberculosis. 
 
 Of the various sanatoria, which were established in imitation of 
 that at Gorbersdorf, we must stop to consider the one best known 
 of all, namely, Davos in Switzerland. Davos is a wide tableland 
 situated at an altitude of 1960 meters, protected by mountains 
 from northerly and northwesterly winds. The best season of the 
 year is the advanced winter, when the covering of snow is constant, 
 the air is pure when there is no wind, the sky is almost always 
 clear and the sun sends down sufficient warmth ; thanks to this, 
 as well as to the dryness and the quietude in the air, it is so warm 
 that the patients are able to be up and about out-of-doors 
 in comparatively light garments. During the other seasons 
 of the year there arrive the unpleasant local wmds from the 
 mountains and plains and then, in the autumn, when the snow 
 begins to fall, and in the spring when it thaws, the climate is 
 damp and inconstant ; and the summer is warm, there is but lit- 
 
— 307 — 
 
 tie shade, and it is dusty. The cHmate of Gorbersdorf is there- 
 fore better during the summer, but there the winter is worse, 
 because during it the weather is often damp and changeable. 
 The majority of other European health-resorts, established on 
 the plan of that at Gorbersdorf, have not the same distinctly 
 mountainous character as Davos has, and resemble in this 
 respect Gorbersdorf. 
 
 Many physicians when comparing Davos with the warm cli- 
 matic places, for instance with those on the Riviera, give the 
 preference to Davos for the following reasons : the air at Davos, 
 thanks to the snow-covered ground, is so pure that it stands in 
 this respect above comparison with the air at the above-named 
 warm places ; at Davos there is no wind during the winter and 
 the climate is therefore more constant than in the warm locali- 
 ties where noxious wmds prevail; in these places the winter is 
 not only warm, but even hot, whereas at Davos it is just warm 
 enough to enable one to be up and about dressed lightly : thanks 
 to this the appetite of the patients living at Davos is better than 
 in those living at the above-named warmer sanatoria. 
 
 From the above you can clearly perceive what an important 
 change took place during the last decades in the climatic treat- 
 ment of chronic pulmonary tuberculosis : whereas formerly the 
 salvation of the patients living in the middle and the northern 
 parts of Europe and generally in countries with a similar cli- 
 mate, was considered to lie in a trip to the South and a prolonged 
 residence there during the cold season of the year, — a trip 
 which was often beset with difficulties and entailed hardships 
 on the patients and their families, which was frequently attend- 
 ed with the risk of a failure, and often impossible for many, — 
 at the^ present time such patients are enabled to apply the cli- 
 matic therapy during the winter season much nearer to their 
 own homes. 
 
 There is also a possibility for this treatment with us, not 
 only in our mountainous localities, but also in the plains so 
 largely prevalent in Russia. The slight relief of the soil in the 
 form of a forest, especially of fir-trees, serves as a sufficient 
 protection from cold winds and exerts a modifying influence on 
 the winter cold, if we desire to select a place which is located 
 
— 308 — 
 
 on the inolines of the soil facing the south. The cover of snow 
 insures pure air. If during the winter, in the severe colds, the 
 patients will be compelled to confine themselves within the 
 house for a longer time than in Western Europe, then during 
 the autumn and spring, when we have yet some frost, while 
 there it is already thawing and damp weather, the condition 
 of things will be reversed. If, finally, on account of the severity 
 of our climate its influence during winter will be inferior to 
 that of Western Europe (and this I question ! ), then how many 
 times will this disadvantage be outweighed by the possibility of 
 avoiding the above alluded to difficulties and risks, which are 
 inseparable from far journej^s and prolonged sojourn in remote 
 countries ; it will remove the necessity for expenses permitted 
 but to a few and frequently bringing ruin to the welfare of 
 many families, necessitating separation from the familiar sur- 
 rounding circumstances and business on the one hand, and 
 compulsory, oppressive idleness in a strange land on the other 
 hand. 
 
 Unfortunately with us it is as yet an affair of the future. 
 Up to now there prevail though to a slighter extent than for- 
 merly, advices for trips to " the South " and " over the border " 
 (meaning Western Europe). Many physicians prefer the ready 
 advice " Take a trip to Cannes, Mentone, San Remo, etc., or to 
 Gorbersdorf, Davos," to the one which requires more labor to 
 explain as to how the patient should conduct himself in the cli- 
 matic circumstances which surround him or, in case these be 
 unsatisfactory, how to take advantage of those near by, frequent- 
 ly of the very near and directly neighboring localities with fa- 
 vorable climatic conditions. Besides, it frequently happens that 
 the advice to go to the South or to Europe is given with such 
 abruptness and so negligently, that the patient decides to under- 
 go the necessary expenses for the trip, under the impression 
 that the trip itself will bring about a cure ; he perceives later 
 on, that the trip failed to cure (it frequently does not even 
 bring about an improvement in health), and that not only a cure 
 but even a satisfactory improvement in health requires a long 
 time, treatment, and a constant observance of hygiene ; having 
 given up the trips which became impossible,his means and affairs 
 
— 309 — 
 
 ruined, he ends by what the physician should have advised him 
 to begin, namely by attempting to improve his health not 
 through temporary, fruitless measures, as trips to the south, 
 but by changing his mode of living in accord with the conditions 
 of his health and by taking ably advantage of the climatic op- 
 portunities presented by the local place of residence or by 
 the one nearest to it. 
 
 A few cases from my practice will serve as illustrations of 
 what I said. 
 
 1. This case, which I observed some twenty-five years ago, 
 has remained indelibly in my mind, as it produced a strong 
 impression, and has been the means of my inaugurating the 
 present practice in the domain of climatic therapy. The pa- 
 tient, forty years old, of average constitution, sober and non- 
 syphilitic, was a grain merchant on the Moscow baggage 
 station of the Moscow Ryazan Railroad. He passed the whole 
 day either in talking (usually loudly, rapidly, without rest, and fre- 
 quently also shouting) out in the dusty or cold air, or in drink- 
 ing tea in the tavern. When I saw the patient, he had been 
 suffering already for about a year and a half from chronic pul- 
 monary tuberculosis of the right lung (approximately the 
 upper third of the superior lobe was attacked), had frequently 
 expectorated blood, was often feverish, grew thin, but was as 
 yet strong. 
 
 After having removed by symptomatic treatment (leeches 
 to the coccyx, quinme, pulvis Doveri) the acute condition 
 for which the patieut consulted me, I made it clear to him 
 that a satisfactory improvement of his health is impossible 
 with his present mode of living, and inquired whether he 
 would" be able to take a trip to the South (it was during 
 winter then), warning him, however, that there might arise a 
 necessity for more than one trip. Patient replied that neither 
 his competency nor his family relations permitted him to even 
 attempt such a thing. Further inquiries elicited the fact, 
 that he had iu his possession, some 200 miles to the south- 
 east of Moscow, a pleasant country place which is neither 
 dusty nor damp, and a fair little house ; some vegetation, vari- 
 ous household buildings and a barn could form a distinct pro- 
 
— 310 — 
 
 tection from the winds ; it was also found that the patient 
 could give up liis present occupation, and having settled down 
 in his country place, would be able to find also some occupa- 
 tion there. 
 
 Having prescribed for the patient treatment with cod-liver 
 oil (we did not, at those times, give creosote in large doses) 
 and the drinking, in the morning, of Obersalzbrunnen with 
 milk, and having instructed him as to what he was to do in 
 case of the appearance of fever and the mcrease of the cough, 
 I positively advised him to leave Moscow and to move to 
 the country place, explaining to him the hj^giene in particu- 
 lar: to permit a temperature in the room which should not 
 be hot, to have a warm water-closet, to use but lukewarm and 
 no hot drinks, to replace the greater part of tea by milk ; nor 
 must his food be hot; to take a bath, not a hot one, during the 
 warm season of the year only, and that not frequently ; during 
 the cold season to sponge the body with a mixture of warm 
 water and brandy; but the chief thing — not to go out-of- 
 doors during severe frosts, when the wmd is cold and when 
 there is no protection against its blasts, or when the air is very 
 damp, or occasionally dusty; and on the other hand to take 
 advantage at any time of staying out-of-doors, when the frost is 
 not severe, say between eight or ten degrees (patient was always 
 habituated to cold), when the weather is quiet and protection 
 against the wind may be obtained along the various country 
 buildings and around the garden or the grove, when the air 
 is neither damp, nor dusty ; not to talk during the cold season 
 of the year while out-of-doors, and generally to talk only as 
 much as necessary, not loudly, and drawing the breath care- 
 fully ; finally, to devote himself to some occupation, but not 
 to work beyond his strength, never permitting himself to 
 become fatigued. 
 
 The patient, being an intelligent, careful man with a strong 
 will power, followed my advice to the letter and appeared be- 
 fore me a year later (during May of the next year), aston- 
 ishing me by such a marked improvement in his health than 
 which I saw no greater, not only from one winter's sojourn, but 
 from that of several winters spent by such patients in the South : 
 
— 311 — 
 
 the nutrition was completely improved, he gathered considerable 
 strength, there was no haemoptysis; fever and aggravation 
 of the cough occurred but at rare intervals, incomparably less 
 frequently than before, the cough in general and the quantity 
 of expectoration diminished, the dullness at the area of the af- 
 fected place changed but little, but the area over which rales 
 had been heard decreased considerably. I must add that 
 the patient did not give up his accustomed occupation, and not 
 more than during fifty days was he compelled to confine him- 
 self within the house, partly on account of the weather, partly 
 because of the fever and the aggravated cough. During the 
 next seven or eight years, he showed himself to me at first 
 every year, and then every other year, usually in May, always 
 in the same good condition as after the first year of his country 
 life. The further condition of the patient is not known to me ; 
 but whoever is familiar with the miserable results generally 
 brought about by the trips to various health-resorts, trips which 
 require constant moving around, from the home to the sanato- 
 rium and back, and which cause so much ruin to the family, 
 to the affairs and to the well-being of the patient — whoever 
 knows all this will certainly perceive the impression produced 
 on my mind by the above-described results of the climatic treat- 
 ment (or to be more precise, by the generally hygienic treatment) 
 at one^s ovjn home. 
 
 Let me tell you of some cases, peculiar in another respect, 
 observed in my recent practice. 
 
 2. In July of last year I was called to see the wife of a country 
 merchant, thirty-one years old, who complained of eough, dysp- 
 noea, emaciation and general weakness, and who desired me to 
 inform her as to whether or not she should go to Yalta (in the 
 Crimea), as advised by her physicians. 
 
 The locality where the patient resides '(in the Tula Govern- 
 ment) is a poor one, and except wmter-time it is either dusty or 
 muddy. The residence is satisfactory, the water-closet cold. 
 The board is good, her beverage consists of hot tea with milk, 
 no alcoholic drinks. Patient has been married for twelve years, 
 has nursed in all eight children, of whom five are alive. No syph- 
 ilis. Notwithstanding the frequent births, the nursing of the 
 
— 312 — 
 
 children and a considerable amount of housework, the patient 
 assists also her husband, spending daily some five hours in a 
 cold flour-store, situated on a dusty street. Patient is very 
 much attached to the children and the family, and is a typical 
 specimen of a good wife and mother, and of a verj^ painstaking 
 housekeeper. 
 
 Until five years ago she had enjoyed good health. Five 
 years ago during autumn patient passed through an attack of 
 pleurisy (severe pains in the left side of the chest, cough, fever ; 
 the principal treatment consisted in the application of Spanish 
 flies, which relieved her), after which she began to cough, at 
 first but little, and later on more and more, and became also 
 feverish ; but of this she took no notice and continued to work 
 as usual. Two months ago the patient began to feel very ill 
 and took to bed: there appeared severe pains in the left side 
 and a considerable fever, while the formerly moderate cough be- 
 came aggravated and the expectoration began to show the pres- 
 ence of blood. In the course of three weeks the fever decreased, 
 but the severe cough, the abundant expectoration and the 
 dyspnoea remained until now, and the patient continues to ema- 
 ciate and weaken. Her treatment consisted m the application 
 of flies, and during two weeks, until the middle of June, she 
 has been taking six drops of creosote daily ; later on, at the be- 
 ginning of July, patient was advised to take a trip to Yalta. 
 
 Status. — Her appetite is poor ; dyspeptic phenomena absent ; 
 she is constipated (patient takes two or three times during the 
 week, thirty or more drops of extr. fluid, cascarse sagradse). 
 The urine contams a small quantity of albumen and a few hy- 
 aline cylinders. Menstruation is regular, of normal quantity and 
 painless. The liver and the spleen are normal ; so is the heart, 
 but the pulse is frequent and weak. There is some dys- 
 pnoea, cough, expectoration of about two tablespoonfuls a day, 
 at times with an admixture of blood ; coughmg causes pain in 
 the left side of the chest. On the lower half of the left side of 
 the chest, posteriorly and laterally, there is dullness on per- 
 cussion, while auscultation elicits bronchial respiratory murmur 
 and some rales ; the apex of the left lung shows a characteristic 
 focus with abundant and loud moist rales ; objective examination 
 
— 313 — 
 
 of the right side gives normal data. The patient is somewhat 
 feverish, her sleep is sound, and not interrupted by the cough, 
 the head aches when the fever is increased. 
 
 The patient and her husband stated to me that the advice to 
 take a trip to Yalta causes them a great deal of anxiety ; that 
 such a trip was for them, plain country people, a matter of un- 
 usual importance, as it might possibly result in many unpleas- 
 ant accidents ; that it was impossible for the husband to accom- 
 pany his wife, and, which is most important of all, she 
 would be unable to take along the children, all of whom were 
 very young as yet; that the mother was so attached to them, 
 and they to her, that separation would be intolerably painful 
 and harmful for the mother's health. The husband told me 
 that the wife having gone without the children to live in a 
 country place, she could not stand the separation but for two 
 days and was compelled to return, while the " children were 
 crying all the time during her absence." Further inquiry elicit- 
 ed the fact that the husband possessed, some four or five miles 
 from his constant residence, a section of forest in a pleasant, dry 
 locality, and that he had built there a spacious and clean little 
 house in a place completely protected from wind and dust. 
 
 My advice was as follows : I could not approve of a residence 
 of two months' duration at Yalta ; on the contrary I feared the 
 possible heat, so harmful for the appetite, and the dust, and I 
 advised the woman to remove together with her children to the 
 above-named country place and to remain there until the appear- 
 ance of snow, when she might return to her constant residence. 
 I explained to the patient and to her husband that it was not 
 only necessary for her to recover from the disease which attacked 
 her two months ago, namely, inflammation of the left lung, but 
 also to get rid of the other affection, which has been ruining 
 her health during the last five years and which settled also in 
 the same lung (tuberculosis of its apex) ; I made it clear to 
 them that she must therefore remain at the place of her con- 
 stant residence only during the winter, when thanks to the 
 snow and frost both dust and dampness are absent, while the 
 rest of the time she is to live in the above-named country place, 
 where a more spacious residence is to be built at once, with 
 
^ 314 — 
 
 conveniences for winter, with good stoves, and chiefly with 
 double floors and double frames. The husband replied at 
 once that he could do all this very readily, that by autumn 
 the house would be ready for occupancy. To this I 
 added, of course, that the patient must take care of herself, 
 must refrain from fatiguing labor, must drink more milk and 
 less hot tea, and must wear drawers (which she did not do 
 before and which were required in view of a possible nephritis) ; 
 as what concerns her outdoor life, I repeated to her my instruc- 
 tions as given to the case described above. I further instructed 
 her to resort to the use of clysters in case of constipation, and 
 to take a laxative only in case the clyster proves ineffectual ; for 
 the cough to drink Obersalzbrunnen with milk ; to take guaiacol 
 in the order explained in the treatment of chronic pulmonary 
 tuberculosis, not exceeding the dose of twenty to twenty-five 
 drops per day (because of the albuminuria, even though it be 
 trifling) ; in case of weakness to take the stimulating drops (tra. 
 valer. seth. and liqu. Anod. Hoffm. aa). 
 
 3. At the beginning of last autumn a land proprietress in one 
 of the country places around Moscow requested of me ad- 
 vice about her daughter. The girl, twelve years old, of a weak- 
 ly constitution and slightly hysterical, passed a year ago through 
 a severe febrile affection, which left her with a cough and debili- 
 tated. The family physician found tuberculous bacilli in the 
 sputum and advised Mentone for the winter. The first two 
 months' residence at Mentone exerted no influence on her health, 
 and only after she commenced taking creosote did her health be- 
 gin to improve markedly. On her return to Russia in the spring 
 the improvement continued (the treatment with creosote was 
 discontinued by this time), and by autumn only the cough re- 
 mained, without any expectoration. 
 
 Status. — The appetite is excellent, the digestion normal, all 
 the abdominal organs, as well as the heart and the circulation, 
 are in good condition, the nutrition, sleep and strength good. 
 Outside of a moderate dry cough the organs of respiration pre- 
 sent nothmg abnormal : objective examination fails to elicit any 
 dyspnoea, pains or any other pathological changes. The physicians 
 have however again advised her to go to Mentone for the winter. 
 
— 315 — 
 
 The girl's mother declared, that in view of the large family, of 
 her husband's affairs and the serious pecuniary expenses 
 incurred b}^ such a trip, this last presents extremely embarrassing 
 diificulties ; that the improvement m the girl's health began not 
 from the time they took up their residence at Mentone, but only 
 two montlis later, when she began the creosote treatment ; that 
 Mentone is crowded and dusty, and that the whole family, re- 
 moved forcibly from the habitual conditions and cu'cumstances 
 of life (they always led a country life in a healthy locality, 
 in an excellently arranged country residence, protected from the 
 winds by the woods) felt as if they had been exiled. I told 
 them that I considered the life at ^lentone as unsuitable for 
 such a family, and that m m}^ opmion the trip to Mentone 
 and back with all the possible accidents attached thereto, as 
 well as the patient's attempt to disaccustom herself from a cli- 
 mate in which she will after all have to live, were much 
 more risky than to remain over winter at home, in the 
 accustomed, favorable place of residence ; I therefore ad- 
 vised to constantly remain in the latter, keeping the same 
 points in view — mutatis mutandis — as explained b}' me in the 
 foregoing cases. As the girl was formerly studying hard, and 
 had at times to pass examinations, which circumstance acted 
 deleteriously on her nervous system, and being of a lively dis- 
 position she talked a great deal while, out-of-doors, I advised 
 to entirely give up the examinations conducted m the manner 
 harmful for the nervous system, to study without unnecessary 
 effort, to talk less, and to strictly refrain from talking when out- 
 of-doors during cold weather. As for treatment I prescribed 
 creosote. 
 
 The above described cases may serve as examples of my hab- 
 itual climatotherapeutic practice. The results of such practice 
 as regards the lasting recovery of health are incomparably better, 
 in my observation, than the results obtained by frequent trips 
 to far-away places with a totally different climate, and by a pro- 
 longed sojourn there. I will not speak of the cares and worries 
 that one avoids in the treatment at home, without these trips. 
 It would however be narrow-mindedness to completely deny the 
 benefit derived from trips with climatic treatment in view. 
 
— 316 — 
 
 Each given case must be individualized, as should always be 
 ■ done in therapy : if in the majority of cases such trips are con- 
 nected with considerable inconvenience and frequently even 
 with serious disturbances, there are on the other hand eases 
 where all these are absent, where on the contrary it becomes 
 beneficial for the patient, not only for climatotherapeutic pur- 
 poses, but also otherwise, to be removed away from various un- 
 favorable conditions surrounding him, and from his habitual 
 mode of living. But it may be stated in a general way, that a 
 trip with climatic treatment in view is particularly indicated in 
 those cases, in which a single trip and but a short sojourn maj^ 
 achieve the purpose of brmging about a recovery of health, as, 
 for instance, in cases of debility after an attack of a severe 
 disease. I had already once occasion to mention the indications for 
 such a trip while analyzing our first case. (Vide the lecture of 
 October 18, 1889, at the end.) But in cases of chronic diseases, 
 principally in chronic pulmonary tuberculosis, in which lasting 
 improvement in and preservation of health requires not only a 
 prolonged, but a constant residence among favorable climatic and 
 generally hygienic surroundings, a trip to a far-away, the more 
 so to a foreign, land is indicated only at the beginning, when it 
 becomes necessary to at once put the patient into favorable cli- 
 matic conditions, and when such are not easily found at home ; 
 but later on it is necessary to search for such conditions in the 
 place of residence or near by, at any rate in the native land, in 
 one's fatherland, where the patient is after all enabled to have 
 some occupation proportionate to his strength (patients with 
 chronic pulmonary tuberculosis are entirely incapable of any 
 activity only in the last, phthisical stage), which would to some 
 extent satisfy him and give him means for a livelihood, which is 
 very rarely possible m a foreign land. 
 
 We have discussed at sufficient length the general hygiene of 
 patients with chronic pulmonary tuberculosis several times be- 
 fore, and also while discussing the therapy of this disease. 
 
TWENTY-SECOND CASE. 
 
 LECTURE OF MARCH 3, J 893. 
 
 Patient, a peasant, nineteen years old, was admitted to the 
 clinic March 1st, complaining of severe dyspnoea, of pain in the 
 left side of the chest, of headache and general weakness. 
 
 Mode of living and anamnesis. — For the last five years pa- 
 tient has lived at Moscow. His rooms are dry and warm, but 
 being a clerk in a green-grocer's shop, he spends his whole day 
 in a basement floor where the store is located. Bathes himself 
 at times during the summer, takes a hot bath once in two weeks, 
 drinks a sufficient quantity of tea, but no brandy ; does not 
 smoke. His board is that of a workingman. Patient is single, 
 never had any venereal diseases. 
 
 Patient comes from a healthy family ; he had smallpox dur- 
 ing childhood, but since then up to the present illness enjoyed 
 good health. February the 27th he remained for a long time 
 in an ice-cellar, was thoroughly chilled and m the evening felt a 
 pain in the left side, had a severe chill and later fever which 
 continued up to the time he entered the clinic, March 1st. 
 On the day of his admission patient was given twelve one- 
 grain powders of calomel, one every hour (before that he did 
 not move his bowels for two days). He had four abundant 
 characteristic calomel evacuations, attended with slight pain : he 
 was then given five drops of tra. opii and his abdomen was 
 wrapped in some flannel ; after this the mtestinal pains quieted 
 down and the loosenesss of the bowels ceased. He was given 
 twice a day twenty-five stimulant drops (tra. valer. aether, and 
 liqu, anod. Hofmanni aa) and the left side of the chest was kept 
 warm by rubbing with warm oil, and then wrapping it with 
 cotton-wadding and flannel. 
 
 Status. — Average constitution. He has no appetite, there 
 
 317 
 
— 318 — 
 
 are no dyspeptic phenomena, nor were there any previous to the 
 disease. Had regular stools before he fell sick ; had no stool 
 during the first two days of the disease, then was given calomel, 
 later opium. During the last twenty-four hours he had one 
 stool, somewhat liquid but without pain. The urine passes 
 freely, 500 c.c. during the twenty-four hours, is rich in urates, 
 contains neither sugar, nor albumen. Tlie abdomen, as well as 
 the whole body, is slightly sensitive to pressure ; there is a hy- 
 pergesthesia cutis in connection with a high temperature. The 
 liver and spleen are normal. The heart, except for the fre- 
 quency of the contractions (pulse 100), is normal ; the pulse, 
 which was somewhat weak on admission, is now good. There is 
 some dyspncea, — respiration 32, on admission 36 per minute, — 
 some trifling pain in the left side of the chest, a slight cough, 
 with some tliick viscid expectoration of a rusty color. There is 
 a dull percussion sound under the left scapula, bronchial breath- 
 ing and vocal fremitus are more pronounced than under the 
 right scapula. Objective examination in the other regions of 
 the chest elicits nothing abnormal. Headache and dizziness 
 on getting up. His sleep is fair. There is general debility. 
 The course of the temperature : the morning of the day before 
 yesterday, on admission, 40.2° R. (104.4° i^.), evening (he 
 had before this some calomel stools), 39° R. (102.2° 1^.), 
 yesterday morning, 38.7° R. (101.6° i^.), in the evening, 
 40° R. (104° F.), this morning, 39. 5° R. (103.2° F.~). 
 
 Diagnosis. — Here, as in the case of the pleurisy with effusion 
 (nineteenth case), we evidently have to do with an acute 
 disease in the cavity of the chest which causes a febrile con- 
 dition, this last appearing simultaneously with the local 
 symptoms, namely pains in the left side of the chest. This 
 disease may be either pneumonia or pleurisy with effusion. 
 If we review the comparison between the symptoms of both 
 diseases, which we did while discussing the above mentioned 
 case, we shall see that the symptoms of the present case speak 
 against pleurisy with effusion, and for pneumonia, namely, for 
 croupous pneumonia (fibrinous) : the pains in the side are not 
 severe ; together with a dull percussion sound there is observed 
 clear bronchial respiration, and not the weak respiratory mur- 
 
— 319 — 
 
 mur of indefinite quality, as in the above-named case of pleurisy 
 with effusion ; the vocal fremitus is increased (there it is weak- 
 ened), the cough is not dry, as it is there, but with expectora- 
 tion and characteristic at that of fibrinous pneumonia ; the 
 affection of the lower lobe of the lung is also characteristic of 
 the same. The course of the temperature, when it became 
 established after its fall caused by calomel passed away, also 
 speaks for pneumonia, namely, the temperature is high, and the 
 difference between the morning (to-day 39.5° R. — 103.2° ^.) and 
 the evening (last evening 40° B. — 104 FS) is trifling, of one-half 
 of a degree, whereas in the above-named case of pleurisy, at the 
 beginning of the patient's stay in the clinic before antipyretics 
 had been prescribed for him, the morning temperature was 38.1 
 R. (100.6° F.~), that of the evening 39.6° R. (103.2° J^.). The mi- 
 croscopical examination of the sputum, so easy of accomplishment 
 in the clinic, but difficult in private practice, is unnecessary in 
 the present case, as the diagnosis is evident beyond doubt. It 
 is otherwise, if we have to deal with a pneumonia in the upper 
 pulmonary lobe, and especially in a patient in whom we are led 
 to suspect the presence of tuberculosis : then it is certainly neces- 
 sary to examine the expectoration for prognostic as well as ther- 
 apeutic purposes ; it ma}" contain in one case tubercular bacilli, 
 in another pneumonic diplococci, and in a thu'd both. 
 
 Prognosis. — The case is serious ; it may terminate in re- 
 covery, but may also end m death ; which of the two it is im- 
 possible to say, but we may certainly with greater probability 
 hope for recovery, in view of the patient's youth, his fair con- 
 stitution and the good condition of his cardiac activity, and also 
 because of the fact that during the two days that the patient 
 has been in the clinic we did not observe any further spread of 
 the pneumonic process. In addition to this, the patient has been 
 placed since the day before yesterday into favorable conditions 
 by his life in the clinic, and is subjected to treatment : the 
 calomel lowered the temperature considerably for more than 
 twenty-four hours, and it was probably the cause why the pneu- 
 monia did not spread. 
 
 Treatment. — We possess as yet no specific remedies for pneu- 
 
— 320 — 
 
 monia,* and have to rely on the symptomatic treatment. We must 
 combat the symptoms of the disease, and prevent any of them 
 from developing to any dangerous extent, until the disease will 
 terminate itself. As ordinarily dangerous symptoms in croupous 
 pneumonia may be considered a very high temperature, a very 
 weakened cardiac activity, and dyspnoea ; the cough (and very 
 rarely pain in the side) may be considered not as a directly 
 dangerous, but as a very embarrassmg symptom which exerts 
 a harmful influence on the patient's condition. 
 
 I prescribe treatment for high temperature in croupous 
 pneumonia only when I see that its effects are fraught with 
 danger. As a measure of the degree of danger of these effects 
 are considered the patient's sensations, the condition of the 
 pulse and the respiration: the higher the fever, the worse the 
 patient feels, and the worse are the pulse and the respiration, 
 and on the contrary, so that with the fall in the temperature 
 and with the termination of the crisis, the patient usually feels 
 well, the pulse becomes good, or yields easily to the effect of 
 cardiac stimulants, and there is no dyspnoea even by the time 
 when the local affection presents as yet no changes and remains 
 in the former extent. 
 
 The worse therefore the patient feels, as evidenced by ex- 
 treme anxiety and a feeling of distress, the weaker the pulse 
 and the greater the dyspncea, the more necessary does it be- 
 come to lower the temperature. 
 
 I have long ago discarded digitalis,! cold baths and quinine 
 as means for lowering the high temperature of croupous pneu- 
 monia ; quinme I give only in the very last stage of the disease, 
 when resolution is prolonged, and when the febrile condition 
 is of a strongly remittent nature in the mornings. I also give it, 
 as described above, in chronic pulmonary tuberculosis, thus : 
 for the morning remission qumine, and for the evening 
 exacerbation phenacetine or antifebrine ; but to lower the 
 
 * The attempts to treat croupous pneumonia, as well as the attempt to 
 create immunity towards it, by the products of the life activity of the mi- 
 cro-organisms considered as the causative agency of the disease, are as 
 yet not ripe enough for practical application. 
 
 t See article on the treatment of croupous pneumonia by calomel. 
 
— 321 — 
 
 temperatui-e of croupous pneumonia I resort to calomel, only 
 in patients of a strong constitution, and only at the incipiency 
 of the disease when the strength is in good condition; espe- 
 cially do I give it when there is an indication for calomel 
 as evidenced by the condition of the gastro-intestinal canal 
 (as constipation, meteorism, and a high position of the dia- 
 phragm, tending to increase the dyspnoja), and by that of the 
 biliary passages. The effect of calomel in croupous pneumonia 
 is explained in the article alluded to, and is partly also seen 
 from the present case. To repeat calomel in croupous pneu- 
 monia is usually unnecessary in view of the short duration 
 of the disease and the danger of weakening the patient. To 
 further lower the temperature, to bring it down from an im- 
 desirable elevation, I usually give phenacetine or antifebrine, 
 ordinarily in the evening when the fever is increased, and in 
 small doses (three to eight grains of phenacetine, or three to five 
 grains of antifebrine), which usually prove satisfactory. I 
 avoid the use of sodium salycilate and of antipyrine in view 
 of their weakenmg effect on the heart, which effect is especially 
 dangerous in pneumonia. 
 
 To keep up the weakened cardiac activity I administer the 
 stimulating drops mentioned here more than once, wine, coffee 
 with cognac, whiskey, less frequently camphor (to persons 
 not habituated to alcohol and unable to bear it). 
 
 Treatment of dyspnoea^ pains and cough. — There occur in- 
 frequent cases in which the dyspnoea is at the beginning of 
 the disease so severe that it requires local bloodlettmg, less 
 frequently general ; these are cases presenting a tempestu- 
 ous onset of croupous pneumonia, when in conjunction with 
 severe pains which embarrass respiration, a considerable portion 
 of one lung becomes suddenly affected, and simultaneously 
 with this, because of the impeded cii'culation in the affected 
 lung and of the weakened cardiac activity (on account of the 
 very high temperature), there takes place an oedema of the 
 other lung which develops rapidly, and is at times accompanied 
 by haemoptysis.* But ordinarily, a sufficient relief of the 
 dyspnoea is obtained by lowering the high temperature, by 
 
 * Vide article on "Bloodletting." 
 
— 322 — 
 
 strengthening the weakened activity of the heart, and by re- 
 lieving the pains and the cough. In case the dyspnoea is very 
 severe and dangerous, as a result of an oedema of the lungs 
 developed in acute cases at the termination of the croupous 
 pneumonia, — in a patient, already debilitated and presenting 
 symptoms of an approaching collapse, — then bloodletting is 
 not to be resorted to (as recommended by many text-books), 
 as it is then a very risky measure under such conditions, but 
 stimulants must be administered, also senega, and large Spanish 
 flies are applied. 
 
 For relieving the pain it is usually sufficient to keep the 
 pamful side of the chest warm (by the aid of warm oil, batting 
 and flannel), to relieve the cough, and the coughing spells 
 which tend to aggravate the pains. It is only on rare oc- 
 casions that we have to resort for the relief of the pain to 
 local bloodletting or to an hypodermatic injection of morphium. 
 
 As the cough aggravates the pain, and through this as well 
 as by embarrassing respiration and circulation, it also aggravates 
 the dyspnoea, and prevents sleep, it must, therefore, be reduced 
 to the possible minimum. As long as the expectoration is 
 scanty, and the rales are either few or entirely absent, we 
 should give codeine, opium, in the form of pulvis Doveri, rarely 
 morphine. I had observed many times that the first thing 
 a physician administers to a patient suffering with pneumonia, 
 is infusum ipecacuanhse which is continued for several days ; 
 this is undoubtedly an error : there is at that time as yet 
 nothing in the bronchi that can be brought awa}^, and the 
 ipecacuanha only tends to aggravate the cough, and if ad- 
 ministered for a long time, it deranges the appetite and prevents 
 its timely return. On the other hand, we must exercise ex- 
 treme caution during the administration of the above-named 
 narcotic remedies. Changes in the course of croupous pneu- 
 monia are liable to take place rapidly: codeine, opium and 
 morphine, which relieved the dry cough, and therefore also 
 the dyspnoea and the pain, thus benefiting the patient greatly 
 until say the fifth or sixth day of the disease, may become harm- 
 ful on the morning of the following day, usually at the time during 
 which the crisis occurs, by aggravating the dyspnoea, at a time, 
 
— 323 — 
 
 when the respiratory passages are filled with liquid contents 
 (as evidenced by abundant subcrepitant and more prominent 
 moist rales, whose appearance is to be carefully watched), on 
 account of the entrance mto them partly of the liquefied pneu- 
 monic mfiltration (although this is usually absorbed), but prin- 
 cipally of the oedematous fluid. Now we must put aside the 
 above-named narcotics, which we gave only yesterday, and 
 while continuing the stimulants, we resort to expectorants, 
 usually to senega in an infusion, 3j - 3ij to fvj, and in severe 
 cases also to large Spanish flies. 
 
 We will now turn to the treatment of our patient. From 
 the data outlined above you will perceive that there are no 
 indications at present for bloodlettuig, nor were there any 
 before. The indication for calomel, as well as its effect in the 
 given case, were already spoken of. What shall we give the 
 patient to-day ? We will first of all give him agaiu five drops 
 of the tincture of opium, as he had some loose stools, although 
 they were painless and appeared once during the twenty-four 
 hours. The opium will also be beneficial in quieting the 
 cough. We will contmue the stimulant drops. Their action 
 is good : twenty-five drops without wine, twice a day, produce 
 a fair pulse. Pain in the left side is sufficiently relieved by 
 the part being kept warm. For the cough — tra, opii, and in 
 case of constipation, one-fourth grain of codeine. As the 
 temperatiu'e is quite high and the dyspnoea very pronounced, 
 we will give him, in view of the probable evening rise of the 
 temperature, three grams of phenacetine. 
 
 FROM THE LECTURE OF MARCH 5, 1893. 
 
 The day before yesterday, at seven p. 3i. the temperature was 
 39.8° R. (103.6° i^.), and after he took three grains of phenace- 
 tine, it fell to 38.8° R. (101.8° _^.) by ten o'clock in the evenmg ; 
 this morning it is 39.5° R. (103.1° i^.). Yesterday morning the 
 area of dullness seems to have spread somewhat upward, to-day 
 it is of the same extent, as it was yesterday ; there is no further 
 spread. Auscultation over the region of dullness elicits bron- 
 chial breathing, no rales anywhere. The pams in the left side, 
 
— 324 — 
 
 as also the cough, are trifling and cause the patient no incon- 
 ' venience ; the dyspnoea is moderate. The pulse is good ; he 
 gets twenty-five stimulating drops four times a day. He is 
 constipated. The sleep is fair, he feels better, the hyperaes- 
 thesia cutis disappeared. 
 
 The prognosis remains favorable, because all the symptoms 
 are slight, the strength is good, and at the present time there 
 is no further spread of the pneumonia ; this is the seventh 
 day of the disease and we may soon expect the ci^isis. 
 
 Treatment : a clyster, coffee with milk (as a cardiac stimu- 
 lant, at the same time counteracting the constipation), stimu- 
 lants, phenacetine and codeine, as necessity requires; finally, 
 in case oedema of the lung supervenes during the crisis, 
 senega, or even a Spanish fly. 
 
 FROM THE LECTURE OF MARCH 16, 1893. 
 
 The day when the last lecture was delivered, the seventh 
 day of the disease, the temperature did not rise m the evening 
 (39.2° i^.— 102.7°^., as against 39.5° i^. — 103.1° I', in the 
 morning) ; on the next, eighth day, the morning temperature was 
 39.6° B. (103.2° #.), but it rapidly fell to 38° R. (100.4° ^.) in 
 the evening; on the ninth day 38.7° R. (101.6°^.) in the mornmg, 
 after three grains of phenacetine 38.4° R. (101.1° i^.) in the even- 
 ing, and on the tenth day in the morning, with the appearance 
 of considerable sweating, 36.2° R. (99.01° _F^.), and since then 
 there is no fever, the appetite appeared and is continuously 
 getting stronger. There was no further spread of the pneu- 
 monic process during the seventh, eighth, and ninth day of 
 the disease ; but with the advent of the crisis the local phe- 
 nomena underwent a rapid change : the dullness began to clear 
 up, the bronchial breathing disappeared, there appeared abun- 
 dant rales and the cough mcreased. Patient took two bottles 
 of an infusion of senega, 3j to fvj a tablespoonful every hour, 
 and by the twelfth day of the disease — March 10th — the 
 cough disappeared, the rales vanished and the percussion 
 sound at the region of the former pneumonia cleared up en- 
 tirely. To-day the patient, who, as you see, is completely 
 improved, leaves the clinic. 
 
A FEW NOTES ON OBJECTIVE EXAM- 
 INATION. 
 
 (^From Various Lectures.') 
 
 While speaking of the general examination of a patient I 
 said : •' By far not everything obtainable by examination is 
 necessary and important for medical conclusions ; we must be 
 particularly careful not to confound diagnostic aims with those 
 necessary to semiotics, for not everything of interest to the semi- 
 otician is necessary to the diagnostician." 
 
 As a matter of fact, every morbid phenomenon is of interest 
 in semiotics as an independent science, as a branch of natural 
 science, whereas for diagnostic purposes only that is of impor- 
 tance, which forms a symptom, a sign of disease ; and the more 
 certain the indication presented by the morbid phenomenon as 
 regards the disease, the more reliable is this phenomenon as a 
 symptom, the more important does it become for diagnosis. 
 Not all the morbid phenomena possess the same value as regards 
 diagnosis ; on the contrary, the number of morbid phenomena 
 important for diagnostic purposes is by far smaller than the 
 number of all the morbid phenomena in general. If we were 
 to compare the sum total of these last, the knowledge of which 
 the student must acquire during his study of semiotics, with 
 the limited number of those, which are made use of not only 
 by very experienced and conscientious physicians in their prac- 
 tice, but even by clinical instructors, then we would find a great 
 difference. I may also say, that not only in private practice, 
 but even in the clinic, are the methods of examination less com- 
 plicated, without losing thereby any of their correctness, than 
 those usually recommended by text-books and by the instruc- 
 tion in semiotics. 
 
 This is the reason why students, who have become familiar 
 
— 326 — 
 
 with semiotics and who come to the clinic, have usually a gen- 
 eral idea of the nature of many morbid phenomena, probably of 
 all, but in the majority of cases they are unable to appreciate 
 their comparative value for diagnosis, and cannot separate 
 the most important of these from the rest ; quite frequently 
 they are able to note in the patient some trifling signs, at the 
 same time failing to perceive valuable symptoms. 
 
 It is certainly the business of the clinical instructor to put 
 prominently before the mind of the future physicians whatever 
 is most important ; this is comparativel}^ but little, but they must 
 be taught to firmly possess this little : it is however desirable 
 that both the text-books and the instruction in semiotics have the 
 same aim in view. Some abbreviation of the course of instruction 
 in semiotics, and stricter choice in the matter to be communi- 
 cated to the students and in what is necessary to be acquired by 
 them, would aid mateiially in reaching such an aim and would 
 be more than timely now, when, with the rapid progress of the 
 various medical sciences, the students are less and less able to 
 satisfy all the requirements of a serious examination. 
 
 I will bring forward a few observations which I usually 
 make, with the aim in view of pointing out what is most impor- 
 tant on various occasions, in connection with the objective ex- 
 amination of the patient, namely, in percussion, auscultation and 
 palpation, except auscultation in diseases of the heart, on 
 which I touched but slightly in the preceding lectures, and 
 which, as well as the examination of this organ, I expect yet 
 to take up in the future. To make the matter clearer I 
 shall instance such a case. I call out a student, and mvite 
 him to auscultate the patient and tell me what he hears. In 
 reply he says that he hears rough breathing. I ask for the 
 meaning of this term, and what condition of the respiratory 
 passages it indicates, but fail to obtain a satisfactory answer. I 
 then remind the students and impress it on their minds to al- 
 ways remember the following data concerning respiratory mur- 
 murs : 
 
 Vesicular respiratory murmur indicates, that the area over 
 which it is heard, contains normal pulmonary tissue, and con- 
 sequently it has a diagnostically definite significance. [Each 
 
— 327 — 
 
 and every symptom, to the importance of which I call the at- 
 tention of the students, is described by me, produced, if pos- 
 sible, by voice imitation, and is demonstrated on the patient to 
 as great a number of students as practicable ; while the resident 
 physicians, the assistants in the clinics, as well as the privat- 
 docenten engaged therein, instruct during the evening hours 
 the students in the skill of determining practically on the 
 patients those diagnostic symptoms, to which I called their 
 attention.] 
 
 Broncliial respiratory murmur indicates that the pulmonary 
 tissue over which it is heard contains no air (the exception 
 refers to the bronchial respiratory murmur transmitted from the 
 larynx and trachea, but then it is heard usually with equal dis- 
 tinctness over both sides of the chest). Besides the bronchial 
 and the vesicular respiratory murmurs, which possess a charac- 
 teristic distinctness in their acoustic qualities and which have 
 a definite diagnostic significance, there are other respiratory 
 murmurs which resemble neither the vesicular nor the bronchial 
 murmurs, and which indicate nothing definite (they can be 
 found both in perfectly healthy respiratory passages, as, for in- 
 stance, in men when breathing quietly, and in various affections 
 of the bronchi, lungs and pleurae) ; these therefore possess 
 no definite significance, and are for this reason called the indef- 
 inite respiratory murmurs. To this class must be referred the 
 so-called rough breathing ; and to distinguish this is for the diag- 
 nostician but an unnecessary burdening of the memory by a 
 rhetorical, but not a diagnostic term. Once the respiratory 
 murmur is neither vesicular nor bronchial, it has no diagnostic 
 significance, and is therefore of an indefinite quality ; whether 
 it be rough or otherwise is of no importance. Under certain 
 conditions, but not independently by itself, the indefinite res- 
 piratory murmur (i. e. the one resembling neither the bronchial 
 nor the vesicular, and whether it be rough or otherwise is 
 not important) may possess a diagnostic importance ; thus, for 
 example, if under one clavicle we hear a vesicular respiratory 
 murmur, and under the other constantly an indefinite one, for 
 instance, the so-called prolonged expiration, one of the varieties 
 of the indefinite respiratory murmur, especially in a patient, 
 
— 328 — 
 
 who excites a suspicion of tuberculosis, tlien we have a founda- 
 ■ tion to conclude, even before the appearance of the more positive 
 symptoms, such as rales and alterations in the percussion sound, 
 that that pulmonary apex is affected, over which we hear the 
 indefinite respiratory murmur. 
 
 In connection with the same we must also make the follow- 
 ing observations : 
 
 About rales. — We must distinguish dry rales (usually 
 whistling ones) and moist rales ; of the latter, the very fine 
 ones, crepitant, as typically represented in the beginning of a 
 pneumonia, then somewhat more prominent, subcrepitant, as 
 typically represented at the stage of resolution of a pneumonic 
 process and at the beginnmg of an oedema of the lungs, 
 and finally the medium and the coarse rales, as typically 
 represented by a pulmonary cedema which spread upward, 
 and by a bronchial catarrh with abundant expectoration. 
 
 Then I advise to memorize well the nature of the rales which 
 characterize the most frequent affections of the respiratory organs. 
 
 1. Abundant moist rales, at the beginning subcrepitant, later 
 more coarse, which appear simultaneously on both sides of the 
 chest, at first under the scapulae and later spreading further and 
 further upward (and parallel with this the dyspnoea becomes 
 aggravated), pomt with certainty to pulmonary oedema, which 
 increases rapidly and requires immediate treatment. 2. Less 
 abundant moist rales on both sides under the scapulae, which 
 remain constantly subcrepitant and do not spread upward, and 
 which are usually heard on deep inspiration, ordinarily in per- 
 sons with a distended abdomen and a highly elevated diaphragm, 
 — which condition prevents a full expansion of the lower 
 pulmonary parts, — point partly to a condition of atalectasis, 
 partly to a slight stationary oedema of these parts. 3. 
 Rales which are heard on either side only over the middle 
 portions of the lungs, and which are not perceived in the apices 
 and the lowest portions, now more diy, now more moist, medium 
 and large bubbling ones, point to a bronchial catarrh, either 
 dry or moist. As a very rare exception I have seen an un- 
 complicated bronchial catarrh (without any affection of the 
 pulmonary tissue) on one side, which lingered from the very 
 
— 329 — 
 
 childhood of the patient, at times quieting down, at others, dur- 
 ing the cold season, taking on an acute form, the predisposition 
 to which catarrhal condition was evidently determined by an in- 
 sufficient expansion of the affected half of the chest during the 
 early part of life (semiatalectasis of the lung ?). On the other 
 hand the above-mentioned rales, if considerably spread over both 
 halves of the chest, may be heard in bronchopneumonia — 
 most frequently of tubercular origin — which attacked both 
 lungs (the differential diagnosis between bronchial catarrh and 
 tubercular bronchopneumonia was spoken of in connection with 
 the twenty-first case). 4. Moist rales, observed over a limited 
 area, in one focus or in several, point to an affection of the 
 lung tissue, — croupous pneumonia, pneumonia complicating 
 grippe, pertussis, etc. ; such a focus exhibiting moist rales in the 
 apex of one or the other lung or of both forms one of the most 
 certain symptoms of tuberculous affection of the lungs. 
 
 In some cases — as in pneumothorax and in cavernse — the 
 respiratory murmurs and rales may possess a particular quality 
 of resonance (simple and metallic), at times of such a pro- 
 nounced and characteristic nature, as to plainly point to the 
 above-named morbid conditions. 
 
 The percussion sound. — The principal quality of this, which 
 must chiefly be taken into account, is its force : a clear, a dull 
 or a flat sound. In rare cases the percussion sound over the 
 chest, ordinarily not resonant, may possess a similar pronounced 
 resonant quality as the phenomena observed in auscultation; it 
 then has a similar diagnostic significance. 
 
 Determination of the dimensions of the heart., liver and spleen. — 
 The dimensions of the heart are firstly determined by palpating 
 the region of the heart-impulse at the apex (I recommend most 
 earnestly exercise in such examination, as it gives most im- 
 portant data), and secondly by percussion over the sternum : in 
 the normal condition the lower half of the sternum gives almost 
 as clear a percussion sound, as the upper one ; while in case of 
 an enlarged heart, and especially of its right half, the per- 
 cussion sound over the lower half of the sternum and to its 
 right is duller than over the neighboring parts — upward and 
 to the right — of the chest wall and the upper half of the 
 
— 330 — 
 
 sternum. The area of the apex beat of the heart and the right 
 border of the dull sound at the cardiac region, present entirely 
 sufficient data by which we can judge of the dimensions of 
 this organ. 
 
 The lower border of the liver and of the spleen is determined 
 by palpation, and the upper border hy percussion. While per- 
 forming the last it is hardly worth while to search for the rib 
 to which it extends. The statement of the text-books " from 
 this rib to that " are but average deductions from many ob- 
 servations. Every individual case will present departures 
 from these mean dimensions. Consequently, if such depar- 
 tures be small, then we cannot deduct therefrom any conclu- 
 sion as regards the alteration in the size of the organ; but if 
 they be considerable, then there is no necessity to occupy one- 
 self with recounting the ribs : for it is plainly apparent, that 
 the area between the superior and the inferior borders is 
 markedly greater, or pronouncedly less extensive, than is 
 peculiar to the organ in its normal condition. It also suffices 
 an experienced look to judge by this area as to whether the 
 organ is replaced or not. This is the reason why I insist, for 
 the sake of acquiring such experience, on exercising as much as 
 possible in defining the borders of the hver and of the spleen, 
 and thus acquire a strong mental hold on the dimensions as 
 well as the localization of the area contained within the above- 
 named borders in the normal condition of these organs, as 
 well as when they are enlarged, diminished and replaced. 
 
 The importance of feeling the pulse, at one time somewhat 
 forgotten, thanks to the enthusiasm generated by the method 
 of percussion and auscultation and also to sphygmography, 
 but at the present time appreciated rightly, requires certainly 
 no necessity for discussion. Of the many peculiarities of the 
 pulse we must at all times define its three principal qualities : 
 its frequency, rhythm and, most important of all, its strength. 
 The strength of the pulse depends on the quantity of blood, on 
 the force of the cardiac contractions and on the elasticity of the 
 arteries. Feeling the pulse enables one to judge certainly only 
 of the results of interaction of these factors. To determine the 
 condition of these last we must consider the other data, the 
 
— 331 — 
 
 condition of nutrition and hsematopoiesis, and the results of the 
 examination of the heart and of the arterial system. Sphygmo- 
 graph}^ and sphygmomanometry, not to speak of the great 
 inconvenience their use occasions in private practice, cannot 
 replace the determmation of the qualities, prmcipally of the 
 strength, of the pulse, nor of the condition of the arteries as 
 obtained by touch. We shall yet have occasion to speak of the 
 pulse, as well as of auscultation of the heart, when analyzing 
 clinically the diseases of this organ. 
 
ELEMENTS OF BALNEOTHERAPY 
 
 FOR THE PRACTICAL PHYSICIAN. 
 
 LECTURES OF APRIL 20 AND 21, 1893. 
 
 While giving clinical, that is, practical instruction in pathol- 
 ogy and therapeutics, the clinician embraces the opportunity, 
 in prescribing the treatment, to touch on all the means pos- 
 sessed, by this last, and in doing this he is enabled to classify 
 these means from his own special clinical, principally individ- 
 ualizing point of view. I therefore since long, almost from the 
 very beginning of my clinical activity, always touched upon the 
 subject of balneotherapy. In former times this was the more 
 necessary, as the student at the clinic had almost no idea about 
 this subject, because it formed no part of the curriculum of 
 university instruction. During recent years among the various 
 courses of our medical schools there were also established courses 
 in balneotherapy, but I still keep to my custom of discussing 
 the subject in my lectures ; in doing this I am also urged on by 
 my former students, who attest to the value of these lectures 
 by their own experience. As far as the internal employment 
 of mineral waters is concerned, I spoke of the necessity of its 
 clinical characteristic ; but there is another reason for the utility 
 of such a characteristic of balneotherapy, which is common to 
 both the external and the internal employment of mineral 
 waters. 
 
 The reason for this lies in the practice, common to all hand- 
 books, text-books and courses of balneotherapy, of expounding 
 together the employment of mineral waters both for external 
 and internal uses, while discussing the subject in general, as 
 well as in the description of special kinds of mineral waters. 
 The subject of balneotherapy in general, that is, the science 
 of the application of mineral waters for external and internal 
 332 
 
— 333 — 
 
 use, is very extensive, extremely complicated and varied ; there 
 is hardly a department of special pathology on which it does not 
 touch. By the internal use of the mineral waters we aim principal- 
 ly to influence the mucous membranes, the blood, the nutrition and 
 the various secretions, and through all these, the nervous system ; 
 while by their external use we act through the skin on the 
 nervous system, and then through this last on the other parts 
 of the organism. It is thus apparent, that the numerous and 
 various diseases, for which the mineral waters are administered 
 internally, differ from the great number and variety of diseases, 
 in which they are applied externally ; it is consequently but 
 too evident how different may be the indications for the in- 
 ternal use of mineral waters from those for the external use of 
 the same. To this we must subjoin the following : that the 
 experience proving the effectiveness of the mineral waters was 
 obtained at the places where these are located, and consequent- 
 ly their curative efficacy, as shown in certain diseases, was due 
 not only to their employment, but also to the peculiar charac- 
 teristics of these localities, to the climatic, dietetic and general 
 conditions, as well as to the change in the mode of living of the 
 patients who took up their residence there. To correctly ap- 
 preciate the proper action of the mineral waters, balneotherapy 
 must take into consideration also these last influences, climatic 
 and otherwise, generally hygienic. All these balneotherapy must 
 consequently touch upon. This many-sidedness of the subject, 
 which is determined by the great variety of its contents, consti- 
 tutes a great obstacle in penetrating into the true nature of 
 balneotherapy, especially so for the beginner, who in a general 
 way finds it difficult to differentiate the enormous mass of ma- 
 terial T)ffered to him for acquisition during the few years of his 
 university (medical") course. 
 
 Therefore to better define the so important therapeutic value 
 of the mineral waters proper, I continue to discuss this sub- 
 ject also at the present time during my clinical instruction ; and 
 for the sake of still greater clearness I discuss the internal use 
 of the mineral waters separately, and the external use, or halneo- 
 therapi/ in the narroiv acceptation of the term, also separately, after 
 you had been shown during the course of the year the applica- 
 
— 334 — 
 
 tion of various balneotherapeutic agencies, — as the warm baths, 
 hot air-baths, douches, cold and warm compresses, etc. ; all these 
 were demonstrated and explained to you, as well as the indications 
 for the use of other similar agencies, as, for instance, alkaline 
 baths in the cases we came across (thus in the thirteenth case). 
 
 In speaking of balneotherapy in the narrow sense of the word 
 (the external use of waters) I only aim to give its fundamental 
 principles, the most important which should always be fresh in the 
 memory and clear to the understanding of the practical physi- 
 cian, and which are not always clearly defined, but rather made 
 vague in- the above-mentioned complicated and diversfied treat- 
 ment of the subject by handbooks, text-books and various 
 courses. The exposition of this most important matter is sub- 
 divided into three parts : the action of the waters, the varieties 
 of the same, and a short sketch of diseases in which the waters 
 are applied externally. 
 
 The action of waters in their external application is principally 
 determined by their temperature, and to a lesser extent by their 
 composition and mechanical effect. 
 
 I. The Effect of the Temperature of the Waters. 
 
 1. O71 the nervoiis system. — Waters, the temperature of which 
 approaches that of the surface of the body — 27° R. (92.8° F.^ 
 to 28° R. (95° F.^ — are known as thermically indifferent ; with 
 a higher temperature — 29° R. (97.2° i^.) and more — as warm 
 or hot; with a lower temperature — 26° R. (90.6° i^.), and less 
 — as cool or cold. 
 
 The thermically indifferent waters exert by themselves no 
 effect on the nervous system ; but by keeping the body in an 
 equable temperature, they protect it from the irritation pro- 
 duced by the constantly changing external temperature, and 
 thus induce a quieting effect. Cold baths exert a stimulating 
 effect on the central nervous system, calling forth a spirited 
 mental state and a desire for mental and physical activity, and 
 remove contrary conditions. Warm baths act on the nervous 
 system in a weakening manner, causing fatigue, unwillingness 
 to work and inclination to sleep ; they quiet the condition of 
 excitement. Such an effect of the cold and of the warm baths 
 
— 335 — 
 
 is observed in the majority of cases, but there occur also nu- 
 merous exceptions ; in describing' the external use of waters in 
 diseases of the nervous system I shall speak of this more. 
 
 The effect of baths on the central nervous system may take 
 place through various ways : directly in a centripetal way 
 through the sensory nerves of the skin, through reflex action on 
 the vasomotors of the cerebral and the cerebro-spinal vessels, 
 and consequently through alterations in the cerebral and cere- 
 bro-spinal distribution and circulation of blood, through the va- 
 cillations produced in this last by changes which are caused by 
 the baths in the general circulation (as, for instance, by the in- 
 flux of blood to the external parts after warm baths), later on 
 through alterations produced by baths in the general nutrition. 
 By influencing the nervous centres through the skin, the baths 
 may exert an effect through these last on all the nervous func- 
 tions — sensation and motion, nutrition and secretion. The 
 mechanism of this action is not known with certaint}^, but the 
 fact of its existence is beyond any doubt ; thus : warm baths 
 quiet pains and convulsions, cold baths may call out muscu- 
 lar contractions, as evidenced in the treatment of constipation 
 by cold douches on the abdomen or into the rectum ; later on 
 we shall discuss the important changes which may be produced 
 by baths of various temperatures on the temperature of the body, 
 on the body metabolism, on the secretions, on the calibre of the 
 vessels, distribution and movement of the blood and lymph, and 
 the activity of the heart and the respiration ; all these changes, 
 as I said before, are reflected in their turn in the condition of 
 the nervous system. 
 
 2. On the temperature of the body. — The thermically indifferent 
 baths, produce no marked effect on the loss and production of 
 heat by the body. In cool and cold baths, up to a certain de- 
 gree of cold and within a certain limit of time, the body is at 
 first chilled, but later on it becomes rapidly warm and the in- 
 ternal bodily temperature is not lowered, but remains normal, 
 or is even raised. Similar to the action of cold baths is that of 
 other cooling hydrotherapeutic procedures, as douches, semi- 
 baths, sponging with a wet towel. The constancy of the inter- 
 nal bodily temperature in the presence of a considerable loss of 
 
— 336 — 
 
 heat in a cold bath is determined by the diminution of this loss 
 as caused by the contraction of the peripheral vessels and by 
 the increased production of heat in the body. But if the degree 
 of cold and the time during which the bath is being taken ex- 
 ceed certain limits — which are, of course, variable in different 
 cases — then the body, having become warmed after the first 
 chill, is chilled anew, does not any more become warmed either 
 in the bath or out of it, and is subjected to an abnormal state, 
 which is made apparent by a condition of general weakness, in- 
 stead of stimulation, by loss of appetite, and by a red saturated 
 urine containing a great amount of urea and uric acid. If the 
 use of such baths or of similar hydrotherapeutic procedures be 
 resorted to repeatedly during a careless and negligent treatment, 
 then there is established a genuine febrile condition, accompa- 
 nied by emaciation of the body, which may lead eventually to a 
 serious disturbance of health ; any curative effect of such a 
 treatment is certainly out of the question. 
 
 Warm and hot baths prevent the loss of heat by the body 
 and even bring warmth to the body, and therefore the internal 
 bodily temperature is raised while in them ; thus Mosler observed 
 that in baths of 40° G. (104° ^.) to 44° C. (111.2° 1^.) the 
 temperature in the cavity of the mouth was raised to 38.6° H. 
 (118.8° -F.), and Bartels noted that after a ten minutes' stay in 
 the steam bath at the temperature of 53° G. (about 127° i^.) 
 the temperature in the rectum was raised from 38° Ft. to 40.4° R. 
 (about 122.5° F.y 
 
 3. On the tissue metabolism and on the secretions. — The ther- 
 mically indifferent baths, not influencing the loss and produc- 
 tion of heat by the body, exert no marked effect on the tissue 
 metabolism and on the secretions. 
 
 Cold baths, and generally the loss of heat, increase the 
 excretion and consequently the production of carbonic acid, i. e. 
 the combustion of fats, in proportion to the degree of this loss, 
 and consequently to the increased production of heat ; the body 
 becomes lean. If the degree of cold and the duration of the 
 bath are kept within the above-mentioned limits, so that the 
 body, after becoming warm after the first chill, is not chilled 
 later on, then the excretion of urea, representing the disinte- 
 
- 337 — 
 
 gration of the albumens, is not altered by such baths ; but if 
 these limits are exceeded, that is, if the body, having become 
 warm after the first chill, is later on chilled again and does not 
 become warmed any more, then there develops a morbid condi- 
 tion which passes into fever, and with this the excretion of 
 urea and of uric acid, representing the disintegration of the 
 albumens, becomes increased. 
 
 Hot baths, by raising the temperature of the body, increase 
 both the excretion of urea, which means the disintegration of the 
 albumens, and the excretion of carbonic acid, i. e. the combus- 
 tion of fats. After warm, and particularly after hot baths, the 
 body perspires (consequently it loses heat), while the amount 
 of urine is diminished and its concentration is increased. 
 
 4. On the circulation and respiration. — The thermically in- 
 different baths exert no marked effect on the calibre of the 
 vessels, and consequently also on the distribution of blood 
 throughout the body, on the frequency and force of the cardiac 
 contraction (the pulse), nor on the frequency and depth of the 
 respiratory movements. 
 
 The body becomes first pale in a cold bath, as its vessels are 
 constricted, then the color changes to red, the vessels dilating 
 and the circulation growing quicker, these phenomena remain- 
 ing after the bath; in the unnecessarily cold and prolonged 
 baths, the skin takes on a blue tinge, which is a sign of venous 
 hypersemia and of slackened circulation. 
 
 In a hot bath the skin grows red, on account of a dilatation of 
 the vessels, which effect lasts for some time also after the bath. 
 Very hot water, the application of which is, of course, possible 
 only in a local way, determines a contraction of the vessels ; 
 this is the basis for certain therapeutic measures in gynsecology, 
 as the use of hot vaginal douches for metrorrhagise and to assist 
 in the absorption of exudations formed as a result of a parame- 
 tritis. 
 
 In a cold bath the contractions of the heart, the pulse, be- 
 come stronger and are at first more frequent (because the simul- 
 taneous contraction at the beginning of the peripheral vessels 
 increases the blood-pressure and thus excites the activity of the 
 left ventricle), but grow less frequent later on. 
 
■ — 338 — 
 
 In a hot bath the contractions of the heart, the pulse, become 
 more frequent and weak in proportion to the rise of the internal 
 bodily temperature. 
 
 In a cold bath the respiratory movements become deeper and 
 more frequent in proportion to the excretion of carbonic acid. 
 In a hot bath the respiratory movements become more frequent 
 in proportion to the increase of the internal bodily temperature 
 and to the increased excretion of carbonic acid. 
 
 II. The Effects of the Component Parts of the Waters. 
 
 The most important component parts of the waters used 
 externally are common salt, carbonic acid and sodium carbon- 
 ate. 
 
 Experiments have shown, that a salt bath, containing three 
 per cent of common salt, increases (as compared with a bath of 
 water not containing any salt, at the same temperature and of 
 the same duration) the consumption of oxygen and the 
 excretion of carbonic acid ; this effect does not take place, if 
 the nerve-endings be paralyzed by curare. From this it be- 
 comes apparent, that the sodium chloride in the above-named 
 concentrated solution irritates the nerve endings of the skin 
 and in this way exerts a strong influence on the metabolism and 
 on the secretions. Medical observations concerning the effec- 
 tiveness of salt baths, as in scrofulosis, rickets, unabsorbed 
 exudations, etc., have long ago proved the fact of such an 
 influence. Salt baths of the above-named concentrated solu- 
 tion cause the superficial vessels first to contract (the skin 
 becomes pale), and later on to strongly and continuously dilate 
 (the skin grows red and remains so for quite a considerable 
 time after the bath) ; thus the salt baths, besides mfluencing 
 the circulation, and consequently the nutrition of the general 
 integuments, may also exert an influence on the distribution of 
 the blood throughout the body, and through this means as well as 
 by the above-mentioned irritation of nerves of the skia, also on 
 the nervous sj^stem. 
 
 The carbonic acid, when present in the bath in a sufficient 
 quantity, irritates the peripheral endings of the nerves and in 
 this way acts as a stimulant to the nervous system. 
 
— 339 — 
 
 The sodium carbonate, in the quantity found in the alkaline 
 waters employed for bathing purposes, causes but a slight irri- 
 tation of the peripheral endings of the nerves, rather contrari- 
 wise, quieting them, improving the condition of the skin by the 
 fact that it assists in the removal of the fats (by saponifying 
 them) as they accumulate in the mouths of the glands of the 
 skin, and also in the removal of the epidermis. 
 
 Sulphur seems to exert some effect on the skin, because sul- 
 phur baths proved to be beneficial in certain cutaneous affec- 
 tions ; any further effect than that the sulphur baths do not 
 apparently exert, and they are also considered as chemically 
 indifferent waters. 
 
 Other bodies found in mineral waters employed for baths, 
 do not cause any marked effects. 
 
 The substances found in the mineral muds, as the organic 
 acids, sodium chloride, iron sulphate and other salts, exert an 
 irritating effect on the peripheral nerve endmgs, as may be 
 inferred from the curative effect of the muds, but we possess 
 ng positive knowledge concerning this subject. 
 
 Even if absorption, in the bath, of certain substances by the 
 body does take place, it is of such trifling extent, that it pos- 
 sesses no practical significance. 
 
 III. The Effect of Mechanical Influences during the External 
 Use of Waters. 
 
 The mfluences of such a nature, as in out-door bathing the 
 current in the river and the waves in the sea, the concussions of 
 the skin in the fan-like douches under a high pressure, the 
 friction in the half-baths and m the wet spongings, and various 
 other massage-like procedures, act as irritants on the skin, i. e. 
 in the same sense as the thermic and the chemical agencies, and 
 consequently they enhance the effect of these last. The 
 movements made by the patient, as in swimming and other 
 movements in sea-bathing, friction of one's own body in the 
 front in half-baths and wet spongings, exert an influence on the 
 metabolism and on the secretions, on the circulation and 
 respiration in the same way as the above-mentioned agencies. 
 
— 340 
 
 THE VAEIOUS CLASSES OF WATERS. 
 
 1. The chemically indifferent tvaters, usually warm (acrato- 
 thermse), contain but one or less to a thousand of component 
 parts — usually of alkaline carbonates, chlorates or sulphates — 
 namely, not more than any river water, and therefore they act 
 only by their temperature. They are used either as ihermically 
 indifferent waters, which protect the body from irritation by the 
 continuously changing external temperature, which means that 
 they quiet the nervous system in various nervous disorders, 
 especially in those in which the symptoms of hypersesthesia pre- 
 vail, principally in neurasthenia and in hysteria ; or they are em- 
 ployed in the form of warm and hot baths, deriving the blood 
 towards the periphery in hypersemia of the internal organs, 
 and exert a pronounced effect on metabolism and absorption in 
 the_ several varieties of chronic polyarthritis, gout, syphilis, and 
 metallic poisonings. Of the well known waters of this class I 
 shall name as examples, Schlangenbad,* Ragatz,f Gastein,| 
 Teplitz,§ Leuk,|| Plombieres,^ Abas-Touman.** To this class 
 
 * In the province of Hesse-Nassau, Prussia, six miles west of Wiesba- 
 den. 
 
 t In the canton of St. Gall, Switzerland, situated on the Tamina in lat. 
 47° N., long. 9° 30' E. It is noted for its hot springs, and has about fifty 
 thousand visitors annually. 
 
 I A valley in the crown land of Salzburg, Austria-Hungary, south of 
 Salzburg. It is famous for its picturesque scenery. At Wilbad-Gastein 
 there are hot springs. 
 
 § A town and watering place in Northern Bohemia, situated in the val- 
 ley of the Biela, near the mountains, forty-six miles northwest of Prague. 
 It is one of the most frequented places in Europe, and has been the scene 
 of several conferences of princes. Population in 1890 (commune), 17,526. 
 
 II Leuk (loik), P. Loueche (lo-esh), a village in the canton of Valais, 
 Switzerland, situated on the Rhone, fourteen miles northeast of Sion. 
 
 1 In the department of Vosges, France, situated on the Augrogne, 
 fifteen miles south of Epinal. It has the most important mineral springs 
 in the Vosges, with thermo-mineral, iron and alkaline baths. It was 
 known to the Romans and was greatly developed by Napoleon III. 
 
 ** A watering place on the Caucasus. 
 
— 341 — 
 
 also belong the sulphur waters, as, for instance, those of 
 Aachen * and of Pyatigorsk.f 
 
 I must now make some general remarks concerning not 
 only the enumerated watering places, but any others as well. 
 It were a great, unpardonable error, in view of the fact that the 
 above-named (and any other) watering places are classified in 
 one category, to consider them as identical and to send patients 
 there indiscriminately, as, for instance, to send a nervous, ema- 
 ciated female patient, for whom the thermically indifferent baths 
 are suitable, to Teplitz or Pyatigorsk, where the warm and hot 
 springs are situated, and to send a gouty patient, with a multiple 
 arthritis, who would be benefited hj warm or even hot baths, to 
 Schlangenbad with its thermically indifferent baths. This would 
 be as great an error as if we were to prescribe for a patient Ems 
 while he needs Marienbad, or on the contrary. Every watering 
 place possesses certain peculiarities which must be taken into 
 consideration. These peculiarities depend on numerous con- 
 ditions. The difference in the temperature of the baths was 
 spoken of before. The method of employing them is also of 
 importance. Let us take, for the sake of comparison, Franzens- 
 bad and Saki (in Crimea, near Eupatoria). In both places 
 mkieral moor is employed, but in Franzensbad it is added to a 
 water bath of a mostly thermically indifferent temperature, and 
 the bath is taken within a closed space, while in Saki the pa- 
 tient is put directly into a mass of mud which has been pre- 
 pared since morning in the open air and which was strongly 
 heated by the rays of the sun, and he is covered up with a simi- 
 lar mass of mud, so that the temperature of such a bath is raised 
 high, and the bath is a hot one. It is self-understood that Fran- 
 zensbad benefits a different class of patients, than are benefited 
 by Saki. To Franzensbad flock nervous, emaciated men and 
 
 * Aaclien is the German name for Aix-la-Chapelle, in the Rhine prov- 
 ince, Prussia, about lat. 50° 46' X., long. 6° 5' E., an imjHjrtant commer- 
 cial and railway centre. It was founded by the Romans as a watering- 
 place. 
 
 t A town in the Terek Territory, Ciscaucasia, Russia, situated on an 
 affluent of the Kuma in lat. 44° 4' N., long. 42° 8' E. It is noted as a 
 watering place on account of its sulphur springs. Pojiulation in 1889, 
 13,114. 
 
— 342 — 
 
 women (we shall have occasion later to speak of the use of 
 moor-baths hi Franzensbad for diseases of women), because 
 many observers have proved that the thermicallj indifferent 
 moor-baths exert frequently even a greater quieting effect on 
 the nervous system, than the thermically indifferent baths of the 
 chemically indifferent springs (acrato thermae). In Saki you 
 will see gouty and syphilitic patients with inveterate affections 
 of many joints, and others in whom it is expected the hot 
 baths will exert a strong influence on the metabolism and 
 absorption. 
 
 A particularly important part m determining the special 
 peculiarities of the various watering places is to be attributed 
 to their climate. To better explain its influence, let us continue 
 the former comparison between Franzensbad and Saki. Pa- 
 tients with weak nerves, who usually bear heat badly, would 
 be harmed by a sojoui'n during the extremely hot summer at 
 Saki, but on the contrary they would profit by the cool summer 
 of the Franzensbad valley ; whereas for patients, who are bene- 
 fited by the hot mud-baths (and these in the open air), the hot 
 summer in Saki would be very suitable, but not the cool sum- 
 mer at Franzensbad, that may bring on a cold in a locality 
 much visited and exposed to every wind. 
 
 Another example : both Gastein and Pyatigorsk possess 
 warm springs of a similar temperature; but the patients who 
 come to Gastein, who are frequently advanced in years, are 
 emaciated, with failing nutrition, with weak nerves, and whose 
 nervous condition and nutrition improve so well under the 
 influence of the mountainous, cool climate and pure air of Gastein, 
 would fare poorly at Pyatigorsk with its hot summer, and dusty 
 and malodorous air ; whereas for patients, who are treated by 
 baths, mercury and iodides, and who therefore are easily pre- 
 disposed to cold, the hot summer and the warm soil of Pyati- 
 gorsk are very suitable.* Another example: it is a quite differ- 
 ent thing to order salt baths in Stara Russa (in the Novgorod 
 
 * I do not speak here of the peculiar characteristics of the water of the 
 warm Gastein springs to conduct an electric current, as proved recently 
 by exact physical investigations, because the nature of its therapeutic 
 value (and this last we have no foundation to deny) is not known with 
 certainty. 
 
— 343 — 
 
 Government) with its damp and cool summer, or in Slavyansk 
 (in the Charkoff Government) with its dry and hot summer 
 or at the Odessa estuary, where the summer heat is modified by 
 the influence of the Black Sea. 
 
 Then for the patient who, for the sake of a trip to the water- 
 ing place, leaves his habitual surroundings, his usual mode of 
 living and his ordinary diet, the degree of comfort and the 
 conditions of life at this place are of no small importance : one 
 enjoys a quiet, restful locality, rich in natural beauties ; the 
 other is more benefited by a great, populous, lively centre, as the 
 most frequented watering places become during the " season." 
 Finally, it is of course of very great importance as to what sort 
 of a physician will supervise and direct the treatment at the 
 watering place. 
 
 The above is sufficient to show how necessary it is for the 
 physician to act thoughtfully not only when he advises a trip 
 to a watering place, which is in the majority of cases so burden- 
 some for the patient, but also when he recommends a certain 
 watering place. It is necessary to become thoroughly acquaint- 
 ed with such places, at least with the most important of them, 
 either through the medium of literature, or, which is better, by 
 a personal visit. As a summer trip with the purpose of resting 
 or of travelling, the physician will find nothing more pleasant 
 than a trip to the watering places for a personal acquaintance 
 with them, as well as for the observation and treatment of 
 diseases, the sufferers with which flock thither. The watering 
 places form a sort of a clinic of such diseases. 
 
 I will turn now to the further examination of the waters. 
 . 2. Salt waters (containing common salt). — Their action is of 
 a double nature — thermic and chemical ; the benefit derived 
 therefrom is apparent : that the thermic agency may by itself 
 exert a strong effect on the processes of metabolism and absorp- 
 tion, we must have a recourse either to hot baths — 31° R. 
 (101.8° F.) and higher, or to cold ones — 21° B. (79.2° #.) 
 and lower, for which the majority of cases will present contra- 
 indications ; the addition to the thermic effect of a chemical 
 agency — the common salt — which acts in the same manner as 
 the thermic one, enables us to confine ourselves in such cases 
 
— 344 — 
 
 to either thermically indifferent baths, 28° R. (95° i^,) to 
 27° R. (92.7° F.\ or to warm, 29° R. (97.2° F.) to 30° R. 
 (99.5° i^.), or to cool ones, 26° R. (90.5^.) to 22° R. (81.5° F.), 
 and it certainly increases also the action of both the hot and the 
 cold baths. The percentage of common salt in such baths is 
 usually from two to four, seldom greater, while at the beginning, 
 for a very sensitive skin and in the case of children, it is even 
 smaller, beginning with one per cent. The chief indications for 
 the use of salt baths are : scrofula, rickets, chronic exudations, 
 chronic multiple arthritis (chronic articular "rheumatism"), less 
 frequently diseases of the nervous system. The salt water sprmgs 
 are very abundant in Western Europe ; the places particularly 
 frequented are Kreutznach,* Wiesbaden,! Soden,| Ischl,§ Gmun- 
 den,|| Reichenhall,^ and others. Of our springs — Stara Russa, 
 Slavyansk and the Black Sea estuary at Odessa (their action, 
 in a general way, is similar to that of the salt springs). 
 
 3. Oarhonated waters, containing a great quantity of free car- 
 bonic acid, as Schwalbach,** or our Narzan in Kisslovodsk. 
 These are used in the form of cool baths ; in the thermically in- 
 different, and especially in the warm ones the carbonic acid 
 evaporates rapidly. The effect is partly of a thermic nature, but 
 principally, thanks to the carbonic acid, strongly stimulating. 
 They are indicated in cases of neurasthenia and hysteria (also 
 
 * In the Rhine province, situated on the Nabe, twenty-one miles west 
 southwest of Maintz. 
 
 t In Hesse-iSTassau, Prussia, three miles from Rhine and six miles north 
 by west of Maintz. It was known in Roman times ; is frequented annually 
 by about ninety thousand visitors. 
 
 I In Hesse-Nassau, nine miles west northwest of Frankfort on the 
 Main. 
 
 § In Upper Austria, at the junction of the rivers Ischl and Fraun, 
 twenty-seven miles east by south of Salzburg. It is the favorite resort of 
 the Austrian royal family and nobility. Population in 1891 (commune), 
 8,473. 
 
 II In Upper Austria, situated on the lake of Traun, thirty-three miles 
 southwest of Linz. 
 
 T[ In Upper Bavaria, situated on the Saalach, nine miles southwest of 
 Salzburg. 
 
 ** Or Langenschwalbach in Hesse-Nassau, Prussia, eight miles north- 
 west of Wiesbaden. Population (1890), 2,698. 
 
— 345 — 
 
 in conjunction with chlorosis and anaemia) with the character of 
 depression, and contraindicated in these diseases if they present 
 the character of excitement. Thej are also employed after 
 treatment by warm and hot baths to remove the condition of 
 debility and the predisposition to colds, created by these last, 
 as for instance, the baths of Narzan after treatment at Pyati- 
 gorsk. 
 
 4. Salt ivaters tvhieh are at the same time carbonated^ as the 
 artesian springs of Rehme-Oeynhausen in Prussia. Their action 
 is of a complicated nature, — thermical, chemical, and, thanks 
 to the carbonic acid, strongly stimulating to the nervous system; 
 their employment therefore requires particularly careful consid- 
 eration : empirically they are recommended in diseases of the 
 nervous system, especially in the different varieties of tabes 
 dorsalis. 
 
 5. Mineral muds, added to baths of mineral ivaters, i. e. em- 
 ployed in the form of dissolved mud-baths, are employed at many 
 foreign watering places ; with us in the Pyatigorsk group of min- 
 eral waters the mud of the lake of Tambuktan is employed for 
 diluted mud-baths. Franzensbad has been particularly famous 
 for a long time for its moorbader. To what was already said 
 about their use we must add their employment in diseases of 
 women, in which they are very frequently applied. The effect 
 of the Franzensbad moor-baths in diseases of women is usu- 
 ally explained and described in the following manner: The 
 mud-bath causes uterine contractions, these being the more 
 pronounced in proportion to the state of flabbiness and enlarge- 
 ment of the uterus. Thus, if the mud-baths be used in a case of 
 insufficient involution of the uterus soon after normal delivery 
 or after abortion, then the identical phenomena are observed as 
 accompany in the normal course of the lying-in period the pro- 
 cess of involution of the uterus, namely, labor-like sensations 
 and an increased secretion resembling lochia, and containing 
 formative elements peculiar to this last. And just as after- 
 pains cause the narrowing and obliteration of the uterine ves- 
 sels, thus weakening the nutrition of the uterine muscle and 
 bringing about the transformation of its albuminous substances 
 into easily absorbable fats, in the same manner the con- 
 
^ 346 — 
 
 tractions of the uterus caused by the mud-baths determme the 
 identical process in case of uterine subinvolution. If as a result 
 of a prolonged state of subinvolution of the uterus its mucous 
 membrane has also suffered, then a prolonged employment of 
 mud-baths causes a return to the normal condition not only of 
 the uterine muscle, but also of its mucous membrane, llie ab- 
 sorption of exudations in the parametrium is also assisted by the 
 use of the baths in question. The drinking of the waters of 
 Franzensbad springs, which are slightly laxative and are bene- 
 ficial in digestive disturbances to which these women are usu- 
 ally subjected, assists in the treatment by mud-baths. 
 
 6. The mineral muds emijloyed directly as such. — Those of 
 Saki, spoken of above, at Tchocra, near Kertch, at Tinack, near 
 Astrachan. The foreign physicians, as far as we are aware, do 
 not employ these methods of treatment. 
 
 7. Sea-bathing. — The effective agencies in this are as fol- 
 lows : 
 
 The psychical effect of the sea-view, especially on those whose 
 constant residence is far from the seashore, is usually benefi- 
 cial by inducing a restful, hearty mental state, and inspiring 
 love of life ; other beneficent factors are : the salt and the low 
 temperature of the sea- water (usually below 21° 7?. — 79.2° F. — 
 80 that it acts like a cold salt bath) ; the continuously inter- 
 changing effects of the temperature of the water and of that of 
 the air as the body is either wholly or partly immersed in the 
 water : these temperatures are usually variable, the water being 
 fresher, the air warmer, and on the contrary; besides, the air is 
 usually in motion (the winds), and so is the water, which fact 
 tends to even more increase the variability of the temperature ; 
 and a changeable temperature stimulates the peripheral nerves 
 much quicker than one that is constant, whether it be low or 
 high ; considerable mechanical influences : the wind, the waves, 
 the motions of the bather; the humid, pure air of the seashore, 
 which is under the greatest atmospheric pressure and conse- 
 quently rich in oxygen. 
 
 It is evident from the above, that the effect of sea-bathing is 
 very pronounced on the nervous system as well as on nutrition 
 (as the appetite is very much increased by it, sea-bathing is con- 
 
— 347 — 
 
 traindicated for patients with poor digestive powers). Sea- 
 bathing is recommended principally for cases of neurasthenia 
 and hysteria with the character of depression, and contraindi- 
 cated in the same affections with the character of excitement. 
 For the indications and contraindications to sea-bathing in the 
 colder climates (in the Baltic Sea, Northern Sea, and LaManche) 
 and in the warmer (Bay of Biscay, Mediterranean, Black and 
 Caspian Seas) compare below, in the treatment of diseases of 
 the nervous system, the general indications and contraindica- 
 tions to cold and warm baths. Sea-bathing is also recommended 
 after treatment with the warm and hot baths to remove the 
 weakness and predisposition to cold created by them; thus after 
 treatment with the Saki mud-baths, the patients are recommended 
 sea-bathing, for which purpose is very suitable the seashore 
 near Eupatoria (in the Crimea) with its warm water and warm 
 air during the summer. Sea-bathing is also sometimes pre- 
 scribed for suitable cases of scrofula in place of salt baths ; and 
 also in some certain cases of superfluous fat or general obesity. 
 
 I will say a few words on some other varieties of baths. Tlie 
 hot-air baths. Their strong effect was sufficiently explained in 
 the analysis of the sixteenth case of chronic parenchymatous 
 nephritis. 
 
 Fir-tree baths. — These are prepared by adding to baths of 
 plain or mineral water a distillation by steam of pine and fir nee- 
 dles, containing ethereal oils, and a decoction of these last con- 
 taining tar, turpentine and organic acids. The effect is that of 
 a stimulant. The electric baths, together with the other methods 
 of applying electricity, are discussed with the subject of electro- 
 therapy. 
 
 8. Hydrotherapy. — All the hydrotherapeutic procedures are 
 generally applied in such a manner, that the patient becomes at 
 first chilled, and is later on warmed or, in view of the fact that 
 the cooling of the body acts the stronger the warmer the body 
 before the cooling began, he is at first warmed up, then chilled, 
 and later is warmed up finally. This final warming up is known 
 as the reaction. For the treatment to succeed, the reaction 
 must be complete : if it be absent or incomplete, a condition 
 similar to fever ensues, and in case the hydrotherapeutic proce- 
 
— 348 — 
 
 dures are frequently repeated without any reaction following 
 them, a genuine febrile condition is developed which continues 
 also after the cessation of the hydrotherapeutic treatment, and 
 which debilitates the patient, as was explained already in con- 
 nection with the effects of cold baths. I will state here that 
 the same may occur to the patient also while bathing in the sea 
 or anywhere else, if the bather remains in the water for a long 
 time ; therefore, having become chilled on immersing in the 
 water and warmed up later, the bather must emerge from his 
 bath while he is warmed, before secondary chilling takes place. 
 
 The hydrotherapeutic procedures act both thermically and 
 mechanically ; their effect is ver}- strong, especially on the ner- 
 vous system. They are principally recommended for diseases 
 of the nervous system, particularly for neurasthenia and hys- 
 teria ; they are also recommended for the removal of the predis- 
 position to colds, for superfluous fat and in some other cases. 
 
 The hydrotherapeutic procedures, namely, the various forms 
 in which hydrotherapy is applied, are general and local. 
 
 Of the general forms the best is the fan-like douche under a 
 high pressure. The construction of such a douche enables one 
 to change the temperature of the water rapidly, almost instantly, 
 and therefore not only can the patient be first warmed up and 
 then cooled off, but this process can be repeated as many times 
 as necessary. The form of the water as it strikes the body in 
 spurts increases the stimulating effect of the douches. Finally, 
 the water strikes the body with a force which the construction 
 of the douche permits of varying and causing it to become, if 
 necessary, very considerable. Consequently such a douche 
 exerts simultaneously both a thermic and a mechanical effect, 
 whereas in the other most frequently applied procedures, as 
 rubbings and half-baths, a mechanical effect is brought about by 
 the aid of massage, i. e. by the assistance of a very skillful ma- 
 nipulator. The douche is directed all over the body, from below 
 upward and backward, except on the head.* The antiquated 
 
 * (Addition to the first edition.) All that was said of the fan-like douche 
 refers to cool and cold-water douches. In some cases hot-water douches 
 are very beneficial : local, from 35° B. (110.8° F.) to 40° E. (122° F.), in 
 the form of a single stream, most frequently in obstinate " rhevimatic " 
 affections (usually arthritis and neuritis, less frequently myositis of 
 
— 349 — 
 
 douches which are unfortunately not dismissed as yet by lay- 
 men, in which the principal mass of the spurting water strikes 
 the head, are very harmful. 
 
 Of the other general procedures the most used and undoubted- 
 ly effective and beneficial ones are the rubbings and the half- 
 baths. At times, to be sure in but rare cases, they are borne 
 better than the fan-like douche under high pressure, although 
 the majority of patients express a preference for the latter. 
 
 Of the local forms of applying hydrotherapy the most fre- 
 quently used ones are : cooling of the head, in hyperaemia of 
 the brain, heat to it in ansemia of the brain, watery clysters, a 
 warming compress, etc. 
 
 9. It is evident from the above-outlined sketch that it is not 
 necessary for balneotherapeutic treatment always, in every case, 
 to send the patient away to a watering place, to the seashore, 
 or to some large city with a well constructed hydrotherapeutic 
 institution. The most important varieties of baths, baths of 
 variable temperatures and salt baths, at times with the addition 
 of soda, may be prescribed and carried out with the necessary 
 implements at the patient's residence. Sea-bathing may be re- 
 placed by bathing in the river or in a lake. Hydrotherapeutic 
 rubbings and half-baths may be carried out everywhere by in- 
 structing a servant how to do it. For the fan-like douches 
 there are portable apparatuses, which give a sufficiently high 
 pressure, thus : the portable douches of Piet and the much 
 cheaper pumps of Allweiler, which are conveniently affixed to 
 the douches. 
 
 I must say here a few words concerning the use of our popu- 
 lar bath (Russian bath) . Its hygieniQ value, as evidenced by 
 its purifying the skin, removing the fats and dirt which ob- 
 struct the glands of the skin, and by keeping up the normal 
 functional activity of the skin, is very great, and especially so 
 for the laboring class of the community ; but its employment 
 
 gouty, syphilitic, catarrhal, traumatic and other origin) in persons unable 
 to bear cold — usually in conjunction with massage (and, if necessary, 
 with the contemporaneous treatment of the gout and the syphilis), and 
 also in diseases of women ; general, from 33° R. (106.2° F.) to 38° B. 
 (117.2° F.), in the form of a fan-like douche under high pressure, for neu- 
 rasthenia and hysteria in debilitated, aneemic and chilly persons. 
 
— 350 — 
 
 during the cold season of the year, in bad weather, entails the 
 risk of catching cold on returning from the bath-house. With- 
 out therefore dissuading healthy people habituated to it from 
 employing it, and advising only to avoid hot baths and bathing 
 during bad weather, I must say that the use of these baths 
 must be strictly limited, or even prohibited, to persons who are 
 weakly and predisposed to colds, the more so to ailing ones. 
 The therapeutic effect of the bath and of the usual massage con- 
 nected therewith, in cases of slight ailments due to a cold, but 
 of a " rheumatic " and not of a catarrhal origin, is beyond 
 doubt beneficial, but during the cold season of the year and in 
 bad weather it is accompanied by considerable risks. 
 
 Balneotherapeutic procedures employed in a warm room 
 may be applied during all the seasons of the year ; but the 
 best season for such treatment is certainly the warm one, 
 when a prolonged stay out-doors is possible without risking a 
 cold. As regards the time of the day, all the balneotherapeu- 
 tic applications must be made not on an empty stomach, but 
 best after the morning coffee or tea, after a previous evacuation 
 of bowels. 
 
 The duration of the balneotherapeutic course of treatment 
 depends certainly on the peculiarities of the given case, but in 
 the majority of cases it does not require more than one and a 
 half or two months. An unnecessarily prolonged hydrothera- 
 peutic treatment (and I have seen it prolonged not only over 
 half a year, but even over one or two years) is much oftener 
 harmful than beneficial, by debilitating the nutrition and the 
 condition of the nervous system, and by inculcating in the pa- 
 tients habits of constant artificial stimulation by the aid of 
 hydrotherapeutic procedures, of which, later on, they can but 
 with difficulty rid themselves. 
 
 A short outline of the diseases in which the waters are used ex- 
 ternally^ will give you some idea of the extent of balneothera- 
 peutic applications and of the importance of this method of 
 treatment. 
 
 1. Diseases oftlie nervous system. — In neurasthenia and hysteria 
 with their multiform manifestations balneotherapy is consid- 
 ered to be the most important method of treatment, both on ac- 
 
— 351 — 
 
 count of the effectiveness of its action and the variability and 
 extent of its application. The chief rule to be observed here 
 is as follows : in proportion as we have a young patient with a 
 strong constitution, in whom the condition of the internal organs 
 need excite no apprehension, whose nutrition is good, and in 
 whom the nervous disturbances bear the character of debility, 
 the more suitable it is to use cool and cold water, such as con- 
 tains a large proportion of carbonic acid, and the balneothera- 
 peutic forms of application of a stimulating nature, as douches, 
 sponging, half -baths, sea-bathing ; all these necessitating motion 
 of the water, movements on the part of the patient and massage. 
 On the contrary, if our patient is older, possessing a weak con- 
 stitution, in whom the condition of one or another of internal 
 organs excites grave apprehensions, while his nutrition is poor 
 and the nervous disturbances have the character of excitability, 
 the more suitable are thermically indifferent waters and balneo- 
 therapeutic applications of a quieting nature, such as do not 
 necessitate any movement either on the part of the patient or of 
 the water, namely, baths. 
 
 But this rule is only applicable to the majority of cases ; in 
 the considerable minority, in which the above-enumerated con- 
 ditions do not coincide (as, for instance, when the patient is 
 young, but weak constitutionally, or young, of a strong consti- 
 tution, but emaciated, debilitated and chilly, and so on ; or the 
 patient is not young, but of a strong constitution and nutrition, 
 while his nervous disturbances have the character of debility 
 etc.), after inquiring carefully of the patient as to the former 
 effect on him of a cold and a warm bath (as bathing outside 
 and indoors, warm baths), we must act in a manner reverse to 
 this rule. Finally, there may occur cases which present no 
 positive indications for either of the methods and m which a 
 careful trial will determine the method to be resorted to. 
 
 Diseases of the brain, principally disturbances of the circula- 
 tion as determined by a condition of atheromatosis of the arte- 
 ries (general and those of the brain in particular) and by other 
 causes. For these the chemically and thermically indifferent 
 baths are suitable ; at times also the warm ones (not over 29° M. — 
 97.2° #.) and the slightly alkaline, namely, those containing but 
 
— 352 — 
 
 a small quantitj- of sodium chloride and of soda, and also cooling 
 of the head (in some cases warming it) ; cold and hot baths, as 
 well as the applications tending to stimulation, are contraindi- 
 cated. 
 
 Diseases of the spinal corcl^ principally tabes. For these the 
 thermically indifferent, salt and salt-gaseous (with a moderate 
 quantity of common salt and carbonic acid) baths are suitable, 
 as well as slight hydrotherapy (sponging). Hot and cold baths, 
 baths containing great quantities of salt and carbonic acid, 
 as well as strongly stimulating forms of application, as douches 
 and sea-bathing, are contraindicated. 
 
 2. Diseases of the digestive organs. — For gastro-intestinal 
 neurasthenia, which is expressed in a weakened condition of 
 the nervo-muscular apparatus of the intestines and stomach, 
 various douches, cool, cold, and of changeable temperature, or 
 a warming compress on the abdomen, in connection of course 
 with simultaneous general hydrotherapy for the general neuras- 
 thenic condition, are very beneficial. In catarrhal conditions of 
 the stomach, intestines and the biliary passages, as well as in 
 biliary calculi, warm baths form an excellent adjunct to the 
 ordinary treatment of these diseases. 
 
 3. Warm baths are equally beneficial for renal gravel, for 
 pyelitis, catarrh of the ureters and the urinary hladder, while cases 
 of acute and chronic 7iephritis are benefited also by hot baths. 
 
 4. For hyperoimia of the spleen douches over the left hypo- 
 chondrium, of the same nature as those employed in gastro-in- 
 testinal neurasthenia. 
 
 5. Different varieties of peritoneal inflammation. — Some pa- 
 tients bear ice better, others warm applications, others again a 
 warming compress on the abdomen. 
 
 6. Diseases of the male genital organs, principally the various 
 forms of impotentia virilis. In these the general balneothera- 
 peutic treatment, directed against the general neurasthenic con- 
 dition, is of more importance than the local treatment ; while 
 locally, after the general neurasthenia has been removed, care- 
 ful electrotherapy is particularly efficacious. 
 
 7. Diseases of the female genital orgatis. — We spoke of the 
 peritoneal inflammations above. For painful menstruation a 
 
— 353 — 
 
 rubber bag filled with hot water and applied to the lower part 
 of the abdomen is beneficial. For light cases of metritis, warm 
 sitz-baths. For subinvolution of the uterus and the endometri- 
 tis dependent thereon, and also for exudations in parametrium, 
 the thermically indifferent, salty and moor baths and hot vagmal 
 injections are useful. 
 
 8. Diseases of the resjnratori/ organs. — The inhalation of va- 
 rious atomized liquids for catarrhal conditions of the larynx 
 and trachea. Hot baths followed by sweating in bed while cov- 
 ered by warm blankets are at times resorted to in cases of 
 bronchial catarrh accompanied by very abundant secretions, for 
 the sake of alternating with other methods of treatment, if the 
 patient became so habituated to these last that they fail to ex- 
 ert any marked effect on him ; these baths may be employed 
 only when the condition of the heart permits it, and generally 
 extreme care must be exercised. In pleuritis and in pleuropneu- 
 monitis, a warming compress applied over the affected part of 
 the chest is beneficial ; however, in the majority of cases the pa- 
 tients prefer better to keep this part warm by the aid of warmed 
 oil, cotton-batting and flannel. In chronic pulmonary tubercu- 
 losis the patients, if not feverish, at times bear well the some- 
 what cool sponging prescribed with a view of assisting the func- 
 tion of the skin and simultaneously combating the neurasthenic 
 condition. 
 
 9. Diseases of the heart, — Neuroses of the heart — palpitation, 
 cardiac asthma, angina of nervous character (not the true angina 
 pectoris coronaria), as well as the cardiac, angioneurotic and 
 other neurotic' conditions associated with morbus Basedowi, as 
 well as the weakness of the cardiac muscle determined by it, as evi- 
 denced by a dilated heart and a weak pulse, — all these present 
 indications for the employment of balneotherapeutic treatment, 
 the nature of which depends on the character of the general 
 nervous condition present and of all the peculiarities of the given 
 case (vide above concerning balneotherapy in neurasthenia and 
 hysteria) ; this treatment is indicated not only when the heart 
 and the arteries are in a normal condition, but even when they pre- 
 sent incipient organic alterations ; extreme caution is certainly to 
 be exercised in these cases, and the treatment is to be instituted 
 
— 354 — 
 
 only when there exists a complete compensation of the organic 
 disturbances. 
 
 10. Diseases of nutrition and luematopoiesis. — Chlorosis and 
 ansemia accompanied by their usual neurasthenic and hj-sterical 
 symptoms, present indications, in slight cases, for the use of 
 warm sea or river bathing — 20° R. (11° F.^ to 18° R. (72.5° 
 jP.) — and also of slightly carbonated baths ; for more pronounced 
 cases plain or salty, thermically indifferent baths, while for strong- 
 ly pronounced ones balneotherapeutic treatment is contraindi- 
 cated. For general obesity cool salt baths and river and sea 
 bathing are suitable. For diabetes mellitus, which is etiologi- 
 cally so closely connected with the nervous system, thermically 
 indifferent and slightly cooling spongings are indicated in accord 
 with the condition of this last. For gout thermically indiffer- 
 ent baths; of these the best are salty, alkalme ones. 
 
 11. For scrofulosis. — Thermically mdifferent and cool salt 
 baths, and sea-bathing. 
 
 1 2. For sy])hilis. — Warm baths to assist cleanliness and the 
 functional activity of the skin (which in its turn aids in the 
 better absorption of the mercury), and hot baths to enhance 
 the activity of the metabolic processes, usually given simultane- 
 ously with the administration of the specific treatment ; later on, 
 to remove the debility and the predisposition to colds engendered 
 by such treatment, strong carbonated baths (Xarzan after Pyati- 
 gorsk), sea-bathing and hydrotherapy are resorted to. 
 
 13. In metallic poisoning, most frequently in mercury and 
 lead poisoning, hot baths and later strengthening balneothera- 
 peutic procedures are also used. 
 
 14. What concerns the application of balneotherapeutic pro- 
 cedures for febrile conditions and febrile affections it was spoken 
 of and discussed by me in connection with the several analyzed 
 cases. 
 
 15. Diseases of the skin and of the subjacent tissues. — Cold 
 fomentations and ice in traumata, hypersemia and inflammations. 
 Baths with alkaline carbonates and sulphates for certain erup- 
 tions. 
 
 16. Chronic myosites, neurites (most frequently ischias) and 
 arthrites, as multiple chronic arthritis and chronic articular 
 
— 355 — 
 
 " rheumatism." For these are suitable warm and hot, salt and 
 alkaline baths, as well as the muds, and later, to strengthen the 
 patient who became weak from the treatment and to remove the 
 predisposition to cold, strongly carbonated baths, warm sea- 
 bathing, as in Eupatoria after treatment by the Saki muds, and 
 careful hydropath}". 1 must note the following : Strange as it 
 may seem, I have often observed that treatment of " catarrhal" 
 diseases, namely, of the above-named chronic affections of the 
 organs of locomotion and also catarrhal conditions of the res- 
 piratory and other passages, is often confounded with the 
 treatment of an existing predisposition to colds. Thus the pa- 
 tient tells his physician, that he has "■ rheumatics" and is fre- 
 quently subjected to colds, although he suffers from none at 
 the present time. The physician catches at the word '• rheu- 
 matics," prescribes warm or even hot baths, plain or salty ones (I 
 had occasion to see the Saki mud advised in view only of a pre- 
 disposition to cold, without any cold or '^ rheumatic" affection 
 being present at the time of the advice), which certainly only 
 tend to increase this predisposition. This last condition must 
 be treated not by hot baths and muds, but by removing its causa- 
 tive agencies, which are usually found to lie in gout, syphilis, 
 abuse of alcoholic drinks, in a habit for abundant hot drinks 
 and warm clothing, in neurasthenia, etc. ; while for the treat- 
 ment of neurasthenia and at the same time to inure the body to 
 cold, hydrotherapy and bathing are suitable, and certainly not 
 hot baths or muds. 
 
CHOLERA, PARTICULARLY ITS 
 TREATMENT. 
 
 LECTURE OF MARCH 19, 1893. 
 
 Whether or not we shall be visited by cholera this year is un- 
 certain. The history of the past presents no positive precedents 
 in this regard. Durmg the summer of 1883 Egypt was visited 
 by a very severe epidemic of cholera, the one during which 
 Koch succeeded in finding the cholera bacillus, while the sum- 
 mer of the following year in Egypt was perfectly free from it. 
 
 But it is certainly probable that we may also have an epi- 
 demic this present year. It is true that cholera, which remained 
 over winter and came to life again in the given locality, may 
 not possess the same virulence nor be diffused so extensively 
 as when carried over from another locality ; but still it is pos- 
 sible that many of you will have to face the necessity of com- 
 bating this disease, and I therefore consider it my duty, the 
 duty of a clinician, to assist you as far as it lies in my power 
 by my advice. 
 
 Cholera, as many other diseases, is familiar to you from the 
 systematic course of special pathology; but firstly, this course 
 you attended a year or more ago, and science never remains in 
 one place ; it is never stationary : its level is becoming contin- 
 uously higher and higher and is, besides, constantly changing, 
 presenting not a smooth, but a constantly undulating surface : 
 one point falls, the other rises to the surface. The year just 
 passed, a year of a consideral^le cholera epidemic, was particularly 
 instrumental in compelling us to revise our knowledge concern- 
 ing cholera and especially its treatment. It is therefore imperative 
 that you become acquainted with the results of this revision. But 
 it chiefly devolves on the clinician, in view of a possible epidemic, 
 356 
 
— 357 — 
 
 to discuss the subject of cholera before his students for another 
 reason. After attending on your course of special pathology, 
 you meet later in the clinics all the forms of diseased conditions 
 peculiar to our local and climatic conditions of life ; but or- 
 dinarily you do not chance across cases of cholera. For the long 
 period of my clinical activity, only once, in the sixties, when to 
 my clinic was annexed a department for cholera, did I have the 
 opportunity to discuss cholera cases before the students. But 
 ordinarily, either there are no cases of cholera during the aca- 
 demic year, or, as it happened last year, during the epidemic 
 the senior students of the last year are absent, having been sent 
 away to combat the invasion of the disease. But the syste- 
 matic course of special pathology cannot educate a physician 
 without the aid of the clinic : the information obtained from 
 this course, the therapy (not to speak of its other peculiarities) 
 are of but an approximate nature, and only by individualizing 
 this information, applying it to all the peculiarities of the given 
 case, as taught by the clinic, can we hope for a successful treat- 
 ment. As regards cholera it is the duty of the clinician to as- 
 sist as much as possible in what the clinic is lacking, paying 
 particular attention to treatment, to discuss as far as the lack 
 of clinical individualization will permit, at least the principal 
 forms of the disease, which may l)e seen in patients and which 
 may require treatment. 
 
 The object and character of my lecture is thus determined 
 by what I have said above. The question of the nature of 
 cholera, and also the picture of the disease, will be touched 
 by me only so far as may become necessary for elucidating the 
 prophylaxis and the therapy. 
 
 The Nature of Cholera. 
 
 Cholera belongs to the class of infectious diseases. These 
 diseases are at the present time considered to be caused by mi- 
 cro-organisms, by microbes which invade the organism and pro- 
 duce the diseased condition therein. The microbes of all the 
 infectious diseases have not as yet been discovered, but the very 
 marked similarity, in their chief features, of those diseases the 
 
— 358 — 
 
 microbes of which have not been identified, with those where 
 these have been found, compels us to class both varieties under 
 one category. 
 
 It is not long since there prevailed a classification of infec- 
 tious diseases into miasmatic, contagious, and miasatic-conta- 
 gious. 
 
 By the miasmatic diseases were meant such as are not trans- 
 mitted from one infected by them, to another, and the cause of 
 which, the pathogenic microbes, enter the affected organism 
 from the surrounding elements. The malarial diseases were 
 considered as tj^pes of such affections. 
 
 As contagious diseases were considered such as are capable 
 of being transmitted from one patient to another in a direct 
 manner, without the participation of the surrounding nature. 
 Among these were classified : syphilis, small-pox, measles, scarla- 
 tina, typhus fever, diphtheria, etc. 
 
 By miasmatic-contagious diseases were meant those, which, to 
 become infectious, need the assistance, so to speak, of the sur- 
 rounding elements and the presence therein of some special 
 favorable conditions, without which the person affected by this 
 disease within the given locality is incapable of causing an 
 epidemic ; and on the other hand, the above-named diseases will 
 not develop m the given locality, notwithstanding the presence 
 in the surrounding elements of all the conditions favorable for 
 their development, as long as this locality is not visited by a 
 person who carries within his system the germs of the disease. 
 
 It was therefore assumed, that these, after leaving the pa- 
 tient's organism, are not yet capable of causing infection, but 
 become so after remaining under favorable conditions for a cer- 
 tain time outside of the organism. To this class of diseases 
 belong cholera, typhoid fever, etc. 
 
 At the present time it is impossible to entirely rely upon the 
 classification just outlined : successful experiments have been 
 made, though it is true that they need further confirmation, 
 of inoculation with the malarial diseases directly from the pa- 
 tient to a healthy individual ; syphilis can be transmitted not 
 only directly, but also through the medium of dishes, instru- 
 ments, etc., consequently after it has remained for a certain 
 
— 359 — 
 
 time under the influence of the .surrounding nature : the same is 
 true also of diphtheria. It seems that at certain times, rare 
 though such cases may be, cholera causes a direct infection. 
 Nevertheless, the principal characteristic peculiarities of the 
 different classes of infectious diseases, as outlined above, do 
 exist and are to be kept constantly in mind : malaria is, after 
 all, non-contagious outside of experimentation, and syphilis, 
 measles, small-pox, scarlatina, .typhus fever, diphtheria are of 
 an extremely contagious nature ; while cholera is but slightly con- 
 tagious and, in direct contradistmction to the very contagious 
 diseases, it depends for its development entirely on the con- 
 ditions present in the surrounding nature. 
 
 Outside of the " seed" of the disease and the conditions of 
 the surroundings, an important role m infection, as proved by 
 observation, is played by the individual's predisposition to chol- 
 era, or by the absence of the same. 
 
 I will take a brief survey of our knowledge concerning the 
 three factors which play the chief role m the development of 
 the cholera epidemics. 
 
 The individual predisposition to cholera has been shown by 
 observation to be determined hj digestive disturbances and by 
 failure in nutrition, as evidenced by the fact that a population 
 exhausted by starvation falls an easy prey to the epidemic. 
 It is hardly probable that this fact is the only one determinmg 
 the individual's susceptibility to cholera, but we know nothing 
 more definite about the subject. 
 
 It was Pettenkofer who called particular attention to the 
 conditions of the surrounding elements, the local (meaning the 
 soil and climate) and the temporary, the season of the year and the 
 condition of the weather; but we know nothing positive regarding 
 this matter : thus, for instance, Pettenkofer's theories concerning 
 the influences of the vacillations of the soil- water on the develop- 
 ment of the cholera epidemics have not been substantiated by 
 facts. As an example of the prevalent idea as touching on the 
 influence of the surroundings on the development of cholera 
 epidemics, I will present before you the results of the ob- 
 servations and mvestigations made by the well-known bacteriol- 
 ogist, Prof. Hueppe, during the recently prevalent severe epi- 
 
— 360 — 
 
 demic at Hamburg.* I shall have yet another occasion to 
 touch upon Prof, Hueppe's statements ; and I will therefore 
 only say, as far as they are concerned, that notwithstanding 
 their interest, the facts presented lack verification, while the 
 hypotheses propounded must be proved by facts. 
 
 After analyzing the local conditions, Hueppe considers as the 
 cause of the sudden and very severe breaking out of the cholera 
 epidemic in Hamburg not the conditions in the soil, but the 
 condition of the Hamburg aqueduct. The water is derived 
 from the Elbe, above the city, while the city impurities are 
 conducted into the Elbe below the city ; during the high tide 
 of the sea, these last are carried up the river and reach the place 
 from which the aqueduct starts, without passing through any 
 purifying filter. According to Hueppe, the cholera was im- 
 ported into Hamburg from Russia or France on sailing vessels 
 by patients whose evacuations, without any previous disinfection, 
 polluted the river. As a general fact, Hueppe assumes, basing 
 this assumption on his own investigations and that of others, 
 as Frankel, that the cholera bacilli are rapidly destroyed in the 
 rivers of Europe (although this is somewhat contradicted by 
 investigations of other bacteriologists), and that if cholera spreads 
 along the course of rivers, it does so not by the aid of the cholera 
 bacilli carried by the waters, but through cholera patients sailing 
 on river vessels ; but he points out that during the month of 
 August, 1892, when the Hamburg epidemic began, there were 
 exceptional conditions, as extreme heat, shoaliness of the river 
 and the warm temperature of the water, which contributed to 
 the fact that the cholera bacilli, as he supposes, were enabled to 
 remain longer in the water, were carried into the aqueduct, in 
 some parts of which, as the house reservoirs where the water not 
 being in motion leaves a precipitate and has a warm temperature, 
 they again became virulent and even began to multiply. It is 
 hardly necessary to dilate on the fact that this supposition, how- 
 ever great its probability, lacks verification by facts. f 
 
 * Hueppe, Die Cholera-Epidemie in Hamburg. 1892. Berliner Kli- 
 nisclie Wochenschrift, 1893, Nos. 4-7. 
 
 t Later addition : The spreading of cholei-a, principally through 
 water, is very strongly substantiated by the last investigations of Prof. 
 
— 361 — 
 
 The .seed of cholera, the cholera bacterium (the so-called 
 " comma bacillus " ), was discovered by Koch. He did not pay 
 due attention to the conditions of the surrounding nature, whether 
 local or temporary. He and his followers are justly reproached 
 also for this, that the term " contagiousness " was employed by 
 them in the sense in which the term " infectiousness " is ordi- 
 narily used, and thus cholera, in spite of other investigations 
 (among which I may class also my own, in accord with which 
 cholera is but slightly contagious, i. e. it is but very seldom trans- 
 mitted directly from one person to another), was considered as 
 a directly contagious disease ; it is attributed to them that this 
 fact has engendered a sort of panicky feeling toward cholera, 
 and that it assisted in the adoption of but very one-sided meas- 
 ures for its prevention. According to Hueppe, the observa- 
 tions made during the recent epidemic of cholera at Hamburo- 
 have succeeded in completely eradicating the teaching of the 
 contagiousness of cholera. This has also been verified by the 
 observations of Dr. Wermel during the recent epidemic in Nij- 
 ni Novgorod (vide " Meditzina," 1892, Nos. 36 to 37). 
 
 According to Hueppe, the cholera bacilli are destroyed en 
 masse in the large intestine (by the acidity of its contents, as 
 he assumes), while those which remain and escape from the af- 
 fected organism alive, do not possess any virulency, any power 
 to infect, on account, as Hueffe thinks, of the deficiency of 
 oxygen in the biological processes of the small intestine (a con- 
 dition approaching that of anserobiosis). The cholera bacteria 
 become again virulent and multiply outside of the affected or- 
 ganism under conditions of which we know nothing. The ob- 
 servations, made during the former, as well as during the recent 
 epidemic, to the effect that cholera is but slightly contagious 
 and is but rarely transmitted directly from a sick person to a 
 healthy one, speak certainly in favor of Hueppe's assertion, 
 thus constituting his chief bulwark. But the case brought for- 
 ward by Hueppe in proof of the slight contagiousness of the 
 
 Koch. R. Koch, Ueber die Cholera iu Deutschland wahrend des Winters 
 1892 bis 1893 (in the Deutsche Medic. AVochenschrift, IS^o. 36, 1893) ; also R. 
 Koch, Cholera und Wasserfiltration (in Berliner Klinische Wochenschrift, 
 Xo. 27, 1893). 
 
— 362 — 
 
 cholera bacilli expelled from the yick organism (in this case u 
 child devoured the excreta of his father affected by cholera, as 
 they resembled rice soup, and remained unaffected), can hardly 
 prove anything, because of its singularity ; it is possible that the 
 child possessed an individual non-predisposition to cholera, a 
 natural immunity toward it. I may as well state here that 
 the various experiments of swallowing pure cultures of cholera 
 bacteria, as has l)een done by Pettenkofer. Emmerich and some 
 A'ienna physicians, without any bad results occurrmg therefi'om. 
 can also hardly be considered as proving anything : not to speak 
 of the individual immunity (although it would be straining the 
 point to constantly consider the same), we are hardly justified in 
 judging by the degree of virulence of the cholera bacilli devel- 
 oped under artificial conditions of pure cultures, of the virulency 
 of the cholera bacteria which left the affected organism and un- 
 derwent a development among unknown, to us. conditions of 
 the surrounding nature. 
 
 The rare cases in which there was a direct transmission of 
 cholera from tbe sick to the healthy, Hueppe explains by the 
 fact that in the presence of a severe diarrhoea the bacteria are 
 enabled to rapidly traverse the intestines, and therefore, as he 
 thinks, remaining but for a short time in a medium deficient in 
 oxygen, they emerge from the affected organism with a suffi- 
 ciently preserved degree of virulence. The comparatively fre- 
 quent occurrence of cholera to be seen among the washer- 
 women who handle linen not sufiiciently disinfected, Hueppe 
 considers as due partly to the presence in the Imen of enormous 
 numbers of bacteria of cholera, as well as of cholera toxine. 
 and also to the fact that the choleraic bacteria, remaining in the 
 linen mixed with the excreta, that is, living outside of the or- 
 ganism, may become anew sulficiently virulent. 
 
 The universally adopted theory of the contagiousness of chol- 
 era, as based on the above-discussed facts and considerations, 
 is as follows : the cholera bacteria enter the org-anism together 
 with the food and drink, per os, multiply exceedingly in the 
 small intestines, invading also their walls, produce a toxine, cause 
 an extremely acute and severe affection of the stomach and in- 
 testines, as evidenced by nausea and diarrhcea, and then, on ac- 
 
— 363 — 
 
 count of the great and rapid loss of the fluid portions of the 
 organism and especially on account of the absorption of the 
 above-named toxine, they call out the phenomena of the algid 
 stage of cholera, so peculiar to the disease, and of which we 
 shall speak later. 
 
 The Form and Course of the Disease. 
 
 In accord with the plan of my lecture, I shall not touch on 
 the epidemiology of cholera. I will only say, that during the 
 cholera epidemics there are observed, more frequently than at 
 other times, intestmal catarrhs (diarrhoese), nervous disturbances 
 of a neurasthenic character, thanks, of course, to the panicky 
 feeling towards cholera prevalent in the population, and also 
 gastric disturbances of a dyspeptic nature, partly also of nervous 
 origin, partly as a result of the sudden change in dietetic habits, 
 of the monotonous food, of the constant use of boiled water, and 
 also as a result of the employment of various " preventive" drops, 
 as hydrochloric acid and others. 
 
 I will now take up the various choleraic affections, but I 
 will call your attention only to their most important characteris- 
 tics, the symptoms and the course, by which we must be guided 
 in making a diagnosis and in prescribmg treatment. 
 
 The incubation period, occupied by the time when the infec- 
 tion took place until the appearance of the disease, is short, usu- 
 ally between one and three days. 
 
 We distinguish three varieties of choleraic affections. 
 
 Choleraic diarrlioea. — AVith a condition of general malaise 
 the patient has abundant fluid stools but slightly colored with 
 bile, usually of a painless nature, but accompanied by consider- 
 able abdominal gurgling. The disease either passes away in a 
 few days (with or even without treatment), or passes- into 
 cholerine, or directly into cholera. The character of the sudden- 
 ly appearing diarrhcea, during an epidemic of cholera, as to 
 whether it be of a choleraic nature or not, can with certainty be 
 decided only by a bacteriological examination of the excreta ; 
 without this last a probable diagnosis only is possible, but not 
 a positive one. But the bacteriological examination, so impor- 
 
— 364 — 
 
 tant f(n- defining the general cliaracter of an epidemic affection, 
 is not practicable for the purpose of diagnosticating cholera in 
 private practice during an epidemic : the results of such an ex- 
 amination are not obtained soon enough, but at a comparatively 
 late time, so that is impossilile. while waiting for them, to leave 
 the sick person witliout any treatment at a time when every 
 hour is precious, and if he happens to suffer from cholerine or 
 cholera, then every moment is invaluable. Besides, it is unrea- 
 sonal)le to waste time and energy on a minute bacteriological 
 examination during a cholera epidemic, when the physician's 
 time is usually wholly occupied and his energy is in a state of 
 extreme tension. Consequently in cases of diarrhoea of which 
 we speak now. we must be content with a prol^able diagnosis. 
 As what concerns treatment in such cases, it will l)e spoken of 
 later. 
 
 Chohrrine. — (leneral malaise, a slight felaile condition, vom- 
 iting and diarrhcea of abundant liquid discharges, at first col- 
 ored, even though slightly, by bile, later colorless; great thirst, 
 ver}- little urine, pulse weak, a rapid decrease in the bodj^ fat, 
 cramps in the calves, general weakness, and weakness of the 
 voice. In a few days the disease passes away, the patient is 
 convalescent, l)ut for a long time, for weeks together, he re- 
 mains very weak. In other less fre([uent cases, with a lack of 
 pro]3er treatment and nursing, the morbid phenomena mcrease 
 and there appear syiiiptoms of the algid stage of genuine cholera, 
 during \Ahich. or during that of reaction following the algid 
 stage, the patient succumbs; but with assistance at the proper 
 time even such cases may tend to terminate favoral)ly. 
 
 (jri'tiuinr cliolera develops either fro]n the above-outlined ail- 
 ments or more frequentlv directly : after one or more days of 
 slight and pauiless diarrh(pa ('• the prodromal "), there sudden- 
 ly takes place an attarlx of cliolera : the evacuations l)ecome all 
 at once frequent and abundant, tliey lose their yellow coloring 
 and take on a resemblance to rice-soup ; to this there is soon 
 superadded vomiting, which consists in the beguuiing of the 
 gastric contents, then of biliary matter, and finally of similar 
 rice-soup-like liquid masses. Even a few hours of such a con- 
 dition may Ije followed by the phenomena of the so-called cold 
 
— 365 — 
 
 period of cholera (stadi urn algidniii, s. cyanoticuin, s. asplncti- 
 cuni ) : the patient lies in a condition of extreme weakness, 
 speechless, at times moaning and whining with a weak voice 
 from the pain caused by the nuiscular cramps, which however 
 pass rapidly; when asked anything he replies slowly (conscious- 
 ness weak) and in an exceedingly weak voice ; the l)ody is cold 
 to the touch, the bodily fullness (turgor vitalis ) is sharply dim- 
 inished, the cheeks fallen in, the nose sharp, the eyes deep in 
 their sockets, the skin is cyanotic and ^v■l■inkled, and if caught 
 between the fingers does not return to its previous condition ; 
 there is an insatiable thirst, no urine, pulse hardly perceptil)le, 
 tones of the heart extremeh' weak. With the appearance of 
 the algid stage the vomiting and diarrh(ea usually diminish. 
 
 The phenomena of the algid stage are undoubtedl}', but onl}^ 
 to some extent, determined by the great loss of tlie fluid por- 
 tions of the organism, and by the results of this loss, as thicken- 
 ing of the blood, disturbances of the circulation, deficiency of 
 oxygen in the blood and tissues, etc., caused by such a great 
 traUsudation into the intestines : the loss of the fluid parts of 
 the organism and the results dependent thereon are insufficient 
 to explain the above-named phenomena. There occur cases, 
 and very severe ones at that, which present an extreme devel- 
 opment of the algid stage, the patients dymg during it, while 
 they have neither diarrhoea nor vomiting (cholera sicca) and 
 autopsy reveals but a trifling exudation into the intestines. 
 
 Moreover, every physician who has ever seen a goodly num- 
 ber of cholera patients, is well aware of the fact that very often 
 there is to be observed a disproportion between the quantity of 
 the liquid evacuations and the symptoms of the algid stage : 
 the first may be very considerable, while the latter are insignifi- 
 cant, and contrariwise. It is thus evident that outside of the 
 great loss of the fluid parts of the organism there must also be 
 some other cause to account for the algid stage of the disease. 
 As such was considered the toxine produced by the cholera 
 bacteria. As a matter of fact both Xicati and liietsch obtained 
 from pure cultures of bacteria a poisonous body, the introduc- 
 tion of which into the systems of animals caused a fall in the 
 temperature, paralytic phenomena and finally death. Out of the 
 
— 366 — 
 
 contents of the small intestines, as found on autopsies, Hueppe 
 obtained a toxine which he considers to be a peptone produced 
 from the albuminoid constituents of the intestinal contents un- 
 der the influence of the cholera bacteria and of deficiency in 
 oxygen. He also obtained an identical toxine from the contents 
 of the large intestuie and from the intestmal secretions of chol- 
 era patients, but in a much smaller quantity ; this leads him to 
 think that the above referred to toxine is partly absorbed by 
 the small intestine, and is partly destroyed by the acidity of the 
 large intestine. Introduced into the systems of animals, as 
 guinea-pigs, rabbits and dogs, the cholera toxine produced a 
 fall of the temperature, paralytic symptoms, and finally death : 
 the paralytic phenomena were sometimes preceded by severe 
 dyspnoea and cyanosis ; the autopsy of the animals so killed 
 revealed the fact that the kidneys, liver, and the heart have un- 
 dergone, according to Hueppe, changes similar to those found 
 in the same organs of patients who died during the algid period 
 of cholera, and on whom autopsies were performed. The ab- 
 sorption of the cholera toxine is certainly very probable, and 
 may be considered as a generally accepted fact, otherwise it 
 would be difficult to explain the so promment and apparently 
 toxic symptoms of the algid stage. (Hueppe assumes that he 
 succeeded in proving the presence of this toxine in the first 
 urine excreted during the reaction stage of cholera, which fol- 
 lows the anuria of the algid stage.) It is beyond doubt that it is 
 not so much the loss of the liquid portion of the organism as the 
 choleraic toxine, which determmes the acute affection of the 
 nervous system in general and that of the vaso-motor in par- 
 ticular, as observed during the algid stage, as well as the changes 
 of the protoplasm, such as the cloudiness and the coagulation-ne- 
 crosis of the muscular heart fibres, of the hepatic and renal 
 epithelia, which are all found at the autopsies of persons dymg 
 durmg this stage of the disease. The affection of the last (the 
 epithelium of the kidney) causes a nepliritis, the symptoms of 
 which become prominent during the next reaction stage, on the 
 pathological anatomy of which I may as well touch now : 
 the vessels and the interstitial substance of the renal parenchyma 
 are not affected, but the morbid pi'ocess (coagulation-neero- 
 
— 367 — 
 
 sis) attacks the epithelium of the glomeruli and of the convo- 
 luted tubules, and it (the epithelium) becomes detached ; in 
 cases of recovery, the epithelium is rapidly regenerated and the 
 nephritis does not pass into a chronic condition (Ley den, Berl. 
 Klinische Woclienschrift, 1893). Without stopping to con- 
 sider, in accord with the plan of my lecture, all the anatomo- 
 pathological data peculiar to the algid stage of cholera and 
 known to you from the systematic course of internal pathology, 
 as the thickening of the blood, the drying up of the tissues and 
 the like, 1 will only call your attention to the changes in the 
 spleen so characteristic in cholera (Prof. Stiller, in the i^erlin. 
 Klin. Wochenschrift, 1898) ; this last is found in patients dy- 
 ing during the algid stage as diminished in size and wrinkled, 
 a condition analogous to that of the vessels and depending, 
 quite probably, on identical causes. According to certain m- 
 vestigations, the spleen in the prodromal period of cholera is 
 hypertrophied, just as it is in other infectious diseases. Durhig 
 the stage of reaction the spleen again increases in size. 
 
 Patients die frequent!}^ while in the algid stage, especially 
 during the very height of the epidemic. If they recover, then 
 the clearly and unmistakabl}' pronounced algid stage is never 
 followed by an immediate recovery, but there take place new 
 and very variable morbid phenomena, which are collectively 
 designated under the name of reaction period or under that 
 of choleraic typhoid ; although the incorrectness of this last term 
 is admitted by everybody, still it became so popular that it is 
 employed by all. These phenomena are of three varieties : 
 
 1. Most frequentl}^ there is an acute nephritis (as evidenced 
 by a small quantity of urine containing much albumen, numbers 
 of cylinders and epithelial cells), accompanied by severe ursemic 
 symptoms. 
 
 2. Much less frequent is a febrile condition, accompanied by 
 typhoid symptoms, without any renal affection, due evidently 
 to the considerable alterations produced during the preceding 
 stages in other organs, — in the intestines, liver, heart, spleen, 
 blood, etc. 
 
 8. Various morbid conditions, their origin apparently due to 
 other infections which found such a favorable soil in an organ- 
 
— 368 — 
 
 ism attacked by cholera : diphtheria of the intestines, of the 
 urinary and biliary bladders, of the vagina, and also of the 
 pharnyx (in conjunction with parotitis), of the larnyx with 
 bronchitis, and, even if not frequently, with pneumonia and in- 
 flammation of the serous membranes, various affections of the 
 skin (as eruptions), ulcers, abscesses, erysipelas. 
 
 All the three varieties of the morbid processes occurring dur- 
 ing the reaction period may occur simultaneously in the most 
 variable combinations. 
 
 A fatal issue is of frequent occurrence also during this period. 
 Recovery after a severe pronounced attack of cholera is a slow 
 process. 
 
 Preventr^e Measuees. 
 
 Following the plan laid out for my lecture, I cannot stop to 
 thoroughly discuss this most important subject, but will only 
 make a few observations. 
 
 Quarantines, as employed heretofore, proved to be inefficient; 
 but it does not occur to me, that the question about quarantines 
 has been decided and that they had been recognized as ineffi- 
 cient or even impossible. To be sure it is difficult to picture to 
 one's self the establishment of an efficient and very strict quar- 
 antme along all the boundaries of the European governments, 
 which are thickly populated and keep up such a lively commu- 
 nication among themselves : this would cause great embarrass- 
 ment and could only be obtained at the cost of considerable 
 expenditures. But the quarantine along the highways leading 
 from the birthplace of cholera, from Asia, is a different matter. 
 Our present Central Asiatic boundaries, tlirough which the re- 
 cent epdiemic of cholera forced its way, extend mostly through 
 wilderness, and do not present any possible means for the estab- 
 lishment of a strict quarantine ; but it is pointed out, that not 
 far from these boundaries there are located mountain-chains 
 which admit of a passage only through certain places, where it 
 would be a very easy matter to establish the strictest quaran- 
 tine which would embarrass only the hisignificant caravan 
 trains. We certainly are not to conclude from the fact that it 
 is impossible to establish reliable quarantines over all tlie Asiatic 
 
— 369 — 
 
 liighvA'ays, that it is useless to do so wherever it is possible. A 
 more direct application of the quarantine over the most impor- 
 tant road from India, the Suez Canal, would probably bear bet- 
 ter results, if not for the selfish opposition of England, which 
 makes it impossible of realization. The brevity of the incuba- 
 tion period of cholera does not require any very prolonged quar- 
 antining. It is hardly probable, that cholera is transferred 
 through goods, unless it be certain special ones, as old clothes 
 and others, the admission of which is usually forbidden by 
 self-protecting governments. Special attention must be paid to 
 the dirty linen of the passengers, by submittmg it to strict dis- 
 infection or even destroying it by fire. It is true, that notwith- 
 standing all the quarantine measures, if the quarantine is kept 
 but for a limited time, which would otherwise cause extreme 
 embarrassment in places with such an extensive travel as for 
 instance the Suez Canal, * there may remain unobserved 
 and may pass on persons sick with but a slight choleraic affec- 
 tion, choleraic diarrhea, but who may however carry with them 
 the seed of infection and under favorable circumstances become 
 the cause of an epidemic. Furthermore, from observations 
 made in Hamburg, it is made certain, that in persons who re- 
 covered from cholera, there are to be found for a long time, even 
 after the intestinal secretions have entirely taken on their normal 
 form, in these secretions the characteristic comma bacilli. How- 
 ever, the fact that the quarantine measures do not act as an 
 absolute bar to the invasion of cholera, need not mean that we 
 must neglect their undoubted usefulness to diminish to a very 
 great extent the possibility of its being transferred. 
 
 To thoroughly interrogate every single passenger, as was 
 practised during the recent epidemic on the railroad lines, is of 
 course a superfluous procedure ; but the watching over the 
 travelling public, at least along tracts with a considerable travel, 
 on railroad and on river lines, the separation of the evidently 
 
 * (A later addition.) The last (1894) international sauitary conference 
 concluded that in place of the quarantine at the Suez, the sanitary in- 
 spection of the sailing vessels by physicians be enforced more strictly, if 
 they arrive from unreliable and doubtful ports, at the time they leave 
 them, as well as during their journey. 
 
— 370 — 
 
 affected ones from the healthy, the application of disinfection 
 and the rendering of necessary aid, are of course necessary 
 measures. 
 
 I will not stop here to discuss the subject of disinfection, its 
 means and ways, its application to the patient, to his linen and 
 his residence, to the affected locality and houses, to the tramway 
 cars, steamboats, etc., as all this is discussed for your benefit by 
 a competent person in special lectures. 
 
 Nor will I speak here of the measures touching upon the re- 
 establishment of the normal conditions in the affected localities ; 
 this is certainly desirable, but it must not be done in a 
 hurry, as is usually done during the approach or even during 
 the attack of the epidemic, but in a substantial manner, requir- 
 ing a long time for its completion in accord with a matured, 
 thought-out plan. 
 
 I cannot help stating here, that at the sight of the above- 
 named hunying measures adopted for the re-establishment of 
 former conditions of health, the use of which measures is doubt- 
 ful while their cost is great, seeing the frequently unreasonable 
 and unnecessary expenditure of means for disinfection, which 
 also entails considerable expenses, the thought occurs that it 
 were bettei' to devote the financial outlays thus expended to 
 obtaining for the indigent population of healthy food and drink, 
 as the benefit derived from these dviring a cholera epidemic is 
 of inestimable value. 
 
 It is absolutely necessary, that a most thorough disinfection 
 be effected around the patient, not only in cases of a clearly pro- 
 nounced choleraic ailment, but in the presence of every doubt- 
 ful diarrhoea ; that the patient's excreta, his linen (if it be but 
 slightly soiled, otherwise burn it) and objects surrounding him 
 should be disinfected. 
 
 An important preventive measure is the careful supervision 
 over persons arriving in the given locality, the isolation of 
 those who present signs of an apparently choleraic and even of 
 a doubtful affection, the innnediate application of thorough dis- 
 infection and also the immediate rendering of the necessary 
 assistance, l^jvery case to which we succeed in applying thor- 
 oughly lljese measures, diminishes the possibility of developing 
 
— 371 — 
 
 or of increasing the epidemic. The fortunate condition of things 
 in Moscow during the last epidemic is undoubtedly to be as- 
 cribed m a great measure to the careful and skillful application of 
 the enumerated measures. 
 
 In July of last yea,r, in view of the serious application of the 
 above-named and other measures, and also on account of other 
 considerations. I expressed a hope (vide the Moscow Gazette, 
 July 16, 1892) that the further course of the epidemic would 
 be of moderate severity, at least in the northern and the north- 
 western provinces of Russia, heretofore not visited by the disease. 
 The course of the epidemic in Nijni Novgorod, Moscow and St. 
 Petersburg and in other localities of the above-named provinces 
 in Russia has completely justified my expectations ; while on 
 the southwest the epidemic was severe. I have no doubt, but 
 that if in Baku and other places of Transcaucasia, in Astrachan, 
 Tzarytzin. Saratov and Samara, the same measures had been 
 adopted as were practised in Moscow, instead of the absence, 
 not only at the beginning but also later on, of any preventive 
 measures, and instead of the street riots which assisted so much 
 in spreading the cholera, the course of the epidemic would 
 have been different ; it would not have developed to such a 
 degree in the cities and would have been prevented from in- 
 vading the villages and country places, where preventive as 
 well as any curative measures are so difficult of application, 
 while the population, which is generally poorly fed, was ex- 
 hausted by a previous failure of the crops. 
 
 The individual measiires of pre caution can be summed up in 
 this, that one must not in any way alter his habitual mode of 
 living, by which we mean a mode which preserves one's 
 health in good order ; in case there be any disturbance of health 
 one must at once look for a physician's advice, also on the return 
 of the habitual disturbances, and especially those of the diges- 
 tive organs ; he must follow a certain once prearranged plan of 
 treatment and hygiene, but under no circumstances is he to be 
 allowed to treat himself by various " cholera" measures, drops, 
 etc., so extensively advertised during the prevalence of an epi- 
 demic ; when perfectly healthy he must avoid the use of the so- 
 called (psuedo) preventive measures, as for instance hydro- 
 
— 372 — 
 
 chloric acid, quinine, etc., wbicli will only tend to disturb 
 digestion, thus creating a predisposition to choleraic affections. 
 Pure spring water need not necessaril}-^ be boiled for drinking 
 purposes, while water of doubtful purity, if its use cannot be 
 avoided, must previously be allowed to settle down, be strained 
 and boiled, and, I must say, it should be drunk only when re- 
 cently boiled, wliile water which had been boiled a long time 
 previously should not be used for drinking purposes. 
 
 The Teeatment. 
 
 I alluded m the beginning of the lecture to the fact, that, 
 to replace as far as it is in my power (because of the absence 
 of cholera patients) the lack of clinical individualization, 
 I wdll discuss at least the most important situations in which a 
 cholera patient may find himself, and to which treatment must 
 be applied : I must also add that this is the more necessary, 
 because of the rapid course of the disease, and the lack of time 
 at the physician's disposal, for the number of sick is usually 
 great ; a calm and circumstantial analysis of the patient's 
 condition is much more difficult in cholera, than in any other 
 disease, and it is therefore necessary to have become previously 
 acquainted with the peculiarities of treatment of the various 
 conditions in which the patient may be found. I must how- 
 ever take a preliminary review of some of the general therapeu- 
 tic statements in connection with the treatment of cholera. 1 
 consider it as of special utility for yon as beginners : a correct 
 view and a clear intelligence constitute the most important re- 
 quisites of successful activity. 
 
 We are frequently told, to be sure not by medical men, that, 
 as the statistical data prove the mortality from cholera to be 
 the same under all systems of treatment, which goes to show 
 the impotence of every kind of treatment of cholera, it is use- 
 less to waste any means on it, and it were better to devote the 
 means on hand to obtaining nourishmg food to that portion of 
 the population, vhich h particularly liable to fall a prey to the 
 disease on account of insufficient nourishment. This assertion 
 can l)e refuted in a few words : only a layman, who in 
 
— 373 — 
 
 judging of the effectiveness of treatment relies on such doubt- 
 ful data as those lent by statistics, could pronounce himself 
 against the treatment of cholera : but every physician who had 
 the opportunity of seeing a sufficient numl)er of cholera patients. 
 and who perceived clearly the difference in the course and the 
 issue of the disease between the cases in which treatment was 
 begun early, and those that were treated late, cannot but be 
 fully persuaded of the effectiveness of and the crying urgency 
 for treatment of cholera patients. 
 
 It is with a certam degree of pomposit}- that the assertion is 
 made that it is not the cholera, but the cholera patient who must 
 be treated. You who are well informed of the fundamental 
 principle of clinical, i. e. practical activity, namely, that in all 
 diseases, without any exceptions, we treat the patient and not the 
 disease, will be astonished and taken aback by such an asser- 
 tion, and you will naturally ask: how otherwise? and when 
 can we see and treat the disease, if not in the patient ? 
 
 As you know, there exists no specific remedy for cholera, i. e. 
 such a remedy as would not act upon some one separate symp- 
 tom of this disease, but striking, so to say, the very centre of 
 the affection, would thus act on all the symptoms, and by de- 
 stroying them, would bring about a cessation of the disease, 
 as quinme does in malaria, sodium salj'cilate in acute articular 
 rheumatism, and to a lesser extent, as the results of the treat- 
 ment are not so positive, mercury and the iodides in syphilis. As 
 we have no such remedy, it remains for us here, as m other dis- 
 eases for which there exist no specific remedies, to pursue a 
 symptomatic treatment, combating separately the symptoms 
 which exhaust the patient, and subject his life to danger, and 
 thus we enable the patient to tide over the disease, and save 
 his life. 
 
 Still it is strange to hear dou1)ts expressed regarding the pos- 
 sibility of a specific treatment of cholera. Where can there be 
 a basis for such doubts in view of the above-named existing spe- 
 cific remedies for certain diseases ? And especially at the pres- 
 ent time, when there had been opened to therapy so many new 
 and promising ways creating a possibility of treating the 
 most serious diseases by the aid of the secretions and of the 
 
— 374 — 
 
 tissues of the organism itself, uiid also by the products of 
 the life-activity of the j)athogenic microbes, the greatest ene- 
 mies of the organism. Who is able to foretell the various means, 
 the remedies, the combinations of various means and remedies, 
 that the therapy of the future will make use of ? 
 
 . Stranger still appears such an assertion : " For other (out- 
 side of cholera) infectious diseases, as typhoid, pneumonia, etc., 
 we have long ago rejected specific remedies, having concluded, 
 that symptomatic treatment only (?) will assist the organism in 
 getting rid of the infectious agency." But this is not true ; 
 nobody ever rejected them ; let there be found to-morrow as re- 
 liable a remedy for typhoid and pneumonia, as quinine is for 
 malaria or salycilate of soda for acute articular rheumatism, and 
 every physician, including the author of the above statement, 
 will at once resort to it, reducing to a minimum, if not discharg- 
 ing altogether, the usual symptomatic treatment ; thus, for in- 
 stance, it happened with the symptomatic treatment of acute 
 articular rheumatism, which was being employed at the time 
 before the specific effect of sodium salycilate became known. 
 It is rather odd to hear it stated, that " the symptomatic treat- 
 ment only will enable the organism to free itself from the infec- 
 tion,'' in view of the effects of the above-named specific remedies 
 in malaria and acute articular rheumatism, effects which excel 
 so much by their accuracy and rapidity the symptomatic treat- 
 ment of those diseases, for which we have no specific treatment. 
 
 Equally strange is the identification of the specific treatment 
 with the routine one. 
 
 This is a confounding of ideas. Routine is not a peculiarity 
 of an}^ metliod of treatment, but surely a deplorable quality in 
 the physician himself: both the specific and the symptomatic 
 methods of treatment may be applied in a routine manner, and 
 again they may also be employed in a non-routine way, so as to 
 pay due attention to the characteristic peculiarities of the given 
 case, of the treated patient, which would but mean to subject 
 him to a system of individualization in treatment. 
 
 I will turn now to the discussion of the treatment as applied 
 to the various conditions in which the patient may be found. 
 
— 375 — 
 
 1. The diarrhcea. — It is self-understood, that not every case 
 of diarrhoea met with during a cholera epidemic is to be treated 
 as a choleraic diarrh(Ea. During such a time we may run across 
 patients suffering with a chronic intestinal catarrh which 
 causes constipation intermittent with diarrhoea, or even a continu- 
 ous diarrhoea ; if the diarrhoea from which such patients suffer, 
 remains during the cholera epidemic in the same condition as it 
 was before, then there is no reason for changing the usual treat- 
 ment of such a diarrhea, for attributing to it a certain •' anti- 
 choleraic '" shade, thus inordinatelj^ frightening the patient. I 
 will add right here, that not only in such cases, but also in cases 
 of doubtful or even undisguised cholera ailment, it is necessary 
 to insistently keep up the patient's spirits by encouraging him 
 that the disease he suffers from is a " simple," and not a " gen- 
 uine choleraic '' affection, thus averting as much as it lies in our 
 power the oppressive mental state, which is produced in the 
 patients by the anxiety of falling a prey to cholera, and which 
 tends to make their condition so much worse. 
 
 We may also see during the cholera epidemic cases of acute 
 diarrh(jea, but apparently of a non-choleraic nature, as for in- 
 stance, acute catarrh of the large mtestine, as evidenced by 
 frequent inclination to stool, tenesmus, pains, and scanty evac- 
 uations with an admixture of mucus and blood. 
 
 However, such cases are rather of infrequent occurence dur- 
 ing a cholera epidemic, and the acute diarrhcese met with at 
 such times are usually, or in all probability, of a choleraic nature 
 fas described above), or of such a character, as not having an 
 apparently Mow-choleraic nature, and they therefore give rise to 
 suspicion of their being of a choleraic origin (" the doubtful 
 cases"). A positive diagnosis, as we explained above, is impos- 
 sible ; the bacteriological examination, which would positively 
 diagnosticate either class of the cases, is not applicable in prac- 
 tice. 
 
 What then is the treatment of such cases ? Having first 
 of all informed yourself by a short inquiry of the kind and 
 quantity of food and drink the patient had been taking recently 
 and of the character of intestinal evacuations, and having in- 
 spected and palpated the abdomen, you should decide as to 
 
whether or not the intestinal canal is sufficiently emptied of 
 its contents. If not, it must be emptied b}^ the aid of laxatives : 
 this precedure, so necessary in any diarrhoea in case of insuffi- 
 cient emptying, the more so of overfilling of the intestines, is 
 the more necessar}^ in cholera affections, in which case the lax- 
 ative may he expected to remove together with the other in- 
 testinal contents the cholera bacteria which so greatly multi- 
 ply in the small intestines, and the toxine produced by them. 
 
 Which laxative is the most suitable for such cases ? Castor 
 oil or calomel with castor oil. I will take up calomel ffi^st. As 
 a laxative calomel is particularly useful, as my observations 
 during the former epidemics of cholera, principally of 1853 and 
 1854, testify, in patients of a robust or at least not of a weak 
 constitution, with a large abdomen ; in those who are subjected 
 to dyspeptic gastric phenomena (in such cases the castor oil is 
 frequently badly borne and is vomited up), to habitual consti- 
 pation, jaundice, to biliary colic attended with constant tender- 
 ness on pressure over the region of the gall-bladder. I admin- 
 ister a four or live grain dose of calomel, repeat it in two hours, 
 and again in two hours (if by that time there have not taken 
 place abundant evacuations sufficient to empty the intestines) ; 
 then I give a tablespoonful of castor oil, which is usually better 
 borne after calomel. To patients who do not present the 
 above-named peculiarities, I only administer castor oil. 
 
 I will also touch here on calomel as a generally "• antichole- 
 raic" remedy. It was recommended as such not only in the 
 bep-inninor of the disease when the intestines are overfilled, but 
 also for the later stages attended by a continuous, even severe 
 diarrhoea, as well as for the algid stage of true cholera, under 
 the assumption, that if taken internally, it will be converted 
 into corrosive sublimate, thus exerting a fatal effect on the 
 cholei'a bacteria found in the small intestines. Galomel is 
 particularly recommended for cholera by the well-known Mii- 
 nich clinician Ziemssen. But I will repeat here what I said in 
 1885, concerning the use of calomel, namely: in cholera I did 
 not see the slightest success from the employment of calomel 
 during the two severe epidemics at Moscow in the years 1853 
 and 1854, when, in the capacity of a resident pliysician of the 
 
— 377 — 
 
 temporary cholera department in the University clinic, I had 
 the opportunity of seeing a great many patients, and when calo- 
 mel formed the ordinary treatment of the disease. Calomel 
 was also tried during the recent epidemic and it was proved, 
 that its use was not only of no positive, but not even of a doubt- 
 ful value. Besides, it is quite probable, that its continuous 
 employment results in producing a harmful effect on the in- 
 testines which had already become strongly affected by the 
 cholera, and on the kidneys, the affection of which, appearing 
 during the period of reaction, is of such frequent occurrence in 
 cholera, and is fraught with grave danger to an organism 
 severely shocked by the preceding course of this disease. The 
 above-named cases, in which, according to my observations, 
 calomel in the begmning of the disease exerts an excellent 
 effect as a laxative remedy, without, I may add, the least dan- 
 ger to the patient, are the only ones, for which I administer 
 the drug in cholera. 
 
 I will add that for the identical purpose of directly acting on 
 the. cholera affection, by destroymg in the intestinal tract the 
 cholera bacteria and the toxine or toxines produced by them, 
 there were recommended, besides calomel, many other drugs, 
 notably salol. Experience proved that they were of the same 
 value as calomel, as far as their direct anticholeraic effect is 
 concerned, and that they also exerted a harmful effect. Hueppe, 
 from his observations during the recent cholera epidemic, recom- 
 mended specially tribromphenolbismuth ; but data communicated 
 by him, as well as the observations of other physicians, fail to 
 show that this remedy deserves any greater credit than calomel, 
 salol, and a host of others recommended until now. 
 
 I return now to the treatment of the diarrhoea. What is to 
 be done for cases, in which, after an evacuation of the intestines 
 had been effected b}- a laxative, the diarrhoea still continues, and 
 also for those cases which present no necessity for the admmis- 
 tration of a laxative, as the physician sees them at a time when 
 the intestinal tract has akeady been evacuated, but meanwhile 
 the diarrhoea continues, thus certainly debilitating the patient? 
 In either class of cases we must first of all give opium, namely, 
 the tincture (tincturaopiisimplexs.thebaica), as the most suitable 
 
— 378 — 
 
 opium preparation, and as one, besides, which can be divided in 
 doses most conveniently, not requiring any weighing, like opium 
 purum and extr. opii aquosuni. The employment of opium at 
 the present time must certainly be explained. 
 
 During the former cholera epidemics opium may be said to 
 have been the most generally employed remedy in doubtful as 
 well as in undisguised cases of choleraic diseases. At the pres- 
 ent time the matter is considered in a different light: starting 
 with the supposition, that opium, by weakening the peristaltic 
 efforts of the intestines, assists in the retention and multiplica- 
 tion (as determined by the greater amount of rest allowed to 
 them) in them of the cholera bacteria, thus at the same time 
 tending to increase the quantity of the produced toxine and the 
 general intoxication of the system, many observers insist upon 
 completely renouncing opium as a remedial agencj^ for chole- 
 raic affections. 
 
 But my observations, as I mentioned above, were sufficient 
 for my formulating the following : I had the opportunity dur- 
 ing the cholera epidemics to cure by moderate doses of opium 
 (of this later on) many cases of diarrhoea, after a preliminary 
 evacuation of the intestinal tract, or without the same when 
 there were no indications for it. The exact nature of these 
 diarrhoeas remained then, and remains now uncertain : it is just 
 as impossilile to assert that they had all been choleraic diarrhoeas, 
 as that they had not. In other, much less frequent, cases, not- 
 withstanding this method of treatment, in conjunction of course 
 with the appropriate hygienic measures, the diarrhoea did not 
 stop and there developed cholerine or genuine cholera. 
 
 With such observations in view I consider it erroneous to 
 reject a remedy which acts so successfully and so rapidlj- in the 
 majority of cases under discussion, and I recommend, after the 
 intestines have been evacuated, to administer at once to an adult 
 patient fifteen or twenty drops of the tincture of opium, and 
 later on, if necessary, in accord with the effect of the opium and 
 the course of the disease, to give the same in five-drop doses 
 and always in warm (boiled) water, or with the addition of 
 strong wine or good clarified brand}^ The ordinary dose is from 
 thirty to forty or even sixty drops during twenty-four hours. 
 
— 379 — 
 
 This treatment I usually continue for one, one and a half, or the 
 longest, for two days. And what is to be done next? In the 
 greater majority of cases, this treatment will brmg about a ces- 
 sation of the diarrhoi'a. In other, less frequent, cases, the diar- 
 rhoea is only diminished, but does not cease altogether, and 
 without taking on in the least the character of a choleraic affec- 
 tion, it is prolonged, and shows an inclination toward becoming 
 chronic ; in such cases, leaving aside opium, I resort to bismuth, 
 especially if the large intestine become affected, or tra. coto, if 
 the small intestme is the seat of the disease, or both together ; 
 I also administer ordmary clysters, or with bismuth, tannin 
 and boric acid. Finally, there are still less frequent cases in 
 which the diarrhoea, m spite of the treatment, becomes aggra- 
 vated, and the affection takes on a choleraic character. Then, 
 but not before one or two days of opium treatment, I set aside 
 the opium, principally because in moderate doses it is ineffective, 
 while the administration of large doses is fraught with danger : 
 for such doses will overcome the irritant influence of the chole- 
 raic affection on the intestinal peristalsis, which may result in 
 constipation — a condition certainly of extreme danger, and a 
 moderate diarrhoea is by far preferable to a non-evacuated intes- 
 tinal tract ; but even if such be not the case, then in view of the 
 possible approach of the algid stage, when the nervous system 
 is most severely affected by the choleraic toxine (with the re- 
 sulting thickened blood and a lack of oxygen), I consider it very 
 dangerous to still more weaken this system by the introduction 
 of large doses of opium. 
 
 Havmg then set aside opium, I administer internally bismuth 
 subnitrate in doses sufficient to put a stop to the excessive diar- 
 rhoea which deprives the organism of so much fluid, namely, 
 ten to fifteen grains at a dose, from four to six times a day ; I 
 recommend bismuth as a remedy reliable in non-choleraic diar- 
 rhoeas, which acts at the same time as a disinfecting agency, is 
 well borne hj the intestines and does not exert any deleterious 
 effect on the nervous system, as would be the case from large 
 doses of opium. 
 
 But as regards the expectations reposed in bismuth as a 
 positive anticholeraic agency, exerting an effect on the cholera 
 
— 380 — 
 
 bacteria and their toxines, which effect would be evidenced by a 
 rapid and decided change of the choleraic affection to the better, 
 these expectations were but little substantiated by observations, 
 just as was the case with calomel, salol, etc. Together with the 
 bismuth I advise for patients suffering from the cholera affection 
 in the condition under discussion large (from 1000 c. c. and 
 more), and hot (38° to 40° C.) watery clysters with tannin (one 
 per cent solution^, as recommended by the well-known Neapol- 
 itan clinician C'antani. 
 
 Cantani * in his treatment of cholera chiefly aims : firf^t, to 
 destroy the cholera bacteria and their toxines m the intestines, 
 and secondly, to diminish the thickening of the blood and to 
 assist in the elimination from the organism of the cholera tox- 
 ine absorbed by the blood. 
 
 To effect his second purpose he recommends the introduction 
 hypodermicall}^ of a solution of common salt (the so-called 
 hypodermoclysis, of which we shall speak in connection with 
 the treatment of the algid period) ; while for the first purpose 
 he resorts to the above-named clysters (enteroclysmata), in the 
 belief that they may reach beyond the ileo-ca3cal valve (valvula 
 Bauhini) into the small intestine and there exert an influence 
 on the bacteria and their toxines. I personally had as yet no 
 opportunity of treating cholera patients since the time (1884) 
 that Cantani called attention to his method ; but there are 
 abundant proofs in the literature of the subject which speak of 
 the merits of Cantani's treatment: both his own and the en- 
 thusiastic reports of many other Italian physicians fell short of 
 the expectations excited, and the percentage of deaths has 
 hardly changed perceptibly since the introduction of this method ; 
 nevertheless, the eiiteroclysmata as well as the hypodermoclys- 
 mata are recognized as useful aids in the treatment of cholera. 
 
 I'he principal effect of large hot enteroclysmata consists in 
 tliat they communicate warmth to the body, which means that 
 they communicate the exciting influence of the heat to an or- 
 ganism weakened by diarrhoea and the cholera affection in 
 general : the diarrhcea and the vomiting diminish, the jDulse 
 grows stronger, the self-feeling becomes better. The entero- 
 
 * Vide liis communication in Berl. Klin. Wochenschrift, No. 37, 1892. 
 
— 381 — 
 
 clysmata exert also some effect by acting on the cholera bac- 
 teria and their toxines in the large intestine, and by removing 
 them.* 
 
 What other measures, outside of those enumerated above, 
 must we resort to in the treatment of the affections under dis- 
 cussion ? I refer of course only to such patients as enjoyed fair 
 health up to the time they fell victims to cholera (we surely 
 cannot touch here on the treatment of persons afflicted with 
 any chi-onic or aoute affection previous to their being attacked 
 with cholera, as that will lead us too far). In sjLich patients, be- 
 sides the intestinal therapy, we must also treat tlie cardiac and 
 the general conditions. To combat these last symptoms, as 
 well as those presented by the intestines, the chief measures 
 resorted to, besides those mentioned above, (Consist in keeping 
 the patient warm (as by a warm bath, by covering the patient 
 well, and particularly hj keeping the abdomen warm, and by 
 giving warm drinks — the best is weak tea), and in the 
 administration of alcohol in the form of wine, cognac, jum and 
 distilled brandy. The hot baths (30° R. and higher), so useful 
 in the algid stage of cholera, are of course unnecessary in the af- 
 fections under consideration : these measures and the employ- 
 ment of enteroclysmata, repeated as necessary, will keep the 
 patient sufficiently warm. 
 
 2. Cholerine or the period of cholera 'proper^ preeeding the algid 
 stage. — The same heat-generating measures and the enteroclys- 
 mata employed repeatedly. For internal use, as far as vomit- 
 ing permits it, bismuth and alcoholics. There are no sure 
 measures against vomiting : we try ice, ether, and in very rare 
 exceptional cases, as, for instance, when the vomiting takes on 
 a dangerous character in cholera patients who are afflicted with 
 cardiac or arterial disease, we resort to hypodermic injections 
 of morphine (one-eighth or one-fourth grain at a time) or cocaine 
 (^. cocaini muriatici gr. xv, aquse destil. fss). A whole or one- 
 
 * (A later addition.) Prof. Genersich recently recommended washing 
 out the whole alimentary canal (so that the fluid introduced per anum 
 is ejected by vomiting per os) in cholera and other diseases (Progres 
 Medical and Deutsche Medicinische Wochenschrift, 189:3). It remains 
 for the future to determine the value and the application of this method 
 of treatment. 
 
— 382 — 
 
 half syringe at a time), the introduction of which into the or- 
 • ganism, with the consequent weakening effect on the nervous sys- 
 tem, is not desirable at all in view of the possible approach of 
 the algid stage. 
 
 But usually vomiting, and its effects on the organism, do 
 not require the use of such strong measures ; moreover, as men- 
 tioned above, the enteroclysmata diminish the vomiting to an 
 extent. Nor do the cramps necessitate the employment of 
 strong measures, such as hypodermic injections of morphine. 
 The best means for combating the cramps is to immediately put 
 the affected part into a position opposite to that into which it 
 was contracted; most frequently the cramps take place in the 
 muscles of the calves extending the foot; it is sufficient to 
 flex the foot and the cramps cease ; however, as was mentioned 
 above, the cramps tend to rapid disappearance by themselves. 
 3. The algid stage of cholera projyer. — The above-named meas- 
 ures contributing heat, including the enteroclysmata, also hot 
 baths : in a general way the body should be kept warm by all 
 suitable means at hand. Later on, with the first symptoms 
 of the approaching algid stage, to counteract the thickening of 
 the blood, the lack of oxygen and the anuria, and also to excite 
 by warmth the heart and the nervous system, resort must be 
 had to Cantani's large (from 300 to 1,000 c. c. at a time) hot 
 (38 ° to 40° C. ) hypodermoclysmata, containing a solution of 
 common table-salt (7.5 to 1,000), injected into places where the 
 skin is easily raised in folds and the subcutaneous layer affords 
 a convenient receptacle for the introduced fluid (except in the 
 region of the neck, into which the introduction subcutaneously 
 of a large quantity of fluid is known to be fraught with dan- 
 ger). Usually after such a hypodermoclysma has been admin- 
 istered, the pidse, hitherto hardly perceptible, grows stronger, 
 and the general weakness of the patient diminishes. It is 
 true that this improvement does not last long, and on the hy- 
 podermoclysma being repeated, it ■ — the improvement — is not as 
 considerable as it was the first time; nevertheless, the value of 
 the hypodermoclysma is beyond doubt, and its employment is 
 unconditionally indicated. The injection into the veins of a 
 salt solution does not offer any advantages over the hypoder- 
 
— 383 — 
 
 moclysmata; it is moreover applied with greater difficulty, 
 unless it be in the hospital, and besides is not devoid of danger. 
 Finally, during the algid stage, it is of the greatest importance to 
 introduce stimulants both internally, such as hot tea, the various 
 alcoholics, ether, camphor, and hypodermically ; for this last 
 we use oleum eamphoratum fortius (1 : 5), one syringeful at a 
 time, and caifeinum natrobenzoicum, from one-third to two- 
 thirds of a syringeful (it is best used thus : 1^.. natri benzoic!, 
 caffeini aa 3ij, aquae destil. 3ss.; such a considerable concentra- 
 tion will assist in keeping the solution in better condition, nor 
 will it become turbid). It needs no explanation that both the 
 hypodermoclysmata, as well as the hypodermic injections of 
 the various stimulants, should be made under the strictest anti- 
 septic precautions.* 
 
 4. TJie period of reaction (typhoid cholera). — The treatment 
 of the nephritis caused by cholera consists in warm baths and 
 abundant drinks. 
 
 The treatment of the typhoid and uraemic symptoms : signs of 
 congestion (as a flushed face) require the application of cold to 
 the head or even the application of leeches to the root of the 
 nose, if the patient is not very weak ; for symptoms indicating 
 excitability of the nervous system (as delirium, etc.) sodium 
 bromide ; and for symptoms of nervous oppression, moschus 
 and washing of the head with fresh water. 
 
 If the body temperature be very high (about -10° 6'., 104° i^.) 
 small doses (three to five grains) of phenacetine or antifebrine 
 will reduce it to an extent. 
 
 * (A later note.) Prof. Slikliareft'sky ( " On the Treatment ot Cholera 
 during the Algid Stage," a reprint from Nos. 16 and 17 of the South- 
 Kussian Medical Gazette, 1893) calls attention to the long forgotten, but 
 according to the observations of many physicians, very effective treatment 
 of the algid period of cholera by the method of Dr. Chapman. "The 
 gist of this method consists in this, that with the aid of cold or heat an 
 effect is produced on the patient's spinal column, w^hile the other parts 
 of the body are subjected to heat in the first case, and to cold in the 
 second by compresses. Thus a rubber bag filled with ice is placed along 
 the spinal column of the patient during the algid stage, and dtiring the 
 typhoid period a similar bag is filled with water at the temperature of 
 38° B." Considering the algid period of cholera as an " infectious neuro- 
 sis," Prof. Shkliareffsky explains from this point of view the effect of 
 Chapman's method of treatment. Prof. Shkliareffsky' s article is full of 
 interesting points. 
 
— 384 — 
 
 The treatment of the various complications — as erysipelas, 
 ulcers, abscesses and diphtheritic affections (as dysentery, etc.) 
 — is to be conducted according to the indications of these com- 
 plications. 
 
 Having spoken thus far of the genuine Asiatic or India 
 cholera, I will now say a few words on cholera nostras. 
 
 The attacks of this disease are similar by their nature and 
 course to those of the genuine cholera, and may also occur with 
 a similar intensity, but are not as extensive as these last: 
 cholera nostras occurs only as an endemic, never as an epidemic 
 disease. The microbe which produces it is as yet unknown ; 
 they failed to find the comma bacilli of the genuine cholera in 
 the evacuation of patients suffermg from our (or European) 
 cholera. During the prevalence of this last Finkler and Pryor 
 found a bacterium similar to, but not identical with, the comma 
 bacillus of genuine cholera ; but in the following epidemics, the 
 Fmkler-Pryor bacilli have not been found. Last spring, there 
 occurred in the vicinity of Paris (at the beginning only there, 
 and at no other place in France) severe cholera-like attacks, but 
 without any notable tendency to further spreading. Consider- 
 ing them of the nature of cholera nostras and noting that they 
 occurred in the localities which had formerly suffered severely 
 from the true Asiatic cholera, some physicians assumed that 
 cholera nostras was but a degenerate descendant of the Asiatic 
 cholera. The treatment of the attack of cholera nostras does 
 not in the least differ from that of the genuine Asiatic cholera. 
 
SUPPLEMENTS. 
 
ON BLOODLETTING. 
 
 AN ADDRESS DELIVERED AT THE ANNUAL MEETING OF THE 
 MOSCOW PHYSIO-MEDICAL SOCIETY, JANUARY, 1889. 
 
 G-entlemen : — I propose to speak of bloodletting — a reme- 
 dial measure the value and importance of whicli an experience 
 extending over many years taught me to appreciate. I shall 
 discuss bloodletting only as applied in the doraam of internal 
 medicine, without touching on its use in surgery, gynaecology, 
 pediatrics, etc. 
 
 This is not the place to dilate on the history of bloodletting, 
 which begins, probably, with the history of medicine itself. I 
 shall only touch on that period m its history, of which I have 
 been an eye-witness myself; I shall do that, that I may show 
 how my own experience was formed concerning the employ- 
 ment of this measure. During my student years and my three 
 years' clinical assistantship, bloodletting, general as well as local, 
 was resorted to frequently and unsparinglj^ : the influence of 
 Broussais was as yet prevalent, although not strongly, and I 
 must add, to a constantly diminishing extent. I visited later, 
 in 1856, Western Europe, and found there a complete reaction 
 against venesection, both in literature and in practice : during 
 my three years' sojourn there, I did not see, in any of the clinics 
 in Germany, Austria and France, the employment of bloodlet- 
 ting, and only very rarely indeed did I witness the use of cup- 
 ping-glasses and leeches. On my return to Moscow, I also 
 found here the beginning of a similar reactionary movement, 
 which resulted in this, that eight or ten years later a similar 
 negative stand was taken against the employment of bloodlet- 
 ting in practice (I do not speak of my own), as obtained at 
 that period in Western Europe, as well as in England. 
 
 Let us consider the position occupied by this subject at 
 the present time. In Western Europe we hear complaints of 
 the unjust condemnation and neglect with which the subject of 
 bloodletting is being treated ; and from such men as, for in- 
 stance, in England, Fen wick, Broadbent and Oliver; in France, 
 
 387 
 
— 388 — 
 
 Hayem ; in Germany, the well-known clinical teachers and 
 authors of special pathology and therapeutics, Liebermeister, 
 Striimpell, and Eichhorst. As all these complain of neglect, 
 this seems to be continuing. Liebermeister, Striimpell and 
 Eiclihorst recommend bloodletting, but they do not give any 
 sufficiently clear indications for its emplojanent, thus showing 
 but a poor personah experience. Eegarding these same recom- 
 mendations it is interesting to note the opinion of another clini- 
 cal teacher and author of a text-book of special pathology and 
 therapeutics, Jiirgensen, who confesses openly to being sceptical 
 towards bloodletting, and who expresses himself as follows : 
 " Personally I am, perhaps, too much afraid of blood, and I 
 will therefore rather not enter my opinion." * He further 
 makes a statement, which is evidently intended for Liebermei- 
 ster, Striimpell and Eiclihorst, authors of the most widel}^ read 
 text-books of special pathology and therapeutics, to this effect : 
 " We observe a tendency m our text-books of to-day not to 
 wholly neglect the use of bloodletting, even if the author in his 
 practice does not employ it at all, or very rarely." | 
 
 As regards medical practice with us, with the exception of 
 Moscow and the ph3^sicians who are the followers of Moscow 
 methods in medicine, everywhere else, in the principal med- 
 ical centres, the university cities, as well as in the regions 
 embraced by their influence, bloodletting, and abstraction 
 of blood in general, is looked upon, as far as I know, with 
 disfavor. I am unable to bring before you any literary ma- 
 terial on the subject, as I am not aware of the existence of 
 any such ; but as far as is known from practice, the stand taken 
 against bloodletting is of a pronouncedly negative character, at 
 least up till now, in the above-named localities. Thus, for in- 
 stance, a patient from a provmoial city who applied a few leech- 
 es by the advice of his physician, a graduate of the Moscow 
 University, and who was considerably relieved by them, later 
 on, while consulting a University professor, not in Moscow, 
 heard him ask, after inquiring about his disease and the treat- 
 ment, " Whoever uses leeches now ? " Or another example : a 
 
 * Ziemssen, Handbucli d. allgemeinen Therapie, I. B., 2 ii. 3 Th., An- 
 tiplilogistisclie Heilmetlioden v. Jiirgensen, S. 159: " Ich fiirineine Person 
 bin vielleiclit iibertrieben blutsclieu iind mochte daher mit meinem Ur- 
 tlieil zuriickhalteu." 
 
 t Ibidem, S. 219: "Man erkennt in unseren heutigen Lelirbiichern das 
 Bestreben die Blutentzieliung uicht ganz fallen zu lassen, audi dann, 
 wenn der Verfasser in praxi seltenen oder gar keinen Gebraucli davon 
 macht." 
 
— 389 — 
 
 patient, who was suffering with pain in the stomach and with 
 nausea due to extreme hypereemia of the liver caused partly by 
 weak cardiac activity, partly by abuse of wine, and who has 
 been taking various drugs without any relief, called in the aid 
 of a Moscow physician. This last ordered leeches to the coccy- 
 geal region : on the very next day the above-named sufferings 
 disappeared, without in the least weakening the patient. One 
 month later the patient returns to his constant place of resi- 
 dence, and tells his former physician, a clinical professor, of the 
 improvement in his health, whereat this last remarks : " But 
 this improvement is only temporary." Patient however replies : 
 •' Whether temporary or not, I cannot say, but I appreciate it 
 dearly, whereas the former medicinal means have not done for 
 me even that much." (3r here is another : a patient, who at 
 the advice of his physician, a Moscow man, applied leeches and 
 was relieved by them, was asked by another doctor, not from 
 Moscow, as to the age of his physician. When told that he — 
 the physician — was thirty years of age, he observed : " I thought 
 he was seventy years old, as he employs such ancient remedies.'" 
 I had occasion to hear a great many similarly expressed opinions ; 
 l)ut I have not heard such as would favor the employment of 
 bloodletting. It is also curious to note, that the unfavorable 
 opinions come from persons, who have never employed blood- 
 lettmg, and who therefore had no personal experience with this 
 method of treatment. 
 
 Turning now to Moscow and the region influenced by its 
 teachings, I will first of all touch upon my j^ersonal relation to 
 the subject under discussion. As I said before, during my 
 student years and my clinical service, l^loodletting was prac- 
 tised frequently and unsparingly, so that I had many an oppor- 
 tunity to witness its undoubted value, when it could not be re- 
 placed in many cases, while in others I also saw great harm 
 caused by it. Of course, only later on, as my practical experi- 
 ence began to mature, did I learn to appreciate with greater 
 exactness its beneficial as well as its harmful effects. The 
 errors of the medical practice of those times consisted in this, 
 that it was taught that bloodlettmg would cure diseases — " the 
 inflammations" — considering as an inflammation pneumonia, 
 acute articular rheumatism, etc. ; consequently, without taking 
 into account the condition of the patient's strength, they re- 
 sorted not only to one, but to repeated bloodlettings (the so- 
 called '' coup sur coup" of Bouillot), not curing the disease, but 
 debilitating the patient, thus increasing to a fatal extent the 
 
— 390 — 
 
 conditions favoring a bad termination of the disease. Another 
 cause of the unfortunate employment of bloodletting was to be 
 found in the imperfectness of diagnostic skill at those times : 
 thus, for instance, in headache, in which out of ten cases we 
 will probably in one resort to bloodletting in the coccygeal 
 region, we then did it if not in all the ten, surely in nine, and 
 we did not put five to eight leeches as is done now, but from 
 ten to twenty and more. As one of the harmful influences of 
 those times must be considered the universal custom of the 
 laitj^ to resort to local, and at times even to general bloodletting 
 without the physician's advice, a custom which fortunately does 
 not exist at the present time, thanks, we must openly confess, 
 to the negative stand taken by the medical profession toward 
 the subject of bloodletting. 
 
 But I must say again, that at the same time, at the beginning 
 of my medical career, 1 had occasion to observe the undisputed 
 benefit from bloodletting and even the impossibility of replac- 
 ing it, and I therefore never left off this method of treatment ; 
 but in accord with my experience extending over many years, 
 with the continually developing medical maturity and the rapid 
 progress in the domain of diagnosis, general pathology and 
 therapeutics, I worked out a different practice of bloodletting. 
 As regards the practice in Moscow, 1 can remember the time — 
 the acme of the period of opposition to bloodletting — when I 
 met almost no colleagues who resorted to bloodletting as a 
 derivative measure, and I had to defend my position when 
 advising its application in consultations. At the present time 
 the matter stands otherwise : my own practice and that of a 
 number of the attending physicians at my clinic, as well as 
 personal assistants who became later on independent practi- 
 tioners and partly also clinical instructors, have brought it about 
 that the employment of bloodletting as a derivative measure 
 in the wsij 1 am applying it, has become firmly established in 
 Moscow and the circle of its medical influence. 
 
 I will explain now the method used in my present prac- 
 tice of bloodletting. I shall be concise, as I intend to speak 
 only of what is proved by facts to be certain, without touch- 
 ing upon theories which explain and prove the benefit de- 
 rived from bloodlettmg. In the present condition of physi- 
 ology and pathology such theories are as yet impossible : there 
 exists no theory that could not be contradicted ; and in doing 
 this, there is always a danger, — to be sure, only when the 
 subject is but superficially discussed, — while disproving the 
 
— 391 — 
 
 theory on which the facts are based, to consider also these last 
 as refuted. My conviction regarding the benefit of bloodlet- 
 ting as based upon facts has been reached by the same method 
 of analyzing and criticising, as my personal conviction of the 
 benefit derived from any other indisputably efficient remedial 
 agencies of our therapy. 
 
 With every bloodletting there takes place a more or less 
 considerable depletion of the circulatory system: this effect of 
 bloodletting surely no one will deny. The so-called derivative 
 effect of bloodletting i« not recognized by all : I am personally 
 convinced of this last effect, and I will explain later on what I 
 mean by it and will show wh}^ I believe in it. 
 
 I. Bloodletting, tvTiere the chief effect is depletion, although 
 at the same time there may he also derivation. 
 
 Venesection is resorted to by me, when in disturbances of 
 the brain or chest circulation there occurs a vital indication, 
 i. e. an indication to save the life from threatening death ; this 
 occurs m the following most important cases. 
 
 Disturhanees of the cerebral circulation. — 1. In the presence 
 of evident symptoms of a threatenmg or an inevitable cerehral 
 apoplexy in patients with atltermatous arteries., usually caused 
 by rupture of the cerebral arteries : in embolism and thrombosis 
 the indications for bloodletting are much less frequent. I must 
 say here a few words concernmg the condition of the pulse. ' 
 Bloodletting m such cases is to be done not only when the 
 pulse is full and strong, but also if it be weak, as long as we 
 have to do with a patient who is not anaemic. Let me say, that 
 the majority of patients present the following appearance ; the 
 pulse is weak, but the patient's nutrition is in a good condition, 
 he does not look anaemic, rather plethoric, and the inquiry 
 from among the surrounding friends elicits the fact, that the 
 patient enjoyed a good appetite and digestion, has never suffered 
 from any loss of blood, has usually complained of feeling warm 
 and not chilly, etc. In such cases the small pulse points not to 
 anaemia, but to a weak condition of the cardiac muscle, name- 
 ly of the left ventricle, or to a disturbance of the innervation 
 of the heart, which in its turn may be due to the disturbance 
 of the cerebral circulation, which occasioned the apoplectic 
 condition. Here we must employ bloodlettmg and administer 
 at the same time stimulants per os or hypodermically : frequent- 
 ly at once after or even during the bloodletting, the pulse 
 becomes fuller and stronger. Bloodletting in these as well as 
 
— 392 — 
 
 in the cases which will be spoken of later, should always be 
 •performed in the presence of a physician. As regards the 
 amount of blood to be abstracted, in this as in other cases, 
 I abstract from adults twelve ounces, but frequently, guided 
 by the condition of the constitution, nutrition and hsemato- 
 poiesis of the patient and other peculiarities of the given case, 
 eight or six ounces. 
 
 2. In the presence of evident symptoms of threatening or 
 already occurring cerebral a'poplexy in fatient^ ivith a chronic ne- 
 phritis and hyjjertrojjliy of tJie left venti-icle. The text-books often 
 recommend bloodletting in the treatment of urtemia, but they 
 fail to give any definite indications, the absence of which among 
 the recommended therapeutical measures forms, however, the 
 usual weak point of many a text-book. In a given case it 
 may lead the young physician into committing a fatal error, 
 namely: if with the urpemic symptoms there are also present 
 signs of threatening cerebral apoplexy, and with these there is 
 a full and strong pulse because of a hypertrophy of the left 
 ventricle, a flushed face, etc., then we must of course employ 
 bloodletting ; but if the symptoms of threatening apoplexy are 
 absent, if the face is pale, the pulse weak, and if there is consider- 
 able oedema, then bloodletting may harm the patient greatly, 
 if it does not directly kill him by hastening the development 
 of cerebral (edema. In such a case we should not resort to 
 bloodletting, l)ut we should administer stimulants, and prin- 
 cipally calomel, as a laxative and diuretic remedy whose effect 
 diminishes directly the ursemic poisoning of the blood. 
 
 Disturbances of the circulation ivithin the chest. 
 
 1. There occur cases, though rarely, of diseases of the heart., 
 most frequently with stenosis of the left venous openmg, when 
 the patient, as yet not anaemic and generally not exhausted, 
 presents a condition of extreme disturbance of the cu-culation, 
 principally of the pulmonary, as evidenced hj severe dyspnoea 
 and by hsemoptysis, and of the portal, as seen by the enlarge- 
 ment and sensitiveness of the liver : here we have no time to 
 wait for the effects of remedies which regulate the cardiac 
 activity and the circulation ; besides, the best of them, namely 
 digitalis, is at times badly borne in such cases and acts slowly : 
 it is slowly absorbed, as you can easily comprehend, on account 
 of the overfilling by blood of the liver, and, consequently, also 
 of the stomach. Here we must employ bloodletting, adminis- 
 ter stimulants (as the pulse is usually weak) — at times calo- 
 mel, if there be an mdication for it, — and later on digitalis, 
 
— 393 ^ 
 
 which by this time will usually he well borne and Avill exert its 
 favorable effects. 
 
 2. There are cases, though not frequent ones, presenting a 
 tumultuous onset of croupous pneumonia, when there becomes 
 affected at once a considerable portion of one lung, and simultane- 
 ously with this, in view of the embarrassed circulation in the 
 affected lung, there appears an oedema of the other healthy 
 lung, which spreads rapidly, and is accompanied at times by 
 haemoptysis. If the patient is not old, and is possessed of a 
 sound constitution and has enjoyed good health before he was 
 attacked by the pneumonia, then we must do bloodletting ; if 
 the pulse, as happens rather unfrequently, be weak, then we 
 must certainly administer simultaneously stimulants. The text- 
 books usuallj' recommend, after explaining that the oedema of 
 the lungs depends on the weakened cardiac activity, for treat- 
 ment stimulants, and for the relief of the right ventricle blood- 
 lettmg from the overfilled venous half of the circulation. 
 
 Again I must point to such a want of precision in the indica- 
 tions, in recommending in such a general way bloodletting for 
 pulmonary oedema. If we deal with a case as described above, 
 then we must of course abstract some blood. But if we have 
 a case of pulmonary cedema which appeared at the termination 
 of an attack of croupous pneumonia, after the seventh or 
 eighth day and later, in a patient already debilitated and 
 presenting symptoms of collapse, then we should not resort 
 to bloodletting, a rather risky procedure in such a case, but 
 we must administer stimulants, resort to large blisters and to 
 the use of senega. However, as regards the recommendation 
 by the text-books of bloodletting for pulmonary oedema we 
 cannot help recalling to our mmd agaui the observation of 
 Jiirgensen, that the authors of the text-books recommend 
 bloodletting, but never employ it themselves. 
 
 Local Bloodletting, cupping-glasses with scarification, and 
 leeches, are employed Ijy me with the aim in view of depleting 
 the blood-vessels, m the followmg, most frec^uent, cases. 
 
 1. In acute pleuropneumonia and acute pleurisy. — In pure 
 pericarditis uncomplicated by a pleurisy of any considerable 
 extent, the resort to bloodletting is rather rare : the therapeutic 
 indication can usually be fulfilled by a large blister. 2. In 
 acute nephritis. 3. In acute inflammation of the great nervous 
 trunks, principally of the sciatic nerves — as in ischias ex 
 neuritide acuta. For all these enumerated cases, I employ 
 cuppmg-glasses with scarification, not leeches. I prefer them 
 
— 394 — 
 
 to leeches in all cases in .which the local conditions permit their 
 employment — for the foUowmg reasons : theii- application, 
 as well as their effect, is more rapid ; bleeding stops at once 
 after the cups are taken off, and there is no consequent bleed- 
 ing, so that we are enabled to extract the desired amount of 
 blood with greater exactness without weakening the patient, 
 as happens frequently with leeches after which it is difficult to 
 stop the bleeding, and there may occur more bleeding later on ; 
 the depleting effect is also accompanied by derivation, which is 
 greater than in the case of leeches, and which is also beneficial in 
 the above-enumerated cases ; finally cupping-glasses with scari- 
 fications are cheaper than leeches and require less care on the 
 part of the patient after they are applied. 
 
 The number of cupping-glasses for the above-considered 
 cases is usually six. seldom four, at times eight ; this last 
 number may be employed, for instance, in pleuropneumonia, 
 when to the pleuritic phenomena, such as severe pains in the 
 side embarrassing breathing, and therefore increasing the dysp- 
 noea, which is itself caused by the pneumonia, there are super- 
 added symptoms of a tempestuous attack of pneumonia with 
 a simultaneous ( edema of the other healthy lung, — symptoms, 
 which were spoken of above, in touching on bloodletting ; in 
 such cases, which are not clearly defined, cupping may replace 
 bloodletting. 
 
 Local abstraction of blood, namely, as I said before, wet 
 cups, are resorted to by me in the above-mentioned cases in the 
 presence of the following conditions : when the patient has not 
 as yet become weakened, therefore usually only at the begin- 
 ning of the disease, during the first two or three days ; in 
 ischias ex neuritide also later ; if the local symptoms, especially 
 the pains, are severe and far advanced. As regards pleuritis 
 I must say that with it also bloodletting is indicated principally 
 by the acuteness of the attack when the patient's condition is 
 as yet not weakened, and not by the causation of the pleurisy : 
 to be sure, we are much more frequently compelled to do 
 bloodletting for pleurisy caused by a cold, or for pleurisy of 
 a pneumonic nature, than for purulent or tuberculous pleurisy ; 
 but these two forms of pleurisy do not by any means present 
 an absolute contraindication to local bloodletting. The eft'ect 
 of bloodletting is usually manifested by the diminution of the 
 excruciating pains and the dyspnoea in cases of chest troubles, 
 by the improvement in the condition of the urine, in acute 
 nephritis, by the decrease of the febrile condition, by the more 
 
— 395 — 
 
 quiet sleep, and — as I can attest from mv own observations 
 — by a more favorable consequent course of the disease. 
 
 Where are the cups to be applied ? In the above-enumer- 
 ated diseases of the chest they are usually apj^lied to the 
 posterior and lateral surfaces of the thorax ; hi nephritis to 
 the back, in the region of the kidney ; in ischias ex neuritide, 
 on the buttocks, some four or five cupping-glasses of medium 
 size around the incisura ischiadica, leaving the central part for 
 the Spanish fly, which must usually be applied soon after, 
 a few hours after the bloodletting. I do not thmk that this 
 last procedure is a trifling affair : m ischias ex neuritide a 
 large fly exerts its best effect when applied to the sides of the 
 incisura ischiadica and to its circumference, and especially if 
 it be applied soon, in a few hours after the bloodletting. But 
 if there be scattered over the part several incisions over the 
 above-named region, as a result of the inaccurate directions 
 of the physician, and to apply a fly directly on these Avould 
 be extremely painful and would tend to cantharis poisoning, 
 then we must either wait or apply the fly to another place ; 
 in either of which cases the patient gains. 
 
 In connection with this I cannot help observing, that in a 
 general way, due attention is often not paid to the mtelligent 
 treatment of the surface of the body at the afl:ected place, and 
 it — the surface — is exploited rather thoughtlessly, forgetting 
 that it is on this surface and with its assistance, that we are 
 sometimes compelled to withstand the last positive struggle 
 against the disease. 
 
 Thus, for instance, in the various chest affections dry cups 
 are applied over the chest to effect a relief from dyspnoea- — 
 a relief usually of but a slight nature and short duration — and 
 these are at times applied in such numbers and with such im- 
 moderate zeal, that at the decided hour, when the consulting- 
 physician is usually called m. — in case for instance, an (jedema 
 of the lungs is developed, and the jDatient can be saved onl}' by 
 the aid of stimulants, by senega, and principally, by large flies 
 applied to the chest (if applied to any other portion of the bodj', 
 we cannot obtain even a shadow of that effect), — the chest is 
 seen to be covered by so many severe ecchymoses resulting from 
 dry cupping, that there is no place over it even for a small fly, 
 whereas, as we said, we must apply a large one, and usually 
 more than one. The same may be said of pamting the skin 
 with the iodine tincture, which is just as little useful in the 
 above-named cases and which, later on, serves as an obstacle to 
 the application of Spanish flies. 
 
— 396 — 
 
 4. For local blood-extraction with depletion in view in dis- 
 eases of the abdomen, usually in circumscribed peritonitis (most 
 frequentl}^ for perityphlitis, at times for pericystitis of the gall- 
 bladder). I resort to leeches (as cupping is inconvenient over 
 the abdomen), from six to ten in number. 
 
 Of local depleting bloodletting — the application of leeches 
 — in the region of the head, I shall speak later, for convenience 
 of exposition, in connection with derivative bloodletting. 
 
 II. Bloodletting, -where ^ altJiough there is also depletion, the 
 
 PPvES^ClPAL EFFECT IS THAT OF A DERIVATIVE. 
 
 To clearly elucidate what I mean by derivative bloodletting. 
 I must first say a few words on the subject of hgemorrhoids. 
 
 AVhat are haemorrhoids ? And does there exist in reality a 
 morbid condition which must be distinctively named " haemor- 
 rhoids " ? The ancient medical works devoted much space to the 
 subject of haemorrhoids. Later the criticism of the views of the 
 ancient writers resulted in a complete rejection of the same, so 
 that for some time haemorrhoids were not treated of by any text- 
 books on pathology. At the present time they again begin at 
 least to speak of the symptoms peculiar to this condition, even 
 if they do not consider it as an independent morbid state : thus 
 the text-book of Eichhorst, the only one of all the modern Ger- 
 man text-books of pathology, in describing the diseases of the 
 rectum and anus, describes haemorrhoidal molumina preceding- 
 haemorrhages from the back passage, and consequently haemor- 
 rhoidal phenomena are alluded to in this connection as a pe- 
 culiarity of the above-named local affections. I held similar 
 views at the beginning of my medical practice, assuming, 
 namely, that there exist no haemorrhoids as a morbid con- 
 dition of an independent nature, and withal of a general character, 
 but that all so-called haemorrhoidal symptoms are but deter- 
 mined by certain diseases of the rectum and anus in the 
 presence of an impeded circulation in the portal system, as 
 caused hy constij)ation, intestinal meteorism, abdominal obesity. 
 hepatic diseases, etc. But experience taught me otherwise : it 
 proved that haemorrhoids constituted a morbid condition by it- 
 self, totally independent of diseases of the rectum, anus or the 
 abdomen in general ; that it may be seen in connection with 
 these, as well as with diseases of any other parts of the organ- 
 ism, but it may also occur without these, in their complete 
 absence ; in fact, it is more frequently absent, when these 
 affections are present. This morbid condition determines the 
 periodical appearance of morbid attacks in the head, spine, chest 
 
— 397 — 
 
 and abdomen, which take on a more or less I'apid or slow devel- 
 opment, and wliich dmippear suddenly with the appearance of 
 haemorrhage, at times from the nose (more frequently in child- 
 hood and boyhood), less frequently from the chest, i. e. haemop- 
 tysis (more often in youth), but most frequently of a •' haemor- 
 rhoidal " character, from the back passage. The nature of the 
 appearance and of the disappearance of the attacks is distmctly 
 angioneurotic, peculiar to other neuroses of the circulatory 
 system, such as migrame. urticaria and others, and I there- 
 fore consider haemorrhoids as an angioneurosu. 
 
 Here is the fost case, which, together with similar ones 
 later on. led me to formulate my idea about the nature of hge- 
 morrhoids. The patient tells me that when a boy he suffered 
 with nose-bleed which was preceded by headaches and a flushed 
 face : with the bleeding the headache would disappear. When 
 a youth he had slight haemoptysis. Imt unaccompanied with 
 any constant cough or generally with any constant attacks in 
 the chest. 
 
 Patient is now forty years old : he is of a robust constitution, 
 with an entirely healthy chest. He complams of periodic ma- 
 laise : there appear heaviness in the head, pain in the neck, 
 disturbed sleep, gloomy and irritable mental state, and indispo- 
 sition to work; he experiences pains along the spinal column, 
 especially in the lumlmr region, a feeling of oppression in the 
 chest and palpitation, intestinal pains, and the stool is some- 
 what difficult ; then there appears haemorrhage from the back 
 passage and all the symptoms vanish. Outside of these attacks, 
 which occur three or four times during the course of the year, 
 and last one or two weeks, and which hinder him in his occu- 
 pation, the patient is entirely healthy and does not present abso- 
 lutely any morbid symptoms either in the rectum and anus or 
 in the abdominal organs in general, or in an}- other part of the 
 organism. 
 
 Such cases of pure, uneomp>licated hcemorrltoids are certaml}^ 
 very rare : during the thirty-nine years of my practice, I have 
 seen only about twenty. I must however state here, that if 
 the symptoms of such uncomplicated haemorrhoids be less pro- 
 nounced, they are usually borne without difficulty, not forming 
 a sufficiently strong reason for calling in the assistance of the 
 doctor. While the cases of haemorrhoids to be seen together 
 with other morbid states of the abdominal as well as of any 
 other organs, are far from being rare : in these mutually com- 
 plicating each other morbid conditions, it is at times possible to 
 
— 398 — 
 
 distingiiisli which part of the attack is to be referred to the 
 haemorrhoids, and which is to be ascribed to other causes ; but 
 at times they are so intermingled that it is impossible to effect 
 this distinction. 
 
 The cause of haemorrhoids is to be looked for m the inborn 
 peculiarity of the organism. This is indicated by the ordinaril}^ 
 observable hereditary predisposition to haemorrhoids, as well as 
 by the absence of other causative agencies. In the above- 
 named cases of pure haemorrhoids I failed to find such agencies 
 either in the condition of the organism itself or outside of it : 
 nor did these cases present the effect of causes which increase 
 the inborn predisposition to haemorrhoids, causes which I shall 
 touch upon later on. As regards the condition of the haema- 
 topoietic faculties in persons presenting symptoms of pure 
 haemorrhoids, some could be considered as plethoric, others, 
 again, as anaemic, while the majoritj^ presented all the signs 
 of normal haematopoiesis. I may add that some of the above- 
 named cases of uncomplicated haemorrhoids presented also other 
 phenomena of angioneurotic nature (such as migraine and urti- 
 caria), and quite frequentl}^ the coincident occurrence of the 
 haemorrhoidal bleeding with the menstrual flow — an angio- 
 neurotic process: in cases of pure, as well as of complicated 
 haemorrhoids in women, the haemorrhoidal bleeding takes place 
 most frequently during or immediately after the menstruation, 
 and also immediately before it. Of the influences which in- 
 crease the predisposition to haemorrhoids, the use, or even 
 more, the abuse, of alcoholic drinks is evidentl}^ one, and quite 
 likely a sedentary life and immoderate horseback riding, espe- 
 cially galloping and trotting on a wild horse. In the above- 
 named cases of pure haemorrhoids, the bleeding, while it 
 determined the disappearance of the morbid symptoms, did not 
 in the very least weaken the patient, neither did it cause any 
 anaemia, or any generally bad consequences ; whereas haemor- 
 rhoidal bleeding aggravated by the abuse of alcohol or by dis- 
 eases of the rectum or anus (as, for instance, by rupture of the 
 dilated veins), may cause dangerous anaemia and debility of 
 the organism. 
 
 I will turn now to derivative blood-letting. It stands to 
 reason beyond doubt, that the observation of cases in which the 
 morbid symptoms m the head, chest, and other organs disap- 
 peared consequent on haemorrhoidal bleeding gave rise to the 
 idea of bloodletting at the circumference of the back passage for 
 affections of the head, chest etc., the aim in view being not de- 
 
— 399 — 
 
 pletioii alone ; to effect depletion onl}-, it would be much more 
 natural, in case. say. of affections of the head, to choose as a 
 place for blood-extraction one much less distant from the head. 
 As a matter of fact, bloodletting from the circumference of the 
 back passage has since long been considered as of a derivative 
 nature. It is certain that at the beginning there occurred fre- 
 quent mistakes, when haemorrhoidal bloodletting was recom- 
 mended for such affections of the head, chest, and other organs, 
 in which not only haemorrhoidal. but any other bloodletting 
 was contraindicated, and it was only in the course of time that 
 experience showed where the former was suitable. To explain 
 the nature of observations on which I base my personal opmion 
 as to a special, not only a depletive, effect of blood-extraction 
 from the circumference of the back passage, I will cite a case 
 in my practice which I had under my observation twenty-five 
 years ago, and about which 1 delivered an address before this 
 society in October, 1864. Although I have had many occasions 
 before as well as since, to see cases proving without doubt a 
 special influence and value of haemorrhoidal blood-extraction, 
 and pointing to indications for it. still this observation is par- 
 ticularly strong in its conclusiveness. 
 
 I was called to attend a woman suffering from severe nose- 
 bleed : she lost a full deep-bottomed plate of blood, and the 
 bleeding still continued in spite of all the adopted measures. 
 Patient was a woman of about forty years of age, of very ro- 
 bust constitution, living in favorable conditions of life : she had 
 until recently enjoyed good health, and at the time presented 
 nothing abnormal, outside of the bleeding and some trifling gene- 
 ral weakness and that of the pulse ; everything was in good order ; 
 there was only a feeling of heaviness in the head and an oppres- 
 sive mental state. Inquiry elicited the fact that some time ago, 
 while driving in a sled, the patient's feet were severely chilled, 
 but on her return home they became warm again and she con- 
 tinued to feel well ; however, the menstrual flow which followed 
 soon after this occurrence and which was formerly regular and 
 abundant, was at that time very scanty and terminated much 
 sooner than at the usual period. By the end of the menstru- 
 ation patient began to feel heaviness in the head, and in a few 
 days there appeared the nose-bleed, the feeling of heaviness not 
 abating. I ordered ice on the head, and for internal adminis- 
 tration infusum secalis cornuti ex 3ij ad 3vj ; in the course of the 
 day and night the bleeding ceased somewhat, but it again in- 
 creased in the morning and she lost another plateful of blood. 
 
— 400 — 
 
 I then put aside the ice and the ergot and ordered four leeches 
 to the circumference of the back passage. By the time the 
 leeches had fallen off the bleeding ceased, and did not return 
 again. On the morning of the next day the heavmess in the 
 head disappeared, tlie patient felt as usual hale and strong ; she 
 did not even complain of weakness ; the following menstrual 
 periods were, as formerly, regular and abundant. 
 
 It is apparent that m this case the action of the four leeches 
 applied to the circumference of the back passage consisted in 
 producing a depletion of the circulatory system : the abundant 
 depletion through the nose — the blood filling a deep-bottomed 
 plate — did not remove the sensation of heaviness, nor did it 
 avert the severe haemorrhage on the next day ; whereas but an 
 insignificant haemorrhoidal blood-extraction (as the four leeches, 
 together with the bleeding following their bites, could at a maxi- 
 mum abstract but eight ounces of blood) stopped the haemor- 
 rhage, relieved the head symptoms, and all this so rapidly and 
 so decidedly, that to ascribe this fact to accident would be equiv- 
 alent to closing one's eyes to an obvious fact, and to manifest- 
 ing one's incapacity for observation. 
 
 If the effect of the haemorrhoidal bloodlettingf in the de- 
 scribed case was not of a depletive nature, what was it then? 
 I call this effect derivative., so that it may not be confounded 
 with depletion, and may be named by a special term ; I em- 
 ploy for this purpose the term derivative, as one long in 'use, 
 but I do not connect with this name, for the sake of explaining 
 the nature of the alluded effect, any theory, which is an impos- 
 sible thing in the present condition of our science. 
 
 I will note here another thing. In the above described case 
 I did not resort to tamponade of the nasal cavity, and the 
 termination of the case has completely justified my mode of 
 action. I will also say, that there occur cases of nose-bleed, in 
 which a tamponade of the nasal cavity may become directly 
 dangerous : thus I had occasion to see patients over sixty or 
 seventy j^ears of age who since childhood had a predisposition 
 to bleeding ; this last is usually preceded by and at times it 
 relieves cerebral congestion. There occur cases in which such 
 haemorrhages become excessive, without however affording any 
 relief to the symptoms in the head : in such I consider tampo- 
 nade as an extremely risky procedure, for it may tend to cere- 
 bral extravasation of blood, and I resort to sliglit haemorrhoidal 
 blood-letting, — usually with the same success as in the above- 
 described case. 
 
— 401 — 
 
 The Indications for Derivative Bloodletting. 
 
 1. In the region of the head. — Cerebral congestion, without a 
 simultaneous affection of the circulatory system, and also 
 in connection with diseases of the heart and blood-vessels, espe- 
 cially in those cases where along with the constantl}^ present 
 phenomena of cerebral congestion (as disturbed sleep, gloomy 
 and irritable mental state, heaviness m the head, pain in the 
 neck and at times in the temples, reeling during walkmg, 
 dizziness on stooping down, etc.) there occur at times also sud- 
 den fluxes of blood to the head (the face flushes rapidly and 
 deeply), reminding one of haemorrlioidal molumina, and threaten- 
 ing with an approaching apoplectic attack. If the phenomena of 
 cerebral congestion are of moderate severity and not of an ur- 
 gent character, I at first regulate the mode of living, prescribe 
 less of mental work, more of exercise, walking, and massage of 
 the feet which are usually cold and chilly in such patients. I 
 regulate the diet, remove various morbid conditions which tend 
 to keep up the cerebral congestion, such as constipation, cough 
 (usually due to a catarrhal condition of the larynx or the 
 bronchi), and only then do I resort to the derivative bloodletting, 
 when the above-named measures fail to produce the desired ef- 
 fect. But if the phenomena of cerebral congestion be strongly 
 developed and the patient be of robust constitution with good 
 nutrition and good haematopoiesis, and particularly if the above- 
 mentioned influxes occur, then I at once apply a few leeches (in 
 very threatening cases, as I explained above, I do bloodletting), 
 and together with this I resort to the above-enumerated meas- 
 ures. I will state here that an ice-bag applied in such cases to 
 the head exerts but a trifling effect which passes as soon as the 
 bag is taken off. Of the stability and duration of the effects of 
 the derivative bloodletting in the above-named affections of the 
 head, as well as in diseases of other organs, I shall speak later 
 on, when expounding the method of derivative bloodlettmg m 
 connection with the question of repeating the same. 
 
 For the above-described cases of cerebral congestion I do not 
 resort to the application of leeches behind the ears and to the 
 nasal septum, i. e. with a direct depletive purpose. We can apply 
 but a few leeches to the nasal septum (two to four), so that we 
 are unable to get any sufficient effect : and according to some 
 observations we are led to think, that such an insufficient deple- 
 tion from the given place may even tend to increase the phenom- 
 ena of cerebral congestion. The application of leeches behind 
 the ears may certainly relieve the attacks of cerebral congestion ; 
 
_ 402 — 
 
 but /first, we shall be compelled, to effect this, to apply at least 
 twice as may leeches as we would do for the derivative (hae- 
 morrhoidal) bloodletting, i. e. we shall find it necessary to cause 
 twice as great a loss of blood, and secondly, even aftey. such a 
 loss of blood we fail to obtain as complete, stable and lasting an 
 effect, as we do with the derivative bloodletting. 
 
 There is only one class of cases for which I continue to 
 apply, as I consider it an undoubtedly correct and valuable 
 practice, my former method of bloodletting in the region of the 
 head with a direct depletive aim in view. I refer to the appli- 
 cation of two to four leeches to the nasal septum in cases of 
 cerebral hj^eraemia in infectious diseases, most frequently, of 
 course, in typhus and in typhoid fever. There occur cases of 
 these diseases, in which during several days there continue 
 symptoms of cerebral congestion very distressing to the patient, 
 namely: severe headache, insomnia, at times violent delirium, — 
 all these accompan3"mg a distinctly flushed face; then there oc- 
 curs nasal bleeding and the symptoms are considerably relieved 
 (there is nsually with this also a considerable fall in the tem- 
 perature, which continues for some time), without however 
 causmg an}^ marked weakness in the patient. If in such cases 
 the bleeding from the nose does not occur for a long time, while 
 the further development of the symptoms and their deleterious 
 effect on the condition of the patient continue, yielding but 
 slightly to ice applications to the head, then if the patient be at 
 all strong, it is necessary to apply two, rarely three or four 
 leeches to the nasal septum ; bloodlettmg, even if it be inconsider- 
 able (and this is, of course, desirable, in such cases), is suffi- 
 ciently effective in removing the above-mentioned symptoms. 
 The application of leeches to the circumference of the back 
 passage in such patients would be extremely inconvenient ; and 
 besides the eft'ect of the derivative bleeding in these cases is 
 uncertain. 
 
 2. In the region offJie apinal coluvin. — Hyperoimia of the spinal 
 cord mtd of its membranes^ as evidenced by pain along the tract 
 of the spinal column and in the region of both sciatic nerves 
 (the trunks of the last presentmg no tenderness on pressure, 
 thus showing the absence of symptoms of neuritis), occurring in 
 the majority of cases simultaneously with symptoms of cerebral 
 congestion, rarel}- by itself or to a more predominating extent. 
 It is well understood, that before ordering the application of 
 leeches we must by a careful diagnosis determine exactly the na- 
 ture of the affection, so as not to confound with it other diseases 
 
— 403 — 
 
 of the spinal cord and its membranes, as well as spinal synovites 
 neurites and mj^osites, and also various functional nervous dis- 
 turbances, sucb as neurasthenia and hysteria, and abdominal 
 diseases, as hepatic and renal colics, constipation, etc. With a 
 correct diagnosis on hand, the effect of the haemorrhoidal blood- 
 letting on the symptoms of hyperaemia of the spine and its mem- 
 bers is just as stable and complete, as it is in cerebral congestion. 
 It is of course difficult to determine as to how much of this 
 effect is, in these cases, of a derivative character, and how 
 much of a depletive one ; be as it may, it is incomparably more 
 efficacious than bloodletting, even if more abundant, but pro- 
 duced anywhere higher up along the tract of the spinal cord. 
 
 o. In the region of the chest. — (a) In haemoptysis not due to 
 any organic causes, in the presence of healthy lungs and heart. 
 Such haemoptysis, as is well known, usually occurs in young 
 persons predisposed to pulmonary tuberculosis, and also in such 
 young persons, who are not predisposed to this disease, but who 
 have a weakened nervous system, especially as a result of sex- 
 ual irregularities, and who are at the same time inclined to pure 
 haemorrhoids, i. e. haemorrhoids under which, as I explained 
 above, we understand an angioneurotic condition. If a hae- 
 moptysis of this nature does not rapidly yield to other meas- 
 ures, then the most reliable means is slight haemorrhoidal 
 bloodletting. This will of course bring about only a cessation 
 of the haemoptysis for the time being ; later on the repetition 
 of haemoptysis must be met with by radical measures, which 
 consist in strengthening the organism, in removing the neuras- 
 thenia and the sexual irregularities, etc. 
 
 (b) Haemoptysis in pulmonary tubercniosis, excepting those 
 cases in which it is caused by destruction of large blood-vessels 
 in cavernous regions. If the haemoptysis be at all considerable, 
 without yielding quickly to other measures (among other things, 
 in the presence at the same time of constipation with a distend- 
 ed abdomen, which is not relieved by a laxative), and in case 
 the patient does not present any signs of great weakness, then 
 I order two, seldom three leeches to the coccjrx, and I must 
 here testify to the successful effect of such bloodletting ; the 
 haemoptysis ceases without causing any particularly noticeable 
 weakness of the patient. 
 
 (c.) Haemop)tysis in diseases of the heart., princip}ally in affec- 
 tion of the left venous opening. — In these cases, especially if at 
 the same time the liver, as a result of blood-stasis, be enlarged 
 and sensitive, and after the other indications, such as the relief of 
 
— 404 — 
 
 constipation, the regulation of cardiac activity, etc., have been 
 fulfilled without bringmg about the desired results, then we 
 must resort to bloodlettmg. I will recall to your mind what 1 
 said before in connection with bloodletting, that in such cases 
 of a pronounced disturbance of compensation we must employ 
 bloodletting, even before fulfilling the other indications ; in case 
 disturbances of compensation be absent, and the moderate hae- 
 moptyses recur frequently, without yielding to other treatment, 
 then we must apply a few leeches to the coccyx. 
 
 4. hi the ahdominal region. — For blood-stasis in the liver and 
 consequently in cases of impeded circulation in the portal sys- 
 tem, as caused by diseases of the heart, by immoderate eating 
 and by the use of alcoholic drinks, etc. If in such cases of enlarged 
 and sensitive liver there predominate biliary disturbances point- 
 ing to an insufficient secretion of bile (as a bitter taste, at 
 times vomiting of bile, an insufficient coloring of the excreta ; 
 symptoms of biliary pigment in the urine), in connection with a 
 particular tenderness in the region of the gall-bladder and with 
 a simultaneous constipation, then it is advisable to give calomel. 
 But if the enumerated biliary symptoms are absent, then there 
 is an indication for the application of leeches to the coccyx. It 
 is hard to determine as to how much of the effect of the leeches 
 in these cases is of a derivative nature and how much of a 
 depletive one ; but the principal thing is that it is effective, 
 incomparably more so, with a smaller number of leeches, than 
 the effect produced by applying the same along the right hy- 
 pochondrium, which procedure would be an unpardonable mis- 
 take in such cases, just as it would be erroneous in pericystitis 
 of the gall-bladder to apply leeches to the coccyx, instead of 
 along the right hypochondrium. 
 
 5. In inflammation of large haemorrhoidal nodes, leeches 
 when applied to the coccyx, acting at one and the same time 
 both as a depletive and as a derivative measure, serve in very pro- 
 nounced cases as the most effective means. 
 
 In conclusion let me say here a few words regarding the 
 method of employing derivative bloodletting. 
 
 As any other blood-extraction, it must be '•performed in the 
 presence of the physician, and especially so in the above-named 
 cerebral and chest cases. In other cases, in patients who are 
 not weak, we may rely on a male or female assistant-surgeon 
 (Feldscher) if they are well known to the physician, reliable, 
 familiar with the alteration of the pulse, and are able, when 
 
— 405 — 
 
 necessary, to administer stimulants, as Valeriana or Hoffman's 
 drops, which may at times become necessary for patients with 
 a weakened nervous system, or in those who have become 
 frightened even before the leeches are applied. I will state 
 here that a weak pulse does not always constitute a contraindi- 
 cation for derivative bloodletting, as was partly also explained 
 in connection with the subject of the more considerable blood- 
 letting — venesection. Bloodletting should be performed in as 
 spacious and airy a room as possible. 
 
 The time of the day, — The best is during the evening, before 
 going to bed, so that after the application of the leeches the 
 patient may remain m bed until morning ; however, in urgent 
 cases it may be done at any time. 
 
 No leeches are to be applied immediately after taking food, 
 but some time later in accord with the quantity of the same. 
 The intestinal tract should be evacuated as a preliminary meas- 
 ure : if this be sufficiently effected by an injection, then it 
 should be made directly before the leeches are applied ; but if 
 there is a necessity for the employment of a laxative, then, hav- 
 ing administered this last, we must of course wait for its effects 
 and then wait for a few hours before we apply the leeches, and 
 before doing this we administer some stimulant so as to avoid 
 any weakening on the part of the patient. 
 
 The position, of the fatient must be lying, or at least reclining 
 (in dyspnea) on the side. The practice formerly in vogue of 
 performing haemorrhoidal bloodletting with the patient in a 
 sitting posture may tend to call out dangerous fainting. 
 
 The site of the derivative bloodletting is, as explained above, 
 pointed out by nature itself, namely, the circumference of the 
 back passage ; but I order leeches to the coccyx, and not all 
 over the circumference of the anus : for this last is much more 
 painful and serves later as an obstacle to defecation ; it is more- 
 over more difficult to stop the bleeding in this locality and to 
 preserve the necessary cleanliness. 
 
 The day following the bloodletting the patient should remain 
 at home, so that the wounds caused by the leeches may heal the 
 sooner, and in case he feels any weakness — which, if the indica- 
 tion be correctly understood and the number of leeches carefully 
 considered, will occur but very rarely, and even then during 
 the first day only — then he should take two or three doses of 
 the above-named stimulant drops. 
 
 The number of leeches. — During my early practice I had fre- 
 quent occasions to see usually ten leeches applied, seldom less. 
 
— 406 — 
 
 more frequently a greater number, as twelve to fifteen, at times 
 twenty and even more. I was then convinced of the undoubted 
 harm of such considerable extraction of blood, and I began 
 to apply five leeches, thinking that in case of necessity I can 
 repeat the bloodletting. Experience has taught me that there are 
 but very rare cases where we have to repeat, i. e. to apply twice 
 five leeches, in the course of a few days : in the majority of cases 
 five, in exceptional cases six or seven leeches, produce a suffi- 
 cient effect. The number of five (or six to seven) refers to all 
 the above-enumerated indications, with the exception of the 
 chest indication — the haemoptyses : for these I never use more 
 than five, more often four or three, and in pulmonary tuber- 
 culosis, as alluded to above, even two. 
 
 To keep up the bleeding after the leeches fall off. — Experience 
 has proved that derivative bloodletting is attended with the 
 best effects when, after the leeches fall off, the bleeding is kept 
 up by washing the wounds with warm water until the blood, at 
 the beginning usually very dark, becomes bright red in color. 
 
 The repetition of derivative bloodletting. — Among the ob- 
 jections against this last, — raised, however, usually by persons 
 who do not themselves resort to it, and thus lack the necessary 
 experience, — we hear this one, that derivative bloodletting once 
 produced determines by this fact alone the necessity for its being- 
 repeated. From long experience I will state the following : if, 
 for instance, cerebral congestion (and this may be said of the 
 other indications for derivative bleeding) was relieved at the 
 given time by the application of leeches to the coccyx, if with 
 this the causes producing the cerebral congestion were removed, 
 and the patient follows strictly the physician's advice which 
 will result is setting aside these causes, then there is usually no 
 necessity for a repetition of the derivative bleeding. But if 
 the patient neglects the physician's instructions, and conse- 
 quently thus permits the causes of the congestion to further exert 
 their deleterious mfluence, or if these causes be not removable, 
 then certainly, to avoid the worst consequences, we are com- 
 pelled to repeat the application of the leeches once or twice 
 during the year, — rarely, in very exceptional cases, more fre- 
 quently, usually in the course of time, in a smaller number 
 than at the beginning ; but if the number of leeches is ordered 
 with care, in accord with the patient's idiosyncrasies, his con- 
 stitution, haematopoietic ability, and so on, then we never 
 observe any anaemia, nor any weakening of the patient result- 
 ing from derivative bloodletting. 
 
CALOMEL. 
 
 IN HYPERTROPHIC CIRRHOSIS OF THE LIVER AND 
 IN GENERAL THERAPY.* 
 
 The principal mercurial compound used in the treatment of 
 internal diseases, outside of syphilis, is certainly calomel. As 
 is well known, there exist various views regardmg its effective- 
 ness. In England calomel is highly valued and is one of the 
 ordinary, commonly used drugs, although less so than it was at 
 the beginning of the present century, when it became known. 
 In France it is not so much valued and its employment is 
 limited ; but in a general way there is a considerable similitude 
 in its use with the English practice. But it is quite different in 
 Germany. According to Nothnagel and Ross bach there is to 
 be noted a progressive scepticism in the direction of internal 
 mercurial treatment (except in syphilis), so that at the present 
 time there is hardly one positive indication for the use of the 
 drug. The above-named authors consider calomel as a conven- 
 ient laxative at times. As far as I am acquainted, from liter- 
 ature and personal experience, with the modern practice of the 
 German physicians and their attitude toward calomel, I can but 
 substantiate the correctness of the authors' statement. It how- 
 ever occurs to me that calomel is not fully appreciated by the 
 modern German practitioners in its application to the treatment of 
 diseases of the liver, namely, of the biliary tract. Thus, even 
 the work of Binz ( *• Arzneimittellehre " ), the tendency of which 
 can hurdly be called sceptical, contains no such indication for the 
 employment of this drug. The tendency of the Russian 
 practice is similar to what we find among the Germans, name- 
 ly, the same progressive scepticism that began in the fifties ; the 
 condition at present, as far as I am aware, is the same as in 
 Germany, I do not speak of myself and those of my former 
 students who had the opportunity to see me use calomel in the 
 clinic. 
 
 * Address delivered before the Moscow Physio-Medical Society, Jan- 
 uary, 1884. 
 
 407 
 
— 408 — 
 
 During the fifties, when I was a student, and later on as an 
 .assistant in the clinic, I had frequent opportunities to observe 
 the use of calomel. I failed to see an}^ successful results, but 
 saw a great deal of harm done. The causes of this were to 
 be found in the poor diagnostication of those times, in the 
 insufficient exactness of the indications for the use of the 
 remedy, namelj-, in what diseases it should be used, when 
 to begin and when to stop its administration (failure to 
 properly indicate all this led to unnecessary diarrhoeas and 
 exhaustion of the patient) ; then in the inability to prevent the 
 occurrence of stomatitis, as the use of potassium chlorate as 
 a gargle was unknown then. But at the same time I happened 
 to observe once a case outside of the clinic, where an old 
 physician, without making a diagnosis, but simplj' on account 
 of the presence of the "status biliosus," administered calomel 
 in a small, slightly laxative, dose ; the immediate marvellous 
 improvement in the patient's condition has impressed itself 
 upon my memory. Since 1860 I conducted an mde^^endent 
 clinical and private practice, at the beginning of which, under 
 the influence of the general ''■ progressive scepticism "' toward 
 calomel, I almost never used it ; but some four years later I had 
 to resort to it, and since that time I have learned to appreciate 
 the value of this remedy. In the following lines 1 intend to 
 bring forward proofs of my conviction, that calomel in diseases 
 of the biliar}^ passages is a valuable drug which, in the present 
 condition of therapy, cannot be replaced. In connection with 
 this I will also touch, in a few lines, on the use of calomel in 
 erysipelas, typhoid fever, pneumonia, and acute B right's. 
 
 I must touch, in a few words, on what pharmacology calls 
 the phj^siological action of the drug, namely, the influence of 
 calomel on the liver, on the secretion and excretion of bile. 
 The development of scepticism toward calomel, outside of the 
 above-named clinical causes, was undoubtedly aided by the 
 fact, that whereas the phj^sicians have derived the greatest good 
 from the use of calomel in diseases of the liver, and in view of 
 the well-known dark-greenish evacuations following its use 
 have put it down as a cholagogue, pharmacological investi- 
 gations, by the aid of artificial biliary concretions, have led 
 to the conclusion that not only is the quantity of secreted bile 
 not increased by calomel, but on the contrary, after a continuous 
 use of the same, it — the secretion — tends to diminish. But the 
 doubtful conclusions of these pharmacological data as regards 
 the calomel therapy in diseases of the liver are, to say the 
 
— 409 — 
 
 least, premature. It was firstly proved that the dark-greenish 
 color of the usually so abundant calomel evacuations is due 
 to a rapid descent of bile from the superior portion of the 
 intestine, this descent being caused by the employment of 
 calomel (but of no other laxative). Further, let us take the 
 following from the above-mentioned work of Binz : " If, in 
 accord with the investigations of Shiff, we consider that the 
 liver not only prepares, but also excretes the bile already pre- 
 pared and again absorbed by the intestines, then the diminution 
 of the latter after a calomel diarrhcea becomes clear " ; and 
 again : "• In this manner calomel frees the juices of a possible 
 superfluity of any component parts of the bile, and can be 
 called a cholagogue from a point of view totally different from 
 the former." We will add that Shiff's theory, on which the 
 physiologists, thanks to the contradictory results of Sokoloff's 
 work, looked with distrust, has received lately considerable 
 support, if not complete confirmation. Weiss has repeated 
 Sokoloff's experiments in the laboratory of Prof. Boulyginsky, 
 and after three years of labor has arrived at conclusions con- 
 tradicting those of Sokoloff, but substantiating Shiff's theory.* 
 And if this theory be correct, then we may assume that calo- 
 mel, by causing a considerable excretion of bile and thus 
 diminishing its absorption and its return to the liver, cannot 
 but influence also the formation of bile in the liver, as accord- 
 ing to Shiif 's theory the quantity of bile secreted by the liver 
 is made up of that which was reabsorbed and of that which 
 was newly formed. However I do not at all intend to enter 
 upon useless hypotheses. I only desired to show that the 
 present condition of the pharmacological data can in no man- 
 ner serve as a basis, as they sometimes did and do now, for the 
 sceptical view as to the effectiveness of calomel therapy in 
 hepatic diseases. I again repeat, I do not intend to elucidate 
 the pharmacology of calomel, but to bring forward clinical tes- 
 timony as to the effectiveness of this remedy, — rather to deter- 
 mine the diseases, in which its use is successful, and to clearly 
 point out the indication for it in the sphere of such diseases. 
 The English practice, to which calomel owes its reputation, 
 has among other thmgs given a very indefinite indication for 
 the use of calomel, namely, torpor of the liver, an indication, by 
 the way, that remains even up to the present time almost the' 
 most frequent one. The following combination of symptoms 
 is embraced under this designation : constipation or a general 
 
 * Vide The Physiology of Bile. Moscow, 1883. 
 
— 410 — 
 
 irregularity of the intestinal functions, insufficient coloring of 
 the excreta, a too great development of the intestinal gases, 
 a pale, sad face, low spirits, etc. Such a picture of disease may 
 undoubtedly be seen in diseases of the liver, in which neither 
 calomel nor anything else, m the present state of therapy, will 
 be of any avail, as for instance m cancer, in multilocular 
 echinococcus, m simple (Laennec, non hypertrophic) cirrhosis of 
 the liver. Again this picture may also be observed in other 
 diseases of the liver, as in hj-peraemic conditions of that organ, 
 in which calomel may be effective, but m which other drugs 
 will do the same and better, and must be for certain reasons 
 preferred, as, for instance, mmeral waters containmg Glauber's 
 salt (Marienbad). My investigations lead me to thhik that there 
 are only two diseases of the liver, or properly speaking, of the 
 biliary passages, in which calomel is not only efficient, but will 
 do what no other remedy, in thr; present condition of therapy, 
 will, be it a laxative or otherwise. 
 
 These diseases are : severe, especially febrile cases of colic 
 from biliary calculi fcolica hepatica), and hypertrophic cirrhosis 
 of the liver. 
 
 Severe, especially febrile cases of colic from biliary calculi. 
 — During the tirst four 3'ears of my practice, as I said before. 
 I never used calomel. Ijut some twenty years ago I took it up. 
 Here is the first case which induced me to employ it. I will 
 relate it Imelly. as I have had since many more typical cases 
 and had the opportunity of better observation (1 will com- 
 municate one of them later in extensoj. 
 
 Patient was about fifty years old, of good constitution, lived 
 in favorable circumstances and led quite a regular mode of 
 living ; but he was at times careless with his food and also 
 with the use of alcoholic drinks. CUiest and nervous sys- 
 tem normal. Urine reddish in color (no albumen). There were 
 some slight gouty phenomena in the small joints. He was 
 troubled with dyspepsia (there was no evidence of any gastric 
 catarrh), had a tendency to constipation, slight attacks of liver 
 colic, and moderate tenderness on pressure m the region of the 
 gall-l)ladder. Fever absent : condition of strength good. I 
 regulated his mode of living, especially the diet, and pre- 
 scribed Vichy (C'elestins) in the morning on an empty stomach, 
 thi'ee doses aa 3V, at the temperature of freshly drawn milk, 
 and at times, in case of an insufficient emptying of the intes- 
 tines, the third dose of Vichy ^va.s replaced by a similar dose of 
 bitter Friedrichshall water, also warmed somewhat. There 
 
— 411 — 
 
 followed rapid improvement during the first two weeks : ap- 
 petite, sleep and mental condition became better, the dyspeptic 
 phenomena and the pains in the region of the liver disap- 
 peared ; less tendency to constipation. 
 
 Then, after this, a considerable error in diet, and a cold at 
 the same time ; the patient called on me in five days, complain- 
 ing that everything became worse, although he continued the- 
 former treatment. To be sure, the appetite was gone; the pain 
 in the region of the liver grew much sharper and was aggra- 
 vated after drinking the mineral waters, especiall}' the bitter 
 ones ; there appeared slight icteric symptoms and obstinate con- 
 stipation. I stopped the mmeral water and administered castor 
 oil ; he vomited up the first teaspoonful, but had a stool after 
 the second ; but his condition was not ameliorated. There ap- 
 peared febrile condition with an evening exacerbation. I gave 
 him three three-grain doses of quinine in the course of the day. 
 He grew worse by the next day : pains and icteric symptoms 
 aggravated, temperature higher, the patient is weaker and more 
 irritable. I then administered twelve powders of calomel grain 
 j (-f- five grains of sugar) every hour, and at the same time a 
 gargle of potassium chlorate ; verily, tlie effect was magical : the 
 patient had abundant, characteristic calomel evacuations, both 
 the fever and the pains disappeared on the next day, the sleep 
 and the mental condition became normal, the appetite reap- 
 peared. Two days later, the patient returned to his former 
 treatment with the mineral water, and, punished by experience, 
 kept a strict diet, and soon improved completely. 
 
 I will now communicate to you a very typical case, the last 
 of a similar class of cases seen by me, and one of those that I 
 had a good opportunity to observe : the patient was in my clinic 
 last summer and had more than once served as a subject of my 
 clinical lectures before students and physicians. 
 
 Mr. N., a member of the circuit court, forty-two years of age, 
 entered the clinic January 25, 1884, complaining of severe 
 pains in the region of the stomach, under the right hypochon- 
 drium and all over the abdomen, of jaundice, feverishness, and 
 extreme debility. 
 
 Mode of life and anamnesis. — Patient is married, has no syphi- 
 lis, almost never used any alcoholic drinks formerly, while 
 during the last year and a half drank none at all. The 
 principal irregularities in his mode of living were as follows: 
 insufficient sleep (some six hours in the twenty-four), a great 
 amount of mental labor (fourteen hours a day), little exercise 
 
— 412 — 
 
 out of doors, summer in the city ; smoked about fifty cigarettes 
 daily ; had irregular meals — but once a day — and was careless 
 in selecting his food. The last year and a half the patient 
 was compelled by poor health to work less (three hours a day), 
 gave up smoking, and is very careful with his diet ; drinks 
 tea and coffee moderately, without cream or milk, and with but 
 a small quantity of sugar (formerly he used about three-fourths 
 of a pound of sugar in twenty-four hours). Ten years ago 
 there appeared the first symptoms of neurasthenia : low spirits, 
 quick fatigue from mental and physical labor, constipation, al- 
 though the gastric digestion was satisfactorj. The patient 
 took silver nitrate, somewhat improved for a time, but continued 
 to work hard, slept and rested little, and the neurasthenic 
 symptoms became more and more aggravated each year. The 
 constipation particularly increased the last four years and the pa- 
 tient resorted to clysters and at times to castor oil. During 
 June, 1882, he had the first attack of liver colic; in October, the 
 second. The patient drank Vichy and Ems for a week and 
 a half each. In November another attack of colic with nau- 
 sea ; again Vichy and Ems for three weeks. In April, 1883, 
 another attack of colic, and Vichy and Ems for three weeks, and 
 from the latter half of July until the end of August (for about 
 ten weeks) Karlsbad, three glasses per day. September 30th 
 and October 1st, while riding for a long time in a jolting carriage, 
 he experienced a severe attack of colic, for the first time accom- 
 panied by jaundice and fever (chills and later heat). Since 
 then and up to the time he entered the clinic his condition was 
 as follows : every day, some two hours after dinner, he expe- 
 riences a painful sensation in the region of the stomach and in 
 the right hypochondrium. The pain is usually of moderate se- 
 verity and lasts for about one hour ; but once during the week 
 it is quite severe, lasting for several hours, and is accompanied 
 b}^ an increase m the jaundice ; and once in about every two weeks 
 (of late more frequently) there appear attacks of severe colic 
 lasting three to four days, with pronounced jaundice and fever 
 (40°), which begins with a severe chill and lasts during the 
 three or four days. The treatment for this time was as follows : 
 he drank continuously first Vichy, later Ems in small doses (f v 
 three times a day), and used laxatives constantly : either an ad- 
 ditional teaspoon of Karlsbad salt to the mineral water, or a tea- 
 spoonful of powdered rhubarb in a glass of water, and at times 
 castor oil. During the attacks of colic accompanied by fever 
 he was given quinine until he experienced slight buzzing in the 
 
— 413 — 
 
 ears, but this failed to produce any effect on the fever. The 
 result of the treatment unsatisfactory : the attacks of colic 
 and fever continued to increase and became more frequent ; 
 there appeared intestinal pains, which became frequent and 
 more severe on the continuous use of the mineral waters ; the 
 patient became very emaciated, debilitated, lost his sleep and 
 was in bad spirits. 
 
 Status January 2Jf^ ISSJj.. — Patient of medium constitution, 
 and, as mentioned above, emaciated and weak. Thqre is a 
 moderate jaundice of the skin and of the sclerotics. He has 
 almost no appetite, some thirst. Has belching after dinner, and 
 at first heaviness in the stomach, later pains, as described in 
 the anamnesis ; with this there is nausea, and at times vomiting, 
 after which the pains grow less severe for some time. Abdo- 
 men somewhat distended ; moderate pressure elicits pain in the 
 stomach, and much more of it in the region of the gall-bladder ; 
 liver and spleen not enlarged. Notwithstanding the constant 
 use of laxatives, a stool takes place only after a clyster of 
 warm water (and even then not always satisfactorj^) every 
 other day; only castor oil can replace the clyster. The evacua- 
 tions are paler than normal, pale yellow. Besides the attacks 
 of liver colic, i. e. of pains which appear two hours after a 
 meal, in the stomach and under the right hypochondrium, 
 accompanied at times by nausea, the patient is suffering from 
 other pains, evidently of intestinal origin, in the umbilical 
 region and along the course of the large intestine, accompanied 
 by gurgling and relieved after an emission of gases or after a 
 clyster. The urine, 500 c. c. in twenty-four hours, is red, con- 
 tains biliary pigment, but neither albumen, nor sugar. Chest 
 healthy. Pulse 80-90, very weak. Poor sleep, on accomit of 
 abdominal pains. Mental work causes headache. Lately fatigue 
 brings on dizziness, during which the patient grows pale. 
 Oppressed low spirits. Patient was admitted on the third 
 day of his usually severe attack of colic with fever. Tempera- 
 ture in the evening 38.6° R. (101.5° _F.) ; in the morning of the 
 next day 38° B. (100.4°i^.), evenmg 38.8° B. (101.8°i^.). He is 
 lodged in a dry, warm room, and ordered at first to be confined 
 there, not to sit for a long time, to lie down at once on feeling 
 fatigued, not to tire himself with reading, and to keep the 
 abdomen warm (Provence oil and a double layer of flannel). 
 Diet : weak, warm tea, without milk or sugar ; between two or 
 three tablespoonfuls of port wine per day; chicken soup, 
 chicken meat and some white bread ; he is to eat several times 
 
— 414 - 
 
 per day, but never to satiety. When feeling weak and dizzy, 
 he, is given twenty-five drops of Trae. Amnion. Valer. and Liq. 
 Anodyni Hoffmanni aa, twice or three times a day. If neces- 
 sary a clyster of warm water is administered. 
 
 January 27tli. — In the begmning calomel (one grain + live 
 grains of sugar) every hour, and after the fourth dose 
 ever}- two hours ; from this day on constantly gargling his 
 mouth with potassium chlorate (3ij to o^j). After the seventh 
 grain, the patient had a thorough clearing of the bowels with 
 characteristic calomel evacuations, without intestinal pains ; 
 the calomel was stopped at once. 
 
 January 29th. — Morning temperature 37° R. (98.6° F.)^ 
 evenmg 37.2° R. (99° F.) Patient is much better : he has 
 some appetite, almost no colic, intestinal pains less severe and 
 less frequent; amount of urine 1000 c. c, color paler: sleeps 
 well, feels generally better and stronger. 
 
 February 1st. — Condition same, but colic somewhat more 
 severe ; stool onlj^ after a clyster ; had five grains of calomel 
 in the manner as above; two hours after the last dose, the 
 interne, fearing to weaken the patient more with a superfluous 
 dose of calomel, ordered a spoonful of castor oil. Then fol- 
 lowed evacuations as formerly and also a similar improvement. 
 
 February 9th and 10th. — Patient has no fever, feels stronger 
 and heartier, eats better; but the colic has been worse these 
 days ; eight grains of calomel in the former manner. 
 
 February 11th. — No stool. Temperature 39.2° R. (102.5° F.). 
 Had a spoonful of castor oil (this was the last dose ; he was 
 given no more of it). A good calomel evacuation. 
 
 February 12th. — ^iovnmg temperature 36.8° R. (98.2° F.). 
 evening 37.2° R. (99° F.~) ; urine 1500 c. c. of almost normal 
 color ; colic again insignificant, improvement in everything else. 
 Thus up to February 17th. 
 
 February 17th. — An evident error in diet ; ate too much. 
 Colic much stronger. 
 
 February 18th. — A severe chill. Temperature in the morn- 
 ing 40.1° R. (104.1° i^.). Was given calomel, one grain every 
 hour. He had a stool after the fourth dose. a,nd did not get 
 any more. Evening temperature 37,6° R. (99.6° i^.). 
 
 February 19th. — Mornmg temperature 37° R. (98.6° F.~), 
 evening 39.2° R. (102.5° F.^. Xo further laxation. Was 
 given six grains of calomel, as before. 
 
 February 20th. — A good calomel stool. Mornmg tempera- 
 ture 36.9° R. (98.2° ^.), evening 37.1° R. (98.8° F.) No 
 colic. 
 
— 415 — 
 
 From this day on the patient's condition continued improv- 
 ing : the fever disappeared, the patient ate more and digested 
 well (no heaviness and belching) ; the clyster acted better, 
 and at times the bowels moved without any clyster; the 
 intestinal pains appeared at rarer intervals, and were much 
 less severe than formerly ; the color of the urine became 
 normal and the general jaundice began to disappear ; he began 
 to sleep better, has grown stouter and stronger. The attacks 
 of liver colic appeared now and then, but each time they grew 
 weaker and weaker. At such times he was always given calo- 
 mel : February 29th, March 3d, 9th. 15th, eight grains on 
 each day, and the last time, March 24th, four grains, with good 
 effects, without ever causing any laxative action. 
 
 Since March 24th he had no attacks of liver colic, the 
 sensitiveness in the region of the stomach and gall-bladder dis- 
 appeared even before, and a little later the intestinal pains also 
 ceased. The patient began the use "of condurango since April 
 1st, 3SS. in fvj, two tablespoonfuls per day. He left our clinic 
 April 21st entirely improved ; the appetite and digestion be- 
 came normal, he had stools without the aid of clysters, and all 
 the abdominal pains disappeared : he has grown somewhat 
 stouter, quite strong and hearty. Since the latter half of 
 February he had warm baths twice a week : at first at 30° R. — 
 as he was quite chilly — six baths; and before leaving, when 
 with the improvement in sleep, he became less chilly, tliree 
 baths at 28°, 27.5° and 27° R, The baths at 30° R. quieted 
 the patient, while cool ones strengthened him. , 
 
 Twenty years passed in the interval between these two cases 
 the first and the last. During this period I had the opportunity 
 of observing many such patients, and of employing calomel. 
 With all their various peculiarities these cases all present, in 
 their principal traits, the same characters as the two related 
 above. My practice is as follows : the simplest cases of liver 
 colic accompanied by some dyspeptic phenomena require only a 
 strict diet and a generally regulated mode of living ; but such 
 oases are certainly rare. For those that we ordinarily run 
 acj'Oss, with more or less severe attacks of liver colic, gastric 
 ca tarrh and jaundice, I prescribe a strict diet, a regular mode 
 of living and Ems, or Vichy, or Yessentucki, or Karlsbad (less 
 frequently Marienbad), in accord with the peculiarities of the 
 case. Calomel is less frequently administered in fresh, recent 
 cases : much oftener for patients who had suffered for a long 
 time from liver colic and deranged digestion, who have more 
 
— 416 — 
 
 than once gotten well, who had been subjected to recurrent 
 attacks of the disease, have grown weak and thin and are not 
 benefited any more by the use of mineral waters. As the 
 principal indication for the use of calomel I consider not so 
 much the severity of the individual attacks, as the presence of 
 the constant pain in the region of the gall-bladder, generally 
 in the liver, and the fever : calomel administered in such cases 
 has always produced results as splendid as it did in the above- 
 mentioned cases. In a small minority of cases (less than in 
 one out of every twenty), without undoubted symptoms of 
 pericystitis, I ordered leeches — from six to ten alongside the 
 right hypochondrium. 
 
 For the sake of precision I must tell you also of a case which 
 was not benefited by calomel ; however, this case, which etiolog- 
 ically belongs perhaps to the class of cases under consideration, 
 is certainly one of a different nature. The patient, a female of 
 sixty, strongly built, had since her fortieth year suffered from 
 liver colic, had frequently used the mineral waters, but did not 
 complain of any colic lately. Without anything to account for 
 them, there appeared febrile attacks of a pyaemic nature, against 
 which enormous doses of quinine proved ineffectual (the salyci- 
 lates were as yet not in use at those times). As no cause for 
 these attacks could be determined, we, guided by the anamnes- 
 tic data, concluded them to be probably due to abscesses of the 
 liver, as caused by biliarj^ calculi, although there was neither 
 jaundice nor pains in the region of the liver, neither spontane- 
 ous nor on pressure (the liver was felt to be diminished in 
 size). The appetite became somewhat livelier and the next at- 
 tack of fever came later; however the attacks continued as 
 before without cessation up to the time she died. The case 
 was one in private practice, and no autopsy was permitted. 
 
 I usually prescribe one grain of calomel every hour, and after 
 the sixth dose (either before or after it, in accord with the pe- 
 culiarities of the case) every two hours, and after the first good 
 calomel evacuation I stop the drug. 
 
 Ordinarily I give no more than twelve grains in succession, 
 and in case the patient has no loose stools I give a tablespoon- 
 f ul of castor oil two hours after the last dose ; but this is rarel}^ 
 necessary. I have observed that patients in whom castor oil 
 causes nausea, bear it better after calomel. Diarrhcea after 
 calomel is of rather I'are occurrence and is easily checked by a 
 few drops of simple tincture of opium. Larger doses of calo- 
 mel and more frequently administered I found unsuitable : they 
 
— 417 — 
 
 weaken the patient who usually suffers already with poor health, 
 and cause obstinate diarrhoea. With the very first dose of calo- 
 mel that I prescribe, I advise gargling with a solution of potas- 
 sium chlorate (3ij to^vj), and continue this last for a few days 
 after the use of calomel has been stopped. I never observed 
 any trouble in the gums while taking such precautions. 
 
 We hear at times that calomel acts only as a laxative. 
 Neither the pharmacological nor the clinical data present a ba- 
 sis for such a view. But even if calomel acts only as a laxa- 
 tive, are then all the laxatives alike ? Ignorant indeed would 
 be the practitioner who would consider all the laxatives alike, 
 without differentiatmg the cases where each of them may be 
 employed. 
 
 Facts have made it sufficiently clear to me. that whether as 
 a laxative or otherwise, calomel will in certain cases do what, in 
 the present condition of therapeutics, no other laxative, nor 
 generally any other drug, can do. Many a time have I seen 
 cases which, just as the second related case, were not benefited 
 by the various laxatives, including castor oil, when the con- 
 dition of the patient remained the same, or became frequently 
 worse, while calomel turned the scales. 
 
 As far as the particular comparison between calomel and cas- 
 tor oil is concerned, I will say this much : In the above-described 
 diseases of the biliary passages, castor oil can hardly at all be 
 compared to calomel : it only causes a loose stool, without pro- 
 ducing the characteristic, in the case of calomel, dark-greenish, 
 abundant bile-colored evacuations ; nor does it produce that ef- 
 fect on the morbid phenomena in the domam of biliary passages. 
 which is so pronounced and so constant after the use of calo- 
 mel. Besides, it is badly borne in such cases, ofttimes induc- 
 ing vomiting and aggravating the disease. In erysipelas of the 
 face, in typhoid fever, croupous pneumonia and acute Bright's, 
 there is some similarity in the nature of the effect, but an 
 enormous difference in the degree of this last. And to ad- 
 mmister — with the purpose of obtaining an effect similar to 
 that obtained from calomel — doses of castor oil, larger than those 
 used for ordinary laxative effects, would be an unfortunate pro- 
 cedure, as even the ordinary doses are not borne as well as 
 those of calomel, while larger ones would affect injuriously the 
 stomach and the mtestines, which circumstance would result 
 not in improving, but in aggravating the condition of the pa- 
 tient. 
 
 Hypertrophic cirrhosis of the liver. — I observed only one 
 
— 418 — 
 
 case, to which I shall refer here. Novemher 8, 1883, 1 was called 
 for the first time to see N. N. The patient, twenty-three years old, 
 had long since ceased to obey his elders, was extremely irritable, 
 formerly neglected his health entirely, and during his illness 
 lost his faith in medicine, did not follow his physician's instruc- 
 tions, and is in addition to this very weak, so that it is almost 
 impossible to obtain from him any information as to his past. 
 All the data, which we succeeded in obtaining from him and 
 from his relatives after he improved, may be summed up as 
 follows. When fifteen years of age, patient had an attack of 
 diphtheria, after which there remained some hoarseness (paresis 
 of the left vocal cord). During several summers he suffered from 
 intermittent fever, one or two attacks, which yielded quickly 
 to quinine. Patient took to drinking during the last four years, 
 and exclusively wine at that, Madeira (never drank any brandy), 
 in great quantities, from three to five bottles per day, so that 
 he was tipsy almost every day. The last year and a half he 
 became very irritable and lost his appetite. In the summer of 
 1883, he began to have daily vomiting in the morning, after the 
 first glasses of Madeira. During the month of September pa- 
 tient spent much of his time, late in the evenings, in excursions, 
 garden-parties and during bad weather was subjected to attacks 
 of cold. By the middle of September he became feverish, 
 lost his appetite completely, and the whites of his eyes became 
 yellow. A physician was called in September 25th, and detected 
 an enormous enlargement of the liver. At the advice of 
 another physician he gave up drinking wine, and from October 
 11th drank natural Karlsbad water, one and a half glasses per 
 day, somewhat warmed. During the time that he was treated 
 with the Karlsbad water, patient had every day ten to fifteen 
 loose stools, not more than a teaspoonful at a time (hardly one 
 half a glassful during the twenty-four hours), of a painful 
 character ; since then the abdomen became constantly sensitive, 
 especially so in the left lower half. The jaundice became aggra- 
 vated during this period, the abdomen increased in size (the 
 physician diagnosed abdominal dropsy), and there appeared 
 (edema of the legs. The sleep became very poor. October 22d 
 and 23d the patient took infusion of digitalis (from ten grains), 
 but without any result. October 28th, he began to take adonis 
 vernalis, but did not even take the whole of the first bottle. 
 Since then and until November 3d, he took pills made of extr. rhei 
 compos. 3j, extr. hyosciami gr. ij (after he stopped taking the 
 Karlsbad water he became constipated), which produced loose 
 
— 419 — 
 
 stools, similar to those caused b}^ the Karlsbad water : some ten 
 to fifteen stools per day, not more than one teaspoonful at a 
 time. From November Ist to 10th, patient took potassium bromide 
 (ten to fifteen grains at bed-time) for his poor sleep, without 
 any success, and during both days of November 5th and 6th, he 
 took fifteen grains of potassium iodide. 
 
 Status November 8th, 1883. — Patient is generally surrounded 
 by excellent conditions of life ; but the room which he preferably 
 occupies at the present time, is situated m a corner, and has 
 many windows, while near by the patient's very bedstead 
 is a door, through which there blows a strong draught (along- 
 side of this is a cold watercloset). This notwithstanding, pa- 
 tient stubbornly refuses to change his room ; besides, he is very 
 weak. Only two weeks later, when he improved somewhat and 
 grew more obedient, we succeeded in removing him into a large, 
 spacious, entirely satisfactory room, and this removal had in- 
 duced a favorable change in his condition. Outside of four 
 glasses of milk a day, patient neither eats, nor drinks anything : 
 drinks neither wine nor tea, does not smoke (formerl}^ he drank 
 tea and smoked). 
 
 , Patient is of a weak constitution : he is tall, and has a nar- 
 row chest. Is extremely weak and emaciated ; the abdomen is 
 enormously enlarged, the legs are oedematous almost up to the 
 kneds. The whites of the eyes are moderately yellow ; the 
 skin' is yellowish at some places, light-olive colored in others. 
 At the present time (August, 1884), when the patient, as we 
 shall see, improved greatly, and the evacuations for the last six 
 months became normally colored, the color of the skin is light 
 olive. Patient asserts that his skin was thus colored for a very 
 long time, long before the appearance of the evident jaundice 
 in September, 1883. The tongue is normal. There are no 
 gastric disturbances, such as belching, pyrosis, nausea, vomiting, 
 sensation of heaviness and pain in the region of the stomach, 
 either spontaneous or induced by pressure. As mentioned al- 
 ready, he has some ten to fifteen stools daily, a teaspoonful at 
 a time : the evacuations are loose, whitish, slightly but still sure- 
 ly colored by bile, and contain some mucus. There are un- 
 doubted symptoms of accumulated fluid in the abdominal cavity. 
 The circumference of this last at the level of the umbilicus is 
 95 c. m., the distance between the xyphoid cartilage and the 
 symphysis pul^is is 12 c. m. But the abdominal walls are fla]> 
 b}', not distended, and extremely thin (on account of the extreme 
 general emaciation), so that examination of the abdomen is eas- 
 
— 420 — 
 
 ily made. The subcutaneous abdominal veins are not distended. 
 .There is constant pain in the left lower half of the abdomen, 
 which is increased on pressure and at times after evacuations. 
 The amount of urine is 350 to 400 c. c. a day : it is very con- 
 centrated, gives the reaction of the biliary pigments and contains 
 some albumen ; at times there are found in the urinary sedi- 
 ment uric acid cylinders. The spleen is slightly enlarged, not 
 sensitive. The liver is enormous : everj^where equable, preserv- 
 ing its normal shape, and reaching beyond the border of the 
 ribs and down to the umbilicus. The surface of the liver is 
 perfectly smooth, not presenting the least protuberance ; the 
 anterior border is sharp. The liver feels very hard and is 
 entirely insensitive to pressure ; there never were nor are there 
 now any spontaneous pains in the region of this organ. I must 
 repeat again that the extreme thinning out (with the general 
 emaciation) and flabbiness of the abdominal walls enabled us to 
 palpate the liver with an ease, that is only rarely possible. 
 Percussion of the superior border of the liver shows it to be 
 somewhat higher than normally. The respiratory organs are 
 normal ; the condition of the larynx was alluded to above. The 
 heart-beat, perceptible in the mammillary line, is diffuse, but 
 weak ; there is a dull sound in the region of the heart in the 
 normalline; the tones are clear. The pulse is 110 to 120, ex- 
 tremely weak ; the arteries are, however, felt without difficulty, 
 they are somewhat tortuous and apparently slightly thick- 
 ened. The patient is feverish : the evening temperature is be- 
 tween 37.8° R. (100.4° F.) and 38.5° R. (101.3° F.^, the 
 morning the same or more frequently lower. The skin is dry 
 and covered here and there by extensive eccliymotic spots, which 
 reappear easily after a slight pressure. His sleep is restless 
 and lasts only from three to four hours out of the twenty-four. 
 The head does not ache and is generally free. 
 
 The final diagnostic conclusions are reached by me during 
 the exposition of the course of the disease and of the effects of 
 the treatment, for in this way, as will be seen later, we obtain 
 valuable data for the diagnosis. Let me only mention here my 
 first suppositions. I certainly could not stop on simple hyper- 
 aemia of the liver, whether active or passive, as such an assump- 
 tion could not adequately explain the presence of jaundice, the 
 impaction of bile, the enormous enlargement of the liver and 
 the absence of tenderness in the same. Cancer of the liver was 
 excluded on account of the absence of pains on pressure, and by 
 the results of palpation. Closure of the ductus choledochus was 
 
— 421 — 
 
 excluded by me in view of the absence of attacks of hepatic 
 colic in the past and the absence of pain and sensitiveness on 
 pressure at the present time, but chiefly on account of the fact, 
 that notwithstanding the enormously enlarged liver, the evacua- 
 tions were not entirely colorless, and contained some biliary 
 pigment, while the icterus of the face, of the general integu- 
 ments and of the urine was very moderate, being far less consid- 
 erable than when seen in cases of closure of the principal 
 biliary duct. 
 
 Outside of the hypertrophic cirrhosis one would most certain- 
 ly suspect either multilocular echinococcus or syphilis. Against 
 echinococcus there was the shape of the liver, while syphilis 
 was excluded by the fact that neither the patient nor his 
 parents ever had this disease. The presence of abdominal drop- 
 sy I had to refer to peritonitis, which was caused by a cold 
 caught in the patient's rooms ; the following facts lead to such 
 reasoning : the abdominal pams appeared about the middle of 
 October; for a whole month previous to this the patient was 
 confined in his room, lying most of the time in bed clad only 
 in his undergarments, either covered with a quilt, or entirely 
 uncovered when feverish ; while near by the bedstead there was 
 the door, either half or entirely open, through which there en- 
 tered a strong draught from the watercloset alongside of it. 
 The pains appeared at the time when the patient began having, 
 thanks to the Karlsbad, ten to fifteen loose stools per day ; at 
 first they occurred only with each inclination to stool, but later 
 on they becaine constant. As will be seen further on, from 
 the diary of the disease, the matter stood thus : 
 
 When the danger from further colds ceased, when the abdo- 
 men was constantly kept warm, and when, after the use of calo- 
 mel, the diarrhoea disappeared and consequently at once with it 
 there also passed away tlie irritation of the peritoneum by the 
 intestinal movements, then the abdominal pains began to di- 
 minish, so that even in two weeks from the time I began my ob- 
 servation there was a noticeable diminution of the abdomen 
 contemporaneous with the disappearance of the pains. At that 
 time it was as yet impossible to diagnosticate a diminution in 
 the volume of the liver even to the slightest extent ; the be- 
 ginning of this process of diminution was only observed two and 
 one half weeks later. Finally, notwithstanding the considerable 
 abdominal dropsy, the patient did not present the least sign of 
 any distension of the veins on the abdommal surface, although 
 in view of his extreme emaciation this condition could surely be 
 
— 422 — 
 
 very easily perceived ; this condition of the veins, as you know, 
 is observed in cases of abdominal dropsy caused by hepatic dis- 
 ease, on account of impeded circulation in the portal system. 
 
 Thus I put it down as a hypertrophic (biliary) cirrhosis of 
 the liver, catarrh of the large intestine, a peritonitis of moderate 
 severity, particularly in the vicinity of the sigmoid flexure, and 
 also a possible cirrhosis of the kidneys, this last in view of the 
 former abuse of alcohol, the cardiac and arterial phenomena, 
 and the presence of albumen and cylinders in the urine. The 
 considerable development of the cedema of the legs and partly 
 the abdominal dropsy I ascribed to the failure of the cardiac 
 activity induced by the sudden cessation of wine drinking, by 
 the fever and emaciation ; the same may be said partly in re- 
 gard to the poor sleep. Having made the patient as comfort- 
 able as it was possible in his own room, and later, at the first 
 opportunity, having removed him into another more satisfactory 
 one, I advised to keep the abdomen warm by the use of Provence 
 oil and a double abdominal flannel binder, and for nourishment 
 and drink to continue the warm milk (later on, when the appe- 
 tite improved, we added roasted woodcock, without the skin, and 
 some white bread), and to support the cardiac activity and the 
 nervous functions in general, he was given his habitual nervines : 
 a glass of sutticiently strong tea during the day, some six to 
 eight tablespoonfuls of Madeira wine, and three to four times a 
 day twenty-five drops of the mixture of the tinctura valer. 
 aethereae and liquoris anodyni Hoffmanni aa. Guided by my ex- 
 perience in the use of calomel for hepatic colic caused by biliary 
 calculi, I decided to try this remedy in the present case. I 
 also thought of applying Spanish flies to the lower part of the 
 left abdomen, but the considerable ecchymoses just in this re- 
 gion prevented me from doing this : while lying on the left side 
 patient pressed his hand on this region and the ecchymotic 
 spots presented true reprints of the palm and of the fingers. 
 
 Nov. 9. — Gargling of the mouth with potas. chlorate: this 
 the patient continued throughout the whole period of treatment 
 with the calomel, up to the end of June, 1884. Six powders 
 of calomel, containing one grain each : the first three every 
 hour; the others every two hours. The sixth was followed by 
 abundant and characteristic calomel evacuations of a dark-green 
 color, and painless. This time, as well as at other times later 
 on, the patient had one or at most two loose stools from 
 calomel, but never more, always more or less abundant and 
 painless. 
 
— 423 — 
 
 Nov. 10. — Xo stool : the former frequent and useless at- 
 tempts at defecation ceased from this time on. The abdominal 
 pain subsided somewhat, both the pulse and the sleep are mark- 
 edly better : everything else as before. 
 
 Nov. 11. — Three one-grain powders of calomel, one every 
 hour. A good calomel evacuation. 
 
 Nov. 12. — The same treatment, the same result. 
 
 Nov. 13. — Two powders — the same result. 
 
 Nov. 14, 15., 16. and 17. — He was not given an}- calomel 
 during these days. Xo spontaneous stool : a clyster caused a 
 slightly formed evacuation, not of the same dark-greenish color 
 as after calomel, but colored more markedly than it was before, 
 though still less than normal. The appetite began to reappear, 
 the abdominal pains diminished, the sleep is better, the pulse 
 fuller and stronger, although still 120 per minute. Everything 
 else as before. 
 
 Nov. 19^ 20, 22, and 23. — Three grains every day in the 
 former order. The usual effects. 
 
 Nov. 2-j. — The patient is evidently improved : the appetite 
 is livelier, the evacuations are more markedly colored (but stool 
 tgikes place only after a clyster of warm water which is given 
 every other day), the jaundice is less pronounced, the abdominal 
 pains begin to disappear, the al)domen not so large ( oO and 40 
 cm.}, the sleep and pulse better. 
 
 Nov. 26 and 27, 29 and 30, Dee. 3 and 4- — Three grains of 
 calomel as Ijefore. The usual calomel stool, less abundant than 
 formerly. The improvement continues little by little. 
 
 Dec. 7 and 8. — Four grains of calomel daily ; no stool. 
 
 Dec. 9. — Three doses of calomel, two grains every two hours. 
 Four hours after the last dose a tablespoonful of castor oil. 
 Abundant calomel evacuations. 
 
 Dec. 11, 12 and 13. — Appetite markedly better. Stool 
 either spontaneous, or by clyster, fairly well colored, but by far 
 not normally. The jaundice of the eyes and skin is disappear- 
 ing ; but the olive color has remained until now. Xo abdominal 
 pain. But here I will note a most important fact : from this 
 time on the amount of urine has suddenly increased, up to 900 
 or 1,000 c.c. in the twenty-four hours, and it became limpid and 
 free from any biliary pigment : still there is some albumen as 
 yet ; the febrile condition diminished. The fever continued 
 for another six weeks tip to January 2 2d ; but instead of the 
 former evenmg temperature, 87.8° R. (100.4° F.^ to 38.5° R. 
 (^101.3° #.), and at times the same in the morning, the even- 
 
— 424 — 
 
 ing temperature was only 37.6° R. (99.6° F.) to 37.8° R. 
 .(100.4° #.), and the morning about 37° R. (97.6° F.). During 
 these days we could for the first time diagnosticate a slight 
 diminution in the size of the liver. Sleep and pulse (110) still 
 better. No fresh ecchymotic spots appeared agam. As regards 
 treatment we must add that during the past month the patient 
 was given four times quinine, twice in five-grain doses on the 
 days when he did not get any calomel. The quinine was well 
 borne by the stomach, but failed to exert any influence on the 
 fever. 
 
 Dec. 25. — The dimensions of the abdomen are 78 and 33 cm. 
 The cedema of the legs is rapidl}^ dimmishing. Stool agam only 
 by the aid of clysters, the evacuations less in number and their 
 color paler. 
 
 Dec. 26 and 27., 29, 30 and 31. — Three one-grain doses of calo- 
 mel, one every hour. A moderate calomel stool. 
 
 Jan. 3, ISSJf. — Three one-grain doses of calomel, one every 
 hour. No stool. 
 
 Jan. 4-- — Three doses of calomel, two grains every two 
 hours, later a teaspoonful of castor oil. Abundant calomel 
 evacuation. 
 
 From January 5th up to 22d, equable improvement continues. 
 On that day the symptoms of accumulation of fluid in the abdo- 
 men, the cedema of the legs, as well as the fever, have all en- 
 tirely disappeared. The liver continues decreasing in size. Dur- 
 ing this time the patient was given two soap-baths so as to 
 clean his skin ; this weakened him. During the last days 
 the stool is again worse; it is necessary to resort to a clyster, 
 the evacuation is insufficient and its colormg is again lighter. 
 
 Jan. 23. — Four doses of calomel, one grain every hour. No 
 effect. 
 
 Jan. 24. — Three doses of calomel, two grains every two 
 hours. Abundant calomel evacuations. From that time un- 
 til the present (August, 1884) the patient's condition con- 
 tinued to improve. Little by little the appetite grew better 
 than it ever was during the last- three years. The liver con- 
 tinued to shrink in size, although slowl}^ so. The albumen 
 in the urine amounts only to a slight reaction, but it did not 
 disappear entirely. The sleep became entirely normal, while 
 the mental state, as compared with what it was before, is 
 marvellously good. Patient began to take on flesh and gather 
 strength little by little. The evacuations, after the abundant 
 calomel stool, were for a few days spontaneous, in sufficient 
 
— 426 _ 
 
 quantity and fairly well colored ; but later on they grew less 
 abundant and became less colored, till finally a resort to clyster 
 was had again. We then administered calomel again — from 
 now on always in three two-grain doses, every three hours 
 without any castor oil — and obtained the usual good results. 
 Thus calomel was given February 6th, 16th and 26th, March 
 6th and 30th, April 14th, May 1st and 16th, and the last time 
 June 20th. Between March 6th and 80th, when calomel was 
 not administered, he was given for about two weeks fiv of 
 Ems-Kesselbrunnen, three times in the morning, slightly 
 warmed, without the least effect on the patient's condition. 
 At the same time, after the Ems, in view of the fact that not- 
 withstanding the absence of fever the pulse was still frequent 
 (100), we tried digitalis (24 grains in an infusion during three 
 days), but this also failed to exert any effect. The pulse grew 
 less and less frequent only contemporaneously with the improve- 
 ment in health, but even now it is about 90. Finally for the 
 sake of completeness we must add that, thanks to the prolonged 
 recumbent posture, usually on the back, with legs flexed at the 
 knees, the patient developed contractures and paresis of certain 
 muscles of both legs and feet. Gradual exercises by walking, 
 massage and the induced current removed, though slowly, these 
 conditions, and with this the muscles have markedly mcreased 
 in size. vSmce March the induced current was applied to the 
 abdomen so as to act on the intestines and liver. This has 
 apparently also exerted some influence on the constipation ; 
 whether or not the liver was influenced, it is difficult to say, 
 as the liver had diminished in size even before, and since this 
 time it has diminished but little (we also continued the use of 
 calomel). 
 
 At the present time (the end of August, 1884) the patient's 
 condition is as follows : while living during the summer in 
 the country he walks a great deal. For more than two months 
 he had taken no calomel, nor any other treatment. The 
 appetite is good, the digestion is perfectly regular (he resorts 
 to clysters but very seldom), his sleep is excellent, the mental 
 condition good, the patient has grown stout and strong. The 
 urine still contains some albumen, but in a very trifling amount ; 
 the arteries and the heart are in the former condition, the pulse 
 is still about 90. The liver is much smaller m size than it 
 was before, but still certainly larger than the normal liver ; it 
 reaches two fingers' width beyond the border of the ribs and 
 is firmer than normally. The light olive-like color of the skin 
 has not changed. 
 
^ 426 — 
 
 I will return now to the diagnosis, the interest in which in 
 the present case is quite evident. The markedly favorable 
 course of the disease compels us to entirely exclude multiple 
 eohinococcus. It is otherwise with sj'philis : did we not treat 
 a syphilitic liver with a mercurial preparation, calomel ? This 
 supposition cannot be entertained for the following reasons : 
 neither the patient's father (now dead, but whom I knew 
 well) nor his mother had syphilis. The patient himself, who 
 had now acquired boundless implicit confidence in the physi- 
 cian, and who became very docile, declares that he was gener- 
 ally averse to sexual intercourse, had never suffered from any- 
 thing, not even gonorrhea, that he never had any falling out 
 of the hair (this is now remarkably thick), nor any eruptions 
 or ulcers, nor any nocturnal or other pains. The results ob- 
 tained by palpating the liver, namely : the perfect smoothness 
 of its surface, the regularity of its shape and its shaip, free 
 border, also speak agamst syphilis; the slight coloring of the 
 evacuations and the jaundice are also unlikely to be seen in 
 syphilis of the liver. 
 
 Finally, the treatment itself : calomel was always administered 
 so as to cause loose stools, which it did : and it was given at 
 intervals which became more and more prolonged. Every 
 experienced physician is well aware of the fact, that success in 
 treating syphilis of the liver, or generally any severe case of 
 syphilitic affection, cannot be attained by such mtensive mer- 
 curial treatment applied in such a manner, and that it can 
 hardly be expected without a simultaneous use of large doses 
 of potassium iodide. Therefore, even with greater probability 
 than at the beginning of my observation, can I view this 
 case as one of hypertrophic cirrhosis of the liver. It is 
 worth our while to note the following : the etiology of hy- 
 pertrophic or biliary cirrhosis of the liver made clear the fact, 
 that contrary to the simple Laennec cirrhosis, it is seen in those 
 who abuse wine, and not whiskey. The anamnesis of the case 
 described by me substantiates this fact : our patient always 
 di'ank Madeira, never any whiskey. 
 
 A few words concerning the prognosis. Is the improvement 
 in the condition of the liver of a lasting nature ? If the patient 
 will lead as regular a mode of living as he does now, then the 
 recurrence of the icterous symptoms seems to me but slightly 
 probable, and even if it will occur, then in the presence of the 
 effective influence thereon of calomel, it will present no partic- 
 ular danger. It is otherwise if we were to ask, whether or not 
 
— 427 — 
 
 the other variety of hepatic cirrhosis — the Laennec cirrhosis 
 — could develop ; this however is a question we are unable to 
 answer at the present time. The albuminuria and the arterial 
 and cardiac phenomena have certainly a very serious significance 
 as regards the future state of the patient. Be as it may, the 
 improvement m the patient's condition under the given circum- 
 stances is marvellous : the patient's relatives, who last autumn 
 lost all hopes for his recovery, inquire of the physician about the 
 advisability of having the patient married. 
 
 Facial Erysipelas. — For young persons with a good heart 
 and regular digestion, I give quinine until a slight noise in the 
 ears is produced, and if the conditions permit I order general 
 baths of 24° to 20° it., and apply cold compresses to the parts 
 affected by erysipelas. Quinine exerts a favorable effect in 
 lowering the temperature ; the same may be said of the cold 
 compresses, which, together with the quinine, may even directly 
 interrupt the process, when the fever and the further spread of 
 the erysipelas cease. But there occur cases of facial erysipelas 
 in persons of advanced age whose cardiac activity and digestive 
 powers are below normal, who suffer from dyspepsia or gastric 
 catarrh with a tendency to constipation, with attacks of he- 
 patic colic, either m the past or at the present time, and in whom 
 the evacuations are not normally colored. In such cases quinine 
 is badly borne by the stomach, and so are the cold baths, in 
 view of the abdominal distension caused by meteorism and the 
 weak cardiac activity. Neither of the above drugs gives as good 
 results hi such cases, as in those of the preceding class. I replace 
 them by calomel, in one-grain doses every hour (the last doses 
 every two hours), till looseness of the bowels is established ; if 
 this does not take place after twelve grains, I administer castor 
 oil. I never omit in these cases the potassium chlorate gar- 
 gling, A good loose stool is followed by improvement in the me- 
 teorism, the respiration and the condition of the head are made 
 easier, the temperature is lowered for one or two days, the pa- 
 tient is enabled to sleep quietly one or two nights. At times 
 the temperature will fall to the normal without ever rising agam ; 
 then the further spread of the erysipelas ceases. But if the 
 temperature rises again, if the erysipelas spreads further and 
 the condition of the patient's strength is satisfactory, then I ad- 
 minister calomel for the second time in the former fashion. We 
 never have to administer the calomel more than twice, either 
 because the erysipelas ceases, or, in case it does continue, because 
 the fever is slight, and the patient's strength is affected by the 
 
— 428 — 
 
 continuance of the disease. I then prescribe moderate doses of 
 quinine, which is better borne then, after an improvement in the 
 condition of the digestive organs has taken place, thanks to 
 the use of calomel. 
 
 Typhoid Fever. — Like many others, I also witnessed the 
 value of calomel in this disease. In accord with others, I ad- 
 minister it during the iirst week and usually not later than on 
 the eighth or ninth day of the disease. I give it when there is 
 no diarrhoea, when the strength of the patient permits it, and I 
 must say again I particularly insist on giving it to patients 
 with a condition of the digestive organs as described above in 
 touching on the second class of erysipelatous patients. The 
 loose stool after calomel diminishes the meteorism, relieves the 
 breathing and the condition of the head, causes a fall of tem- 
 perature for one or two days, and enables the patient to spend 
 one or two quiet nights (he sleeps better and is less delirious). 
 The favorable effect of two good days at this period on the 
 further course of the disease is not to be underestimated. I 
 o'ive the calomel here in the same manner as I administer it for 
 erysipelas, but I do not repeat it, out of apprehension of weaken- 
 ing the patient ; this apprehension is of even greater importance 
 in typhoid fever than in erysipelas. I cannot help observing 
 here that the assumed specific effect of calomel on the intes- 
 tinal microbes of the typhoid fever does not seem to me partic- 
 ularly probable. We fail to observe a sudden interruption of 
 the fever by calomel, as we do in the case of quinine in mala- 
 ria ; we only witness here a favorable effect on the further 
 course of the disease, just as we did in erysipelas, and, as we 
 shall see presently, in pneumonia, and in acute Bright's, — in 
 processes which have nothing to do with intestinal microbes. 
 On the contrary m cholera, in which we would most certainly 
 expect an effect from the calomel, 1 failed to see the very least 
 effect from it during the two severe epidemics in Moscow, of 1853 
 and 1854, when in my capacity as a resident physician in the 
 temporary cholera ward of the university clinic, I had charge 
 of a great many patients, and calomel constituted the ordinary 
 treatment of cholera. 
 
 Croupous Pneumonia. — During the first two years of my 
 medical practice I used digitalis, but it did not prove efficacious, 
 at times it was even harmful, and since then I never use it in 
 pneumonia. In several cases I tried cold baths and concluded 
 that, although the patient may bear them, they hardly profit by 
 them, if we except a trifling fall of the temperature of but short 
 
— 429 — 
 
 duration. My acquaintance with cairine did not tempt me into 
 trying this drug. From qumine I only obtained a fall of tem- 
 perature of short duration, and this only when administered in 
 enormous doses which are but with difficulty borne by the stom- 
 ach and the nervous system ; I therefore discarded this drug, ex- 
 cept in some protracted cases, when the fever is of a strongly 
 remittent type in the morning, and moderate doses of quinine 
 become effective. Even less suitable for pneumonia do I con- 
 sider sodium salycilate, especially in view of its action on the 
 heart. My principal remedy in the treatment of pneumonia, 
 outside of the usual symptomatic drugs (as Dover's powders 
 for the cough in the beginning when there is but little or no ex- 
 pectoration, wine for the heart, etc.), has been calomel until now, 
 and is even at the present time when antipyrin and antif ebrin are 
 introduced mto practice. I administer it in the same manner 
 as for erysipelas, namely in sthenic cases of pneumonia, to pa- 
 tients of strong constitution, when the condition of their 
 strength is good, mostly during the iirst days of the disease, and 
 particularly when the condition of the digestive organs resem- 
 bles that described above in connection with er3-sipeifttous pa- 
 tients of the second category. The effect is the same as in fa- 
 cial erysipelas and typhoid fever : the looseness of the bowels is 
 followed by a decrease in the size of the abdomen, by relief of 
 the respiration and of the condition of the head, by a fall of the 
 temperature and by at least one quiet night. Such a relief at this 
 stage of a disease of the limited duration of croupous pneumonia, 
 has, according to my observations, the same favorable influence 
 on the further course of the affection, as it has in typhoid fever, 
 if not a better one : at times the fall of temperature caused by 
 the calomel passes directly into the crisis. We usually do not 
 have to repeat the calomel in view of the rapid course of the 
 disease and the danger of weakening the patient. 
 
 Acute Nephritis. — In those cases which developed mdepend- 
 ently of any preceding infectious disease, and also in those seen 
 during the puerperal period, but not connected with puerperal 
 septicaemia, I administer calomel for the first days of the 
 disease, in the same manner as described in connection with 
 erysipelas, with the identical good result, as shown by the con- 
 siderable fall of the temperature and the diminution of the lo- 
 cal phenomena : the pains in the region of the kidneys grow 
 weaker, the urine increases in amount and becomes limpid. If 
 the temperature after this rises again, and the condition of the 
 strength is fair, then I sometimes resort to a repeated use of 
 calomel, just as I do in erysipelas. 
 
— 430 — 
 
 As contraindications to the use of calomel, outside of the 
 weakness of the patient (as evidenced principally by the pulse), 
 are considered severe diarrhceas with abundant exhausting 
 evacuations, but not such as were described when we discussed 
 the case of the patient suffering from hypertrophic cirrhosis of 
 the liver: such a diarrhoea is on the contrary an indication for 
 the use of calomel. 
 
 An Additional Note Appended to the Edition of 1895. 
 
 I will touch now on the indications for the use of calomel in 
 diseases of the biliary passages. 
 
 In my former communication I mentioned two affections of 
 the biliary passages in which calomel should be used, namely, 
 acute, particularly febrile, cases of hepatic colic, and hyper- 
 trophic cirrhosis of the liver. Further observations compel me 
 to widen the range of these indications : calomel should be used, 
 for hypertrophic cirrhosis of the liver, in all (not only acute) 
 cases of biliary calculi and in catarrhal jaundice. 
 
 The indication for the use of calomel in biliary calculi and in 
 catarrhal jaundice I must formulate thus : if the ordinary meas- 
 ures employed in the treatment of the disease, such as a regu- 
 lated regimen, diet, at times warm baths, and chiefly the use of 
 mineral waters, either alkaline or earthy (Contrexeville), im- 
 prove the condition slowly, if we observe constant tenderness 
 in the region of the gall-bladder (in biliary calculi) or over the 
 whole liver (as in catarrhal jaundice), the more so if it be at- 
 tended with a febrile condition (as well as without it), and if the 
 above alluded to contraindications to the use of calomel are ab- 
 sent, then we interrupt the use of the mineral waters and 
 administer calomel in the manner explained in the first commu- 
 nication ; later on we return again to the mineral waters and, if 
 necessary, repeat the calomel ; every time we do that we must 
 of course put aside the mineral waters. 
 
 To illustrate these propositions I shall speak here briefly of 
 the following cases. 
 
 1. Biliary Calculi. — This patient was first treated for an 
 exacerbated chronic catarrh of the large intestine. 
 
 The patient, a woman sixty-seven years old, passed through 
 an attack of dysentery four years ago. She usually complains 
 only of slight dyspeptic symptoms (heaviness and belching after 
 meals), of pain in the region of the gall-bladder, and of irregu- 
 lar stools since the attack of dysentery : either a constipation or 
 a diarrhoea for two or three days. The present condition : an 
 
— 431 — 
 
 accidental cold was followed by loss of appetite, by the ap- 
 pearance of nausea, of intestinal pains, and a feverish condition. 
 On the next day vomiting and diarrhoea accompanied b}- severe 
 intestinal pains : some insufficient liquid stools mixed with mu- 
 cus, but without any blood, three to four per hour : the abdo- 
 men is distended and sensitive, particularly in the region of the 
 colon. Evening temperature 39.2° R. (102,5° FS) ; the urine 
 shows the presence of albumen. In the evening we began to 
 give her one-grain doses of calomel every hour. After the third 
 powder the vomiting ceased ; the ninth dose was followed by 
 abundant painless dark-green evacuations ; the calomel was 
 stopped. Patient began to feel better at once. In the course 
 of three daj^s the temperature fell to the normal ; with this there 
 disappeared also the albumen. The first three days after the 
 calomel she had two to four stools a day ; later, one. The dark- 
 green color of the evacuations continued decreasing during a 
 whole week. Tannin clysters which were used on the fourth 
 day after the calomel brought to a speedy termination what 
 there was left of the intestinal catarrh. 
 
 In a year and a half the patient presented herself to me in 
 the following condition : the nervous system, the chest (outside 
 of a slight atheromatosis of the aorta) and the kidneys normal ; 
 she complains of a constant bitter taste, frequent belching of 
 bile, a feeling of fullness in the stomach, moderate pain in the 
 region of the gall-bladder, aggravated on pressure, and of con- 
 stipation with intermittent diarrhoea. Warmed Ems and Vichy 
 in slight quantities proved of no avail ; while the bitters (nux 
 vomica and condurango) brought but slight relief. I then 
 prescribed one-grain doses of calomel every hour ; after the 
 third powder there appeared abundant dark-greenish stools 
 (painless), three times the first day, twice the next (she was 
 only given three powders of calomel) ; the above-enumerated 
 symptoms have entirely disappeared both from the stomach and 
 the biliary passages for a long time. Only in the course of an- 
 other year did the patient present herself again with the same 
 symptoms, but in a much lighter degree; the same plan of 
 treatment, three one-grain doses of calomel, and the same suc- 
 cess. 
 
 In connection with the above-described case I consider it 
 necessary to touch upon the diagnosis of l^iliary calculi. Some 
 consider as a reliable symptom only undoubted attacks of 
 biliary colic, without paying due attention to the presence of 
 pain in the region of the gall-bladder, of which the patients 
 
— 432 — 
 
 complain, or which is detected by pressure. My observations 
 are of the following nature: in all the cases of biliary calculi 
 which are attended by frequent or infrequent attacks of 
 biliary colic, there is observed a constant, i. e. occurring in 
 the intervals between the attacks, pain, as above-described, in 
 the region of the gall-bladder; exceptions to this are very 
 rare indeed. Further, there occur cases of biliary calculi 
 where the above-mentioned pain is seen without any attacks 
 of liver colic. We also meet various gradations between these 
 two classes of cases : thus it happens that for a long time there 
 is observed only a constant pain in the region of the gall-blad- 
 der, and later there may also appear attacks of biliary colic ; 
 these last may be of variable severity, from the lightest to the 
 very severe ones : then the attacks of biliary colic may cease, 
 thanks to treatment or to a regulated mode of living, and there 
 remains only the constant pain in the gall-bladder, which in its 
 turn may also disappear. In view of all this I consider the 
 above-named constant pain in the region of the gall-bladder 
 as a certain symptom of the presence of biliary calculi therein. 
 
 This pain depends very likely on a chronic inflammation of 
 the walls of the gall-bladder caused by the presence of the calculi: 
 while the attacks of biliary colic are determined by spasms 
 of the nervo-muscular apparatus of the bladder and by the 
 accompanying neuralgia, and is called forth by such mfluences 
 as traumata (a ride over a jolting pavement, inconvenient 
 clothing), mental anguish, dietetic errors, and cold, as when 
 sitting with right side exposed to the window or the street 
 side of the house during the cold season of the year, or while 
 staying out-of-doors with the right side of the body against the 
 cold wind. 
 
 2, Catarrhal Jaundice. — I will describe here one of the cases 
 observed by me. November 12, 1890, there entered our 
 clinic a peasant, thirty years of age, complaining of pain in the 
 region of the stomach, fetid belching, nausea, at times vomit- 
 ing, and of jaundice and general debility. 
 
 Conditions and mode of living. — The locality is healthy, the 
 residence is good, the working-room is very hot (patient is 
 stoker by occupation), and this in connection with a cold 
 watercloset, and the necessity of going out of the room often, 
 gives rise to frequent colds. During the summer the patient 
 bathes in the river ; during the remaining seasons of the year, 
 he takes a weekly bath ; he is subject to sweating. Smokes 
 a little ; is a moderate tea-drinker, does not abuse brandy. Is 
 
— 433 — 
 
 married; is not affected with syphilis. The meals are those 
 of a working-man, consisting of dinner and supper. Works 
 some twelve houi's a day : until the appearance of the present 
 disease the work never tired him. 
 
 Anamiiesis. — Patient comes from a healthy family, and 
 until the last four years enjoyed good health. Then he suf- 
 fered from masked malaria appearing in the form of attacks of 
 excruciatmg pain in the right half of the head, which at times 
 terminated in a severe nose-bleed from the right nostril, causing 
 him to faint. These pains and nose-bleed continued for two 
 years and almost disappeared when the patient moved to 
 another locality. He then improved, although he did not 
 enjoy his former health, and was free from any suffermg for 
 about one year. But for the last year he has been suffering 
 from dyspeptic symptoms pointing to a gastric catarrh (pain 
 in the stomach after a meal, belching and pyrosis ). One week 
 ago, as a result evidently of a cold, the patient began to have a 
 febrile attack, pain in the larynx, hoarseness, the habitual 
 slight cough became aggravated and at the same time there 
 appeared vomiting and diarrhoea, and soon after that also 
 jaundice. 
 
 Statu8 November 13, 1890. — Patient is of average constitu- 
 tion, poor nutrition, with jaundice of the skin and of the eyes. 
 The appetite is very poor, the meals are followed by pain in 
 the stomach, fetid belching, pyrosis and nausea : while in the 
 clinic he had no vomiting. The region of the stomach and the 
 liver, i. e. the subgastric and the right hypochondriac, are sensi- 
 tive to pressure. The liver is somewhat enlarged. The spleen 
 is normal. Had no stool for the last two days (formerly he 
 had diarrhoea). To-day, a clyster brought away a few hard 
 scybala, almost without any biliary pigment, of the color of clay. 
 The urine is of the color of beer, gives a decided reaction of 
 biliary pigment ; contains neither albumen nor sugar. The 
 pulse is not frequent, but somewhat weak. The organs of 
 cu'culation and respiration are normal. The pain in the throat, 
 the hoarseness and the severe cough disappeared and there 
 remained only the habitual slight cough due to chronic 
 lar3rngeal catarrh. Patient has no fever. The sleep is usually 
 good, but last night he could not sleep on account of the itch- 
 ing of the skin. The right half of the head is somewhat pain- 
 ful even now (the supra- and infraorbital nerves of the right 
 side are sensitive to pressure). Fatigue is at times accompan- 
 ied by dizziness, which points to the fact that the former 
 
— 434 — 
 
 abundant losses of blood left the patient in a somewhat anaemic 
 condition. Further than the general debility, there is nothing 
 abnormal in the nervous system and the organs of locomotion. 
 
 The course of the disease. — November 13th, five one-grain 
 powders of calomel every hour, and then five again every two 
 hours. Potas. chlor. for gargling the mouth, four tablespoon- 
 fuls of wine, diet, warmth (flannel) to the abdomen, and rest. 
 Loose, soft, dark-greenish stools, after which the urine became 
 limpid. Since November 15th he was given Ems-Kesselbrun- 
 nen, half a glassful three times a day, one hour before a meal, 
 warmed to the temperature of 28 ° i?., and when necessary in 
 case of constipation, clysters, and to allay the itching, to im- 
 prove the sleep, and also to act on the stomach and the biliary 
 passages, warm baths. By November 21st the dyspeptic phe- 
 nomena diminished, the sleep became better, and the patient 
 felt somewhat stronger; but the icterous phenomena which 
 yielded to calomel reappeared again in their former condition 
 since the loth: the evacuations became colorless, and the urine 
 dark, just as they were before the calomel treatment. Novem- 
 ber 21st we repeated calomel, of course setting aside during the 
 21st and 22d the Ems water, five one-grain powders every hour, 
 and then two more every two hours. The effect was tem- 
 porary, although there followed a more prolonged, relief of the 
 icterous symptoms and of the pains in the region of the liver, 
 similar to what took place after the fust doses of calomel. Then 
 until December 1st, notwithstandmg the use of the Ems water, 
 the extr. fl. condurango (twenty drops twice a day, after a meal), 
 the warm baths and a regulated diet, neither the icterous symp- 
 toms nor the pain in the liver diminished to any marked ex- 
 tent. I will say that after the second dose of calomel the 
 patient had a toothache, especially on the right side, probably on 
 account of carelessness in gargling his mouth ; but there were 
 no symptoms of mercurial stomatitis. December 1st calomel was 
 administered for the third time ; five one-grain powders every 
 hour, then three every two hours, and in two hours after the 
 last powder a tablespoonful of castor oil, the mouth being all 
 this time carefully rinsed with the potassium chlorate solution. 
 Patient had abundant, loose, soft, dark-greenish evacuations, 
 the last of which began to be graduallj^ colored by biliary pig- 
 ment, at first somewhat weaker than normally, and later 
 perfectly normal ; with this the amount of biliary pigmentation 
 in the urine began to diminish rapidly, and the general integu- 
 ments began to pale. The pain in the liver also disappeared 
 
— 435 — 
 
 rapidly after the last abundant calomel evacuation. The pa- 
 tient returned again to the treatment with Ems water, condu- 
 rango and sometimes baths, which was interrupted the last time 
 by the calomel treatment, and December 8th left the clinic en- 
 tirely recovered. 
 
 For the sake of precision I must add that one week before 
 the patient left our clinic an accidental cold (from a draught 
 through the window) caused the appearance of a severe attack 
 of his habitual pain in the right half of the head in connection 
 with a slight febrile condition (37.8°i2.). A clyster containing 
 ten grains of quinine was administered (in view of the previous 
 gastric catarrh), after whicli, accompanied by severe noises in 
 the ears, the fever and the headache disappeared rapidly, the 
 patient felt himself much stronger, and the improvement con- 
 tinued its ordinary course. 
 
SYPHILIS OF THE LUNGS. 
 
 For the last two years we have had no opportunity of obseiT- 
 ing any cases of pulmonary syphilis. Meanwhile at the present 
 time, in connection with the discussion in our lectures of chronic 
 pulmonary tuberculosis, to which syphilis predisposes so readily 
 and together with which it is at times seen, it is but proper to 
 say a few words regarding the syphilitic affection of the lungs 
 (pneumonia syphilitica, lues pulmonum). I shall make use, 
 for this purpose, of my former communications and of the 
 cases observed by me after these had been made. 
 
 My communications were made at the meetings of the 
 Moscow Physio-Medical Society, April 11, 1877, and Janu- 
 ary 16, 1878 (they were afterwards published), consequently 
 several years before the discovery by Koch of the tubercle 
 bacillus — a discovery which determined the specificity of 
 tuberculosis, which up to that time, under the influence of 
 Virchow's theories concerning the subject, was generally con- 
 sidered as an inflammatory process and was usually known 
 in the clinics under the name of chronic pneumonia. The 
 diagnosis of pulmonary diseases was not possessed at that time 
 of such an important means as the detection of tuberculous 
 bacilli in the sputum. This notwithstanding, the above- 
 mentioned communications preserved, as you shall see from 
 the extracts, their clinical, i. e. medico-practical importance. 
 
 From the First Communication. 
 
 Xot every physician has had the opportunity to observe 
 an uncomplicated, positively certain syphilitic affection of the 
 lungs ; but who has not heard, or does not hear at times of 
 certain persons affected with some chest disease, who were 
 for a long time supposed to have suffered from an ordinary 
 pulmonary phthisis and were treated as phthisical persons, but 
 who were cured finally by potassium iodide and mercury ? 
 Excited curiosity will naturally search for the determining 
 differences these cases present as compared with ordmary 
 436 
 
— 437 — 
 
 pulmonary tuberculosis, but it fails to obtain any definite 
 indications. Such indications are absent not only in the 
 literature of the past, but even in that of very recent date. 
 
 Ordinary pulmonary tuberculosis, as is well known, is often 
 seen in syphilitic patients. Those persons who had been in- 
 fected by syphilis and were subjected to the necessary treat- 
 ment therefor, under unfavorable circumstances usually suffer 
 from a radical impairment of their health, which frequently 
 terminates in pulmonary tuberculosis. I had frequent oc- 
 casions to observe, that not only persons who have passed 
 through syphilis, but even those who presented its early or 
 late manifestations, were sufferers from pulmonary tuberculosis 
 in its ordinary form, presenting febrile symptoms, haemoptysis, 
 cough, expectoration, changes in the percussion sound, in the 
 respiratory murmur, and certainly more or less abundant con- 
 stantly present rales. In such cases the attempt to resort to 
 iodides or to mercury (if the syphilitic manifestations at the 
 time present required it) not only produced an improvement in 
 the chest trouble, but usually tended to its rapid and very 
 pronounced aggravation, which compelled one to give up 
 the specific treatment. 
 
 I chanced to observe two cases of chest troubles in syphilitic 
 persons, which are decidedly different from those I have just out- 
 lined. I saw the first case fourteen years ago. Patient, thirty 
 years old, of a good constitution, with a well-developed chest, 
 coming from a family of healthy, sturdily built people, with no 
 case of tuberculosis in the family, and living among favorable 
 conditions of life, had been suffering durmg the last six or 
 seven years with attacks of undoubted syphilitic infection, 
 manifested for the last three years by deep serpiginous ulcers 
 of the skin and periostitis of the tibiae and ulnae, which yielded 
 to the treatment by potassium iodide, and reappeared again 
 after the cessation of the treatment. Several weeks before 
 I sa'w the patient he was complaining of pain and a feeling 
 of oppression in the chest, slight dyspnoea and general weak- 
 ness ; one week before, thanks to an accidental cold, he began 
 to cough slightly and became somewhat feverish. (The pa- 
 tient became during the last years very susceptible to colds, 
 and his attacks of colds usually take the form of a febrile 
 bronchitis of short duration and slight intensity). During the 
 last days patient was confined to his room, the cough quieted 
 down, and the fever disappeared entirely. 
 
 Status. — Patient is costive, his abdomen is somewhat dis- 
 
— 438 — 
 
 tended by intestinal gases, the urine contains neither sugar 
 nor albumen ; there is a slight cough, some expectoration 
 (once or twice in the morning ; patient always fails to preserve 
 it for physician's examination), dyspncea, pain and a feeling 
 of oppression in the chest; both clavicles are very prominent, 
 the sub- and supraclavicular fossae are very marked, and the 
 sound is duller in these places (especially on the right side) 
 than in the area below ; the vocal fremitus is weakened,' while 
 auscultation gives an indefinite respiratory murmur, approach- 
 ing bronchial respiration. Everywhere are heard non-abun- 
 dant rales, characteristic of bronchial catarrh. Patient lost 
 flesh. His sleep is poor. He has slight nocturnal pains in the 
 tibial and ulnar bones. 
 
 During the course of one week patient was confined to his 
 room, took no treatment, and observed the diet prescribed for 
 him in view of the meteorism and his tendency to constipation. 
 From this time the cough and expectoration ceased and the 
 rales disappeared. After weighing all the data as found in the 
 case, I concluded that the pulmonary trouble was of a syphi- 
 litic nature, and required the use of mercury, because during 
 recent years the patient had been constantly treated by potas- 
 sium iodide and had observed that it failed to exert the same 
 decided action it had done formerly ; moreover, he had not been 
 treated by mercury for a long time, and generally had but little 
 mercurial treatment. Circumstances compelled me to adminis- 
 ter the mercurial treatment in a form different from what I 
 usually do. During the fii'st week while he was under my 
 observation, before I commenced the mercurial treatment, 
 patient began to suffer from severe, intolerable itching which 
 became aggravated at night and prevented his sleep. Scratch- 
 ing caused an eruption in the form of very minute red papules, 
 and aggravated the itch ; the spots that the patient could not 
 reach by his hands, and which he therefore did not scratch, 
 were not covered by the eruption. Baths and various external 
 applications were of no avail ; only applications of a corrosive 
 sublimate solution brought considerable relief. In view of 
 this the general mercurial treatment was ordered as follows : 
 externally applications of a solution of bichloride for the itch- 
 ing and the eruption, and also certainly for its internal effect: 
 as the eruption was widely disseminated, the applications of the 
 bichloride solution had to be done over an extensive surface ; 
 internally strong Zittmann's decoction (Decoctum Sarsaparillae 
 Compositum Fortius P. G.), as a slight laxative, and at the 
 
— 439 — 
 
 same time as a mercurial preparation. The itching and the 
 eruption disappeared rapidly ; this was|followed by a return of 
 the sleep, and after four weeks of such treatment, the dyspnoea, 
 pain and the sensation of oppression in the chest passed away. 
 the sub- and supraclavicular fossae became less marked, for, 
 thanks to the improved appetite and digestion, the patient 
 grew a little stouter, while the above-described symptoms 
 which had been elicited by palpation, percussion and ausculta- 
 tion, could not be observed again : the chest in these regions, 
 as everywhere else, presented nothing abnormal. I had several 
 occasions to run across the patient during the next eight years : 
 he complained somewhat of gastric and nervous disturbances, 
 but his chest, outside of slight, rapidly passing bronchitic 
 troubles, was healthy. 
 
 The second case, which I had under observation six years 
 ago (during the winter of 1870-71), is a complete duplicate of 
 the foregoing one. Patient was also thirty years old, of a very 
 robust constitution, living under favorable conditions ; he had 
 been suffering from syphilis for nine years, the last five years 
 principally from various periostites and from ozoena. Was once 
 treated with mercury at the beginning of the disease, but since this 
 took only potassium iodide, which has ceased recently to exert 
 its formerly good effect. For the last few years patient began 
 also to suffer from slight disturbances of digestion and of the 
 nervous system, and also from bronchitis of a febrile type of a 
 slight nature and rapidly yielding to rest at home and the use 
 of quinine. For some time before I saw the patient first, he 
 was taken sick with his usual febrile bronchitis, but this time 
 it was accompanied by pain in the chest, and by dyspnea ; these 
 were not present formerly. Patient confined himself within, 
 the house, and when I was called to see him for the fu'st time 
 he had no fever, and the cough was just passing away. 
 
 Status. — Patient has a slight cough without expectoration ; 
 dyspnoea, a feeling of oppression and pain in the chest ; the 
 clavicles are very prominent, and the sub- and supraclavicular 
 fossae are sharply marked, especiallj- on the right side : over 
 these places the sound is duller and the vocal fremitus weaker 
 than in the area below, especially on the right side, while the 
 respiratory murmur is of an indefinite quality, approaching 
 bronchial respiration ; over the whole chest there are heard rales 
 here and there, peculiar to bronchial catarrh ; there is no fever, 
 patient became somewhat emaciated. As in the first case, pa- 
 tient was given no treatment during the first week: for the 
 
— 440 — 
 
 same reasons as guided me in the first case, I wanted to examine 
 the disease more thoroughly, before prescribing specific treat- 
 ment in the presence of such chest symptoms ; during this time 
 the cough disappeared entirely, as well as the rales, while the 
 other symptoms remained unchanged. Guided by the same 
 reasons as in the first case, mercurial treatment was ordered, in 
 the form of inunctions with mercurial ointment. Altogether 
 twenty-five inunctions were made : five of ten grains each, five 
 of fifteen grains, and fifteen of twenty grains each. During the 
 course of the treatment the morbid symptoms began to disappear, 
 and at the termination of the same there was neither dyspnoea 
 nor any feeling of oppression or pains in the chest ; the above- 
 described symptoms, which were observed on the objective ex- 
 amination of the chest have also disappeared, the sub- and 
 supraclavicular fossa became much less prominent, partly, of 
 course, on account of the fact that, thanks to the corrected diet, 
 the appetite and the digestion were in good order during the 
 treatment, and the patient grew somewhat stout. 
 
 The first case impressed me, not because the chest symptoms 
 which could excite a suspicion of pulmonary tuberculosis, yielded 
 so completely to the effects of the mercurial treatment, but be- 
 cause the whole group of these symptoms presented such a sharp 
 distinction from the collection of symptoms of ordinary pul- 
 monary phthisis, and the patient himself resembled a consump- 
 tive so little ; it was only the second observation, in which all 
 the characteristics of the first case were repeated with photo- 
 graphic accuracy, which led me to the conclusion that I had to 
 deal not with a group of coincidently connected symptoms, but 
 with a permanent form of syphilitic pneumonia, in its genuine, 
 uncomplicated form ; a diseased condition, which semiotically 
 and diagiiostically differs greatly from the picture of ordi- 
 nary pulmonary tuberculosis in non-syphilitics, as well as in 
 syphilitics. The principal criterion by which we could judge 
 that in both cases the affection was undoubtedly of a syphilitic 
 nature, the criterion ex juvantibus was but too apparent : under 
 the influence of the mercurial treatment the morbid phenomena 
 disappeared. My conviction was even more strengthened by 
 all we know concerning the anatomical alterations in the pul- 
 monary tissue when it becomes aft'ected by syphilis, the inter- 
 stitial and gummatous character of these alterations which 
 result in the thickening of the pulmonary tissue, and in the ex- 
 pulsion of air therefrom — all of which coincided so fully with 
 the nature of the symptoms observed in the above-described 
 cases on their objective examination. 
 
— 441 — 
 
 Putting now together the peculiarities of these cases which 
 enable us to recognize syphilitic pneumonia in its pure, uncom- 
 plicated form, as distinguished from chronic pulmonary tuber- 
 culosis seen in non-syphilitic patients, as well as in syphilitics, 
 we get the following: 
 
 1. Anamnestic and other data, pointing to an affection of the 
 patient's organism by syphilis. 
 
 2. The robust constitution of the patient. It is very likely 
 that persons with weak constitutions and with a predisposition 
 to ordinary — tuberculous — consumption, are rather sooner af- 
 fected by the disease, their lives not being prolonged until the 
 appearance of late syphilitic manifestations, to which belongs 
 syphilitic pneumonia. 
 
 3. The objective symptoms of thickening of the lungs are as 
 follows : dull percussion sound, weakened vocal fremitus, alter- 
 ation in the normal respiratory mui'mur. A sharp marking out 
 of the sub- and supra-clavicular fossae, due very likely to an 
 adhesive pleurisy, which accompanies syphilitic pneumonia as 
 frequently as adhesive perihepatitis accompanies syphilitic he- 
 patitis. Dyspnoea, a feelhig of oppression and pain in the 
 chest. 
 
 4. Absence of haemoptysis, cough, expectoration and rales. 
 
 5. Absence of febrile condition. 
 
 6. The decided effect of the specific treatment. 
 
 That such cases of syphilitic pneumonia as described above 
 may in their further course, if not recognized and treated at the 
 beginning, or if not presenting any possibility for treatment un- 
 der given conditions, become complicated by other affections of 
 the respiratory organs, such as a severe bronchitis, a pleurisy 
 with effusion, an acute and chronic pneumonia of non-syphilitic 
 nature, and then appear in another form, is both possible and 
 probable ; but such complicated cases do not permit a deduction 
 to be drawn therefrom in regard to the diagnostic, prognostic, 
 and therapeutic conclusions about syphilis of the lungs. 
 
 FRo:\r THE Second Cojvoiijnicatiox. 
 
 Patient, thirty-two years old, entered the facult}^ clinic Octo- 
 ber 21, 1877, complaining of dyspncea, cough, loss of voice, 
 swelling of the legs, and enlargement of the abdomen. 
 
 Mode of living and anamnesis. — Patient lives in a damp lo- 
 cality. Residence and board good. He was addicted. to much 
 smoking, and to immoderate whiskey drinking (neither smoked 
 
— 442 — 
 
 nor drank lately), and being a superintendent of an estate, he 
 talked much and loudly, and fatigued himself. 
 
 Patient comes from a healthy family. In February, 1870 
 (when twenty-live years old), he had post-coitum ulcera penis, 
 which passed away in the course of two months and a half with 
 the aid of local treatment solely. In November of the same 
 year there appeared a papular eruption, and later on ulcers on 
 the skin. With the aid of thirty inunctions with mercurial 
 ointment, and eight bottles of potassium iodide, everything dis- 
 appeared by February, 1871. 
 
 During March, 1872, there appeared nocturnal pains and 
 slight swellings of the clavicles and of the tibiae ; these lasted 
 for eight months and disappeared without treatment. During 
 the next four years our patient enjoyed good health. In March, 
 1877, there appeared a cough with dyspnoea and expectoration; 
 during June various oedemata and general weakness ; in July, 
 hoarseness of the voice and pain on deglutition. Later on, by 
 the time he entered the clinic, all the enumerated symptoms in- 
 creased rapidly, with the exception of the cough which dimin- 
 ished during summer and remained so (since autumn the patient 
 was conhned within doors) ; there were but trifling febrile symp- 
 toms, if we are to judge from the inquiry. 
 
 Status. — The appetite is poor, there are slight dyspeptic 
 phenomena ; diarrhoea ; ascites. The liver and spleen do not 
 admit of palpation. The urine is 600 c.c. in quantity during 
 twenty-four hours ; it is reddish, turbid, and contains much al- 
 bumen and many cylinders. 
 
 There is pain in the throat on swallowing and coughing ; 
 complete aphonia : laryngoscopic examination shows a condi- 
 tion of thickening and softening of the mucous membrane of 
 the true and false vocal cords and of the epiglottis, and later 
 on also the presence of ulcers in these parts. There is severe 
 dyspnoea ; the cough is but slight, expectoration of a muco- 
 purulent character, with an admixture of blood, the quantity of 
 the expectoration at the beginning Ijeing about one-fourth of a 
 glassful for twenty-four hours ; later on the quantity of expec- 
 toration and the cough became very insignificant. On the right 
 side the sound is dull over the clavicle and from there down to 
 the third rib ; thence downward it grows clearer ; in the subscap- 
 ular fossa and also between the scapula and the vertebral column 
 upward, the sound is also dull. On the left side, immediately 
 above and below the clavicle, the sound is somewhat dull, but 
 excepting these regions it is everywhere clear. All over the 
 
— 443 — 
 
 lungs there are heard whistling rales ; besides these, in the area 
 of the dull sound on the right side, there is heard a respira- 
 tory murmur approaching bronchial respiration, and very few 
 loud moist rales ; on the right side prolonged expiration. — The 
 impulse of the heart is not displaced, but it is weak : its tones 
 are clear. 
 
 The pulse is 96, somewhat weak. The evening temperature 
 reaches 38° B, (100.4° F.). There is everywhere a slight 
 anasarca, which is considerable on the foot and the leg. The 
 skin presents traces of serpiginous ulcers. The sleep is poor. 
 There is general debility. 
 
 The course of the disease. — Durmg the first days the patient 
 was given Dover's powder and some quinine. The cough rap- 
 idly diminished after this, and so did the quantit}" of expectora- 
 tion and the number of rales ; but the diarrhoea increased some- 
 what, and quinine was therefore put aside, and tra. opii simplex 
 was given. A week after the patient's admission to the clinic 
 the fever began to increase somewhat, the pulse grew weak, 
 notwithstanding the use of stimulants (as wine and tra. 
 valer. aether.), the dropsical phenomena became more marked, 
 and there appeared uraemic symptoms : heaviness and pain in 
 thef head, and nausea. November 8th there appeared erysipelas 
 accompanied by considerable fever (39.7° M. — 103.6° ^.), and 
 November 12th patient died. Durmg all the time that the pa- 
 tient remained in the clinic, the area of the dull sound over the 
 surface of the chest increased gradually from above do^vnward ; 
 during the last days it was impossible to examine the chest pos- 
 teriorly on account of the patient's extreme debility. 
 
 The patient was under the observation of our clmical assis- 
 tant, Dr. V. G. Nesteroff. The first communication made by 
 me in regard to syphilitic pneumonia led him to think of the 
 possible presence of such in the present case, in view of the fact 
 that the symptoms of thickenmg of the lungs, and especially of 
 the right one, were so considerable, while the fever was slight 
 and moist rales were observed only over a very limited area 
 (under the right clavicle), while the whistling ones disappeared 
 during the first week of the patient's sojourn in the clinic. 
 
 While analyzing the case before my students, I arrived at 
 the following diagnostic conclusions : 1. Chronic inflammation 
 of the kidneys (large kidney, i. e. chronic parenchymatous ne- 
 phritis). 2. The ascites and the diarrhoea may possibly have 
 their special causation in an alcoholic or syphilitic cirrhosis of 
 the liver. 3. A simple or degenerative atrophy of the heart. 4. As 
 
^ 444 — 
 
 regards the pulmonary affection, I agreed with Dr. Nesteroff 
 that the peculiarities of the case, as observed by him, together 
 with the anamnestic data, and the nature of the laryngeal 
 changes, lead us to recognize in the present case a syphilitic 
 pneumonia ; but as fever, haemoptysis, cough, expectoration, 
 and moist rales, although observed in a small degree, are still 
 not entirely absent, as was the case with the patients who suf- 
 fered from a pure syphilitic affection of the lungs, and who were 
 spoken of in my first communication, we may then assume that 
 the present case presents neither a pure syphilitic pneumonia, 
 nor a pure ordinarj^ chronic one (the usual pulmonary consump- 
 tion), but very possibly a contemporaneous affection of the 
 lungs by both processes. As regards treatment, the specific — - 
 antisyphilitic — treatment was contraindicated by the multitude 
 of painful affections, and by the extreme failure of nutrition 
 and strength, as well as by the fact that the syphilitic affection 
 of the lungs was not pure, but complicated by phenomena of 
 ordinary consumption. 
 
 The autopsy was performed by the then decent of pathologi- 
 cal anatomy (now professor of general pathology), A. B. Vogt. 
 The results of an extensive report and of the microscopical ex- 
 amination are as follows : syphilitic disease of the larynx (ulcers, 
 scars, diffuse papillary growths), agglutinated pleura, syphilitic 
 (interstitial and gummatous) affection of the upper lobes of both 
 lungs (especially of the right one), a chronic catarrhal pneumo- 
 nia also of the right lung (of its upper and middle lobes), an 
 acute, developed during the last days of patient's life, catarrhal 
 inflammation of the lower portions of both lungs, " brown " 
 atrophy (atrophia fusca^ of the cardiac muscle (the cardiac 
 valves and orifices are not altered) ; a syphilitic interstitial he- 
 patitis, amyloid degeneration of the spleen ; the increased size of 
 the kidneys presents sharply defined signs of Bright's disease. 
 
 While communicating this case at the annual (January, 1878) 
 meeting of the Physio-Medical Society, I arrived at the follow- 
 ing conclusions : 1. What I alluded to in my first communi- 
 cation of April, 1877, as possible and probable, became a real 
 fact in this case : namely, the syphilitic pneumonia was proved 
 to have become complicated by bronchitis, adhesive pleurisy and 
 by chronic catarrhal pneumonia,"* as well as by acute. 2. This 
 case proves that it is possible to diagnose not only a pure syph- 
 ilitic pneumonia, but a complicated one as well. 
 
 * Sucli was the name at that time, under the influence of Virchow's 
 teaching, of chronic pulmonary tuberculosis. 
 
— 445 — 
 
 Observations made by me in the domain of diseases of the 
 respiratory organs, and especially of syphilis and pulmonar}^ 
 tuberculosis, during the last fifteen years — since my second 
 communication on syphilis pulmonum — strengthen my asser- 
 tions which were put forward by me in the above communica- 
 tions, touching upon the semiotics and the diagnosis of simple 
 and complicated syphilitic pneumonia. As what concerns 
 the treatment of this last I must make a correction. In the 
 above communications I spoke against specific treatment in 
 syphilitic pneumonia complicated by tuberculosis, in view of 
 the fact, that during such a treatment this last is liable to 
 rapid advances. For the immense majority of such cases this 
 position holds good even now. But with the aid of modern 
 diagnosis (as the presence of tuberculous bacilli in the sputum 
 enables one at times to recognize early even very slightly diffused 
 affections of the lungs by tuberculosis, and consequently early 
 measures of treatment can be adopted in time), and modern 
 treatment, such as by creosote in large doses, there occur, 
 although rarely, exceptions, as a type of which may serve this 
 case observed by me. 
 
 ,The patient, who became infected with syphilis about ten 
 years ago and who presented at the time seen undoubted 
 manifestations of syphilis of the nervous system, begins to 
 cough more frequently than formerly (he usually coughs 
 because of a laryngeal catarrh brought on by smoking), and 
 complains of pain in the side of the chest ; at the same time he 
 grows somewhat thin and weak, but has no febrile symptoms. 
 Objective investigation shows considerable solidification in the 
 upper lobe of the right lung, and with this there is heard over 
 the solidified area a respiratory murmur of a character ap- 
 proaching bronchial respiration, and at times infrequent, non- 
 abundant rales ; the expectoration, which is very scanty, shows 
 the presence of tuberculous bacilli. Thanks to a sufficiently 
 thorough iodide treatment the symptoms of solidification and 
 pain in the right side disappeared, while the patient himself 
 grew stronger; with the aid of creosote following this treat- 
 ment, the cough diminished to the degree usual with the 
 patient, the rales, as well as the bacilli in the expectoration, 
 disappeared, while the patient himself became so stout and 
 strong, that his health could be called florid. Later on the 
 patient underwent also calomel and iodide treatment, which 
 was ordered because of the other above-mentioned manifesta- 
 tions of syphilis, without any marked impairment of his health 
 and without the slightest symptoms of a recurrence of the 
 pulmonary tuberculosis. 
 
SYPHILIS OF THE HEART. 
 
 Feom the Clln'ical Sta2>:dpoi^"t. 
 
 The short report of my address * which was published in the 
 Contributions to the Pliysio-Medical Society (No. 1, January, 
 1887) contains only my conclusions ; the remaining part of 
 the report is not written by me and it, as well as the references 
 which appeared in many other editions, present certain inaccu- 
 racies due to somewhat .hurried observations. 
 
 Having some time at mj^ disposal during the summer of 
 1889, I decided to prepare for publication also my own com- 
 munication on syphilis of the heart, as I can see from medical 
 literature that the subject is just as interesting now as it was 
 two and a half years ago ; but this communication appears 
 at the present time in a somewhat changed form : first, be- 
 cause the number of cases observed by me has increased, and 
 one of these, which had been under my care in the clinic during 
 the last spring, will be discussed by me later on, as it presents 
 some peculiar characteristics ; and secondly, because I wil] only 
 touch slightly on the general therapy of the diseases of the 
 heart (to this I had to resort in complicated cases of cardiac 
 syphilis ; I therefore spoke of it in particular during my first 
 communication), as I intend to take up the subject and discuss 
 it more fully in the edition of my lectures when treating of the 
 subject of diseases of the heart in general. 
 
 Turning to the literature on the pathology of the subject. I 
 must say that with the exception of some additional matter of a 
 casuistic nature, the subject under discussion did not advance 
 during these two years and a half. 
 
 As regards the pathological anatomy, we have long been 
 informed of the existence of gummatous myocarditis, and we 
 know now of syphilitic affections of both the endocardium 
 and pericardium ; but we posses.s no definite mformation re- 
 
 * Delivered at the annual meeting of the Moscow Physio-Medical 
 Society, January, 1887. 
 
 446 
 
— 447 — 
 
 garding syphilitic affections of the cardiac vessels and nerves, 
 and meanwhile clinical observations, as we shall see later, lead 
 us to the conclusions, that in some cases the syphilitic process 
 attacks the cardiac nerves even to a preeminent degree as com- 
 pared with the other tissues of the organ. As far as the clmi- 
 cal data are concerned, the modern text-books of special pathol- 
 ogy and therapeutics do not pay due attention to syphilis of 
 the heart. To be sure, among the causative agencies of cardiac 
 diseases syphilis is mentioned as one ; gummatous myocarditis 
 is treated of by pathological anatomy ; but there is no mention 
 made of cardiac syphilis in either symptomatology or diagnosis ; 
 while in discussing the treatment some allude to the possibility of 
 a specific treatment in cardiac diseases, while others do not 
 mention even this. Thus the study of the modern text-books 
 will rather tend to cultivate a neglect toward the subject of car- 
 diac syphilis, failing to bestow on it the attention it merits. 
 An impression is abroad that syphilis is but an accidental dis- 
 covery during autopsies, and that it is rather a subject for path- 
 ological anatomy than for the clinic. Be as it may, the study 
 of these text-books fails to convey the idea of the considerable 
 practical importance of this affection. In vain will the student 
 search in these text-books for answers to the questions : What 
 is the clinical aspect of syphilis of the heart ? In what forms 
 does it present itself ? Has this cardiac affection any practical 
 significance so that it can be recognized in time and subjected 
 to successful treatment? How effective may such treatment 
 prove ? 
 
 Up to the present time I have had occasion to observe already 
 more than ten cases. I will first describe those which present 
 a smaller variety of attacks and are less complicated by other 
 diseases. 
 
 The First Case. — Patient is about forty years old, was infected 
 with syphilis, and does not abuse alcoholic drinks. For the last 
 few years he has been suffering with dyspnoea, palpitation, and 
 at times with symptoms of disturbed circulation (as evinced by 
 (jedema of the legs and lungs and by enlargement of the liver), 
 which is but slightly and for a short time relieved by digitalis. 
 The left ventricle is enlarged, but the heart sounds are clear and 
 there are no symptoms of atheromatosis of the arteries: i. e. 
 not only is there no systolic murmur at the sternum, but the 
 arteries are not stiff, and there are no symptoms of a disturbed 
 cerebal circulation. The kidneys are healthy. Treatment by 
 sodium iodide, commencing with ten and increasing up to 100 
 
— 448 — 
 
 grains per day during the period of six weeks, brought about a 
 complete improvement in the patient's condition: all the morbid 
 ■symptoms disappeared, and in the three or four years during 
 which the patient was constantly under my observation, he only 
 had at times attacks of dyspnoea and palpitation of much less 
 frequent occurrence and of slighter intensity than formerly, 
 which yielded rapidly to digitalis ; but he never again had 
 any oedema. The left ventricle diminished in size (the apex 
 beat of the heart is on the left mammillarj^ line, whereas for- 
 merly it reached beyond it) and the pulse became less frequent, 
 stronger and more regular. 
 
 jSTutrition and strength improved considerably. Patient re- 
 peated twice the treatment with sodium iodide. 
 
 The seeojid case is in all respects similar to the foregoing, ex- 
 cept that the patient suffered, not from a disturbance of the 
 general circulation, but from frequent attacks of cardiac asthma 
 which culminated in oedema of the lungs and did not yield to 
 either digitalis or to any other remedies. After a course of 
 energetic treatment with sodium iodide, the attacks disappeared 
 entirely for a long time, and even when they reappeared later on 
 they were much less frequent and of slighter intensity, and 
 yielded rapidly to digitalis. 
 
 Third Case. ■ — Patient is fifty-five years old; is infected 
 with syphilis ; suffered before with acute articular rheumatism, 
 and abused to some extent alcoholic drinks. Has been suffer- 
 ing for more than a year with torturing attacks of angina pec- 
 toris, for which he took a great variety of palliative remedies, 
 lately always nitro-giycerine, several times a day, with but a 
 trifling, rapidly passing, relief. Patient has stiff arteries and 
 presents evident symptoms of insufticiency of the aortic valves 
 (sharp diastolic murmur at the sternum, a jerking pulse, enlarge- 
 ment of the left ventricle); but outside of the attacks of angina 
 pectoris he presents nothing morbid : neither dyspncea, nor pal- 
 pitation, nor any oedema, — all the functions are normal. The 
 sodium iodide treatment relieved the patient considerably and 
 later on inunctions of mercurial ointment brought about a com- 
 plete cessation of the attacks of angina pectoris ; the objective 
 signs of insufficiency of the aortic valves and of general chronic 
 arteritis remained unchanged. 
 
 The fourth case is similar to the third : there were also at- 
 tacks of angina pectoris, which yielded to specific treatment. 
 
 The above-described cases of syphilis of the heart must be 
 considered, from their aspects, as exceptions, because the other 
 
— 449 — 
 
 cases, i. e. the considerable majority of such, present usually 
 another aspect, differing by a great variety of attacks, and by 
 being usually considerably complicated, namely : by alcoholism 
 or gout, by chronic arteritis, gastro-intestinal disturbances, and 
 also by simultaneous syphilitic affections of other organs, most 
 frequently of the nervous system and of the liver. The cardiac 
 symptoms in such cases, as I said above, take on a great variety 
 of forms and are usually all easily discoverable : such as a con- 
 stant dyspnoea with palpitation and a sensation of oppression 
 in the region of the heart, attacks of cardiac asthma, as well as 
 of angina pectoris, considerable cedema and accumulations in 
 the cavities as a result of disturbed circulation. The heart is 
 usually enlarged, especially its left ventricle, and the pulse is 
 weak, frequent and arythmical; a systolic murmur is frequently 
 heard at the sternum. Examination of both the present and 
 the past conditions of the patient either elicits syphilitic infec- 
 tion directly, or makes it very probable. 
 
 The general character of all these cases is such that the 
 most careful and conscientious non-spe.cijic treatment fails to 
 bring about any marked improvement, while a specific treat- 
 rnent consisting of the employment of sodium iodide and of 
 mercurial inunctions results in a lasting improvement : the mor- 
 bid phenomena disappear, there remain only the objective signs 
 of some enlargement of the heart, and at times a weak systolic 
 murmur over the sternum. 
 
 As a type of the above alluded to majority of cases of car- 
 diac syphilis as seen by me, I will now describe more fully the 
 one spoken of before, which was under my observation in the 
 clinic during the last spring, and served as a subject for my 
 clinical lectures during the beginning, the middle and the end 
 of the patient's sojourn in the clinic. 
 
 Patient, thirty-four years old, entered the clinic March 7, 
 1889, in a very aggravated condition, complaining of extreme 
 weakness, dyspnoea, and swelling of the whole body, and espe- 
 cially of the legs. 
 
 Mode of life and anamnesis. — Patient has no constant place 
 of residence, but lives in turn in three different cities, several 
 months in each. His rooms, in a hotel, are not always satis- 
 factory ; the watercloset is always cold. Patient drinks some 
 four glasses of tea per day ; avoids drmking coffee, as it gives 
 rise to palpitation ; has one meal a day, always containing some 
 meat; smokes much, and is addicted to alcoholic drinks : not 
 less than seven wine-glasses of brandy, and seven bottles of beer 
 
— 450 — 
 
 per day ; and three times a month even more than this. With 
 ■ the exception of the last month, such drinking has continued 
 for ten years, but during the last month he entirely discon- 
 tinued the use of alcoholic drinks ; his occupation is not of a 
 fatiguing nature, outside of considerable travel — in winter on 
 sleds, in summer mostly on the steamer. 
 
 The patient is tall and broadly built ; was even when young 
 inclined to corpulence and was subject to attacks of slight 
 dyspnoea, but since he began to abuse alcoholic drinks both the 
 corpulence and dyspncjea increased ; barring this, the patient 
 does not recollect having had any diseases until two years ago. 
 At that time he became infected with syphilis : there appeared 
 an ulcer on the penis, eruptions, and falling out of the hair. 
 Patient took pills of mercury during three months, and after 
 a two months' interval, for another month and a half ; as a re- 
 sult all the above-named symptoms of syphilis disappeared, but 
 the patient began to feel weak and fatigued by his work, which 
 he formerly bore well. Some eight months ago, after an ordinary 
 day's work, he had at night an attack of angina pectoris without 
 any ascribable cause : there was pain along the sternum and 
 in the region of the heart transmitted to the back, left shoulder, 
 and the left arm down to the elbow ; the pain was not severe, 
 but lasted for a whole night and passed away in the morning 
 without any treatment. Since then there occurred nocturnal 
 pains in the legs, in the region of the tibial bones. Patient 
 again took pills of mercury during one month, and the pains in 
 the legs disappeared. 
 
 The second attack of angina pectoris similar to the first one 
 took place on the night of February 1, 1889; it was not severe, 
 but also continued during the whole night, for about eight 
 hours. Patient at once left off drinking brandy and beer, after 
 which he rapidly lost his appetite and grew thin and weak. 
 Three weeks ago the dyspnoea began to increase, and there ap- 
 peared oedema of the legs. Patient took no treatment, and the 
 described attacks, having reached the above-mentioned severe 
 state, compelled him to enter our clinic. 
 
 Status March 7', 1889, — Appetite not as good as it was before ; 
 eating is accompanied by pyrosis, eructations, nausea, and oc- 
 casional vomiting. Since the patient gave up drinking beer 
 and brandy he suffers from constipation ; has every other day 
 some hard evacuations. Until that time he used to have three 
 to four soft, gruel-like, painless stools. The urine is secreted 
 freely, to the amount of 1,000 c.c. in twenty-four hours, of a red 
 
— 451 — 
 
 color, containing neither albumen nor sugar. The liver is en- 
 larged and painful. The spleen presents nothing abnormal. 
 There are symptoms of fluid accumulations in the abdominal 
 cavity, and, as mentioned above, considerable Oidema of the arms, 
 legs, and of the entire subcutaneous tissue. Patient complains 
 of palpitation. On account of the present corpulence, of the 
 cedema of the subcutaneous tissue, and of the weak cardiac ac- 
 tivity, the results obtained by the objective examination of this 
 last are not pronounced: there is a weak cardiac impulse felt at 
 the left mammillar}^ line, but percussion elicits a dull sound over 
 the left half of the sternum, and auscultation a weak systo- 
 lic murmur. The pulse is 120, verj^ weak and arythmical. 
 The dyspn(jea is very pronounced, 46 to 52 per minute; patient 
 is unable to lie down. There is no cough. The condition of 
 the lungs, as shown by percussion, is normal (onl}^ the dia- 
 phragm is somewhat raised), and auscultation shows abundant 
 moist rales under both scapulee. The temperature is 38° R. 
 (98.4° _F.). He hardly sleeps at all on account of the 
 dyspncjea. His mental state is extremely depressed, and at 
 times very irritable. There is considerable weakening of the 
 memory. Xo dizziness, headache, nor any pains, except some in 
 the region of the calves when they are compressed. Extreme 
 weakness of all the movements, and especially of those of the 
 lower extremities. 
 
 Having put the patient in a condition of rest, having limited 
 the quantity of drink to what was absolutely necessary, and 
 after regulating the diet (at the beginning all his food and 
 drink consisted of a glass of tea without sugar in the morning, 
 a half-glass of bouillon and a small cutlet for dinner, and six 
 glasses of milk durmg the whole day ; later on, with the im- 
 provement of the patient, the diet was accordingly changed), 
 we prescribed eight tablespoonfuls of strong Crimea wine per 
 day, the mixture of the aether- valerianate and Hoffman's drops 
 aa at the beginning up to 200 drops per da}', digitalis m an 
 infusion, altogether twenty-four grains during the fii\st two days, 
 a large Spanish fly over the region of the heart, and a clyster in 
 case of necessity. By the third day there occurred some slight 
 improvement : the pulse was 98, the dyspnoea somewhat less 
 severe and the amount of urine was 2500 c.c. ; but on the next 
 day the dyspnoea became again aggravated, and the urine fell 
 to onl}' 1500 c.c. As the clyster evacuated the bowels insuffi- 
 ciently and the abdomen was very much distended, we gave 
 him calomel, one grain every hour : after the fifth dose the 
 
— 452 — 
 
 patient had abundant loose dark-green evacuations, the respira- 
 tion became easier, but the amount of urine did not increase. 
 We then resorted again to the infusion of digitalis, twenty-four 
 grains during two days ; the stimulants, namely the wine and 
 the above-2iamed drops, were given to the patient during all the 
 time that he remained in the clinic, — later on in smaller doses 
 in accord with the improvement of the pulse: only during the 
 last days before patient left the clinic did we leave off these 
 drops. 
 
 The second dose of digitalis given together with the stimu- 
 lants in the first large dose, failed to markedly improve either 
 the pulse or the respiration, or to increase the amount of urine 
 over 2000, and did not produce any marked decrease of the 
 signs of oedema. Putting then aside the digitalis and continu- 
 ing the stimulants, sodium iodide (~ij to 3VJ) was ordered in 
 Ems water (in view of the continuing dyspeptic symptoms), 
 a tablespoonful in a quarter of a glass of the water (altogether 
 between one and one and a half glasses of Ems per day). 
 March 15th, twenty grains of sodium iodide ; 16th, thirty 
 grains; 17th and 18th, forty grains each: the urine rose to 
 3000 c. c. in quantity, the signs of oedema began to diminish, 
 the pulse became less frequent (78-72), breathing grew easier, 
 sleep better, the temperature fell to the normal. From March 
 19th to 2od he had fifty grains of sodium iodide per day, from 
 the 23d to the 28th sixty grains ; with the former quantity of 
 drink the urine amounted to -1000 c.c. ; the cedema passed 
 away, the breathmg became free (20-18), the sleep quiet; the 
 li\'er has diminished considerably in size and is not sensitive, 
 the pulse became regular and strong, but is still frequent (96- 
 100). He was again given iufusion of digitalis (twentj^-four 
 grains of digitalis) during two days, but without any appreciable 
 result. We then again resorted to sodium iodide. 
 
 We must now say a few words concerning the condition of 
 the patient's nervous system. Notwithstanding the consider- 
 able decrease in the extent of the oedema and the increase of 
 the patient's strength, the weakness in the movements of the 
 legs, which was ascribed to general debility and to the great 
 weight of the legs on account of the (jedema, remained in the 
 former condition : the patient was unable to either walk, or 
 to even stand erect ; we could not bring out any tendon 
 reflexes in the legs (the sensibility was preserved). Massage 
 failed to improve the condition of the lower extremities. Such 
 a paretic state of the legs and a considerable weakening of 
 
— 453 — 
 
 the memory, in the presence of an undoubted syphilitic infec- 
 tion of the organism, have naturally led us to suspect a syphi- 
 litic infection also of the nervous system ; we therefore continued 
 the specific treatment the more persistently, constantly increas- 
 ing the dosage of the sodium iodide, from <jO grains per day to 
 90, 100 and 120. By April 19th the patient's condition, out- 
 side of that of the legs, was entirely satisfactory : the appetite 
 was good, the digestion regular, the amount of urine was always 
 1800 c. c. in twenty-four hours, the dimensions of the liver 
 almost normal (the signs of ascites, as mentioned above, dis- 
 appeared even before), breathing free, no palpitation, the pulse 
 7S to 80, regular and strong, the dimensions of the heart de- 
 creased (the percussion sounds on the inferior part of the chest 
 are clear); there remained the weak -systolic murmur at the 
 sternum ; the sleep is good, the mental state hearty, the memory 
 better, nutrition and strength are normal ; but the weakness of the 
 lower extremities has not passed away, although it has diminished 
 somewhat. April 1 9th. he was given eighty grains of sodium 
 iodide, and since the 2()th. sixty grains a day and at the same 
 time inunctions with mercurial ointment. 3j per day, in con- 
 junction of course with a mouth wash of a potassium chlorate 
 solution. With the aid of inunctions the condition of the 
 lower extremities began to improve rapidly. May the first, the 
 patient was compelled by his official duties to leave the clinic ; 
 by this time he was able to walk almost as well as any healthy 
 man, and the tendon reflexes returned; but he was advised to 
 continue the specific treatment for another three weeks so as 
 to obtain a lasting benefit from this treatment which he bore so 
 well. 
 
 In this case, outside of syphilis of the heart and of the nervous 
 system, there was probably also a syphilitic affection of the liver. 
 It is true, that enlargement as well as tenderness of this last 
 might also have been due to blood stagnation, in the presence 
 of a general disturbance of the circulation, and also to alcohol- 
 ism ; but the considerable ascites indicates not only a condi- 
 tion of stagnation, but a more serious affection of the liver, and 
 that this last was of syphilitic, rather than of an alcoholic nature, 
 is seen from the rapid improvement in the condition of the liver 
 under the influence of the iodide treatment. 
 
 As far as the diagnostication of the cardiac condition in the 
 above-described cases is concerned, we are compelled to infer in 
 the first case, if not a pure, then a preeminent affection of the car- 
 diac muscle, namely syphilitic myocarditis ; in the second, third. 
 
— 454 — 
 
 fourth, a preeminent syphilitic affection of the cardiac nerves ; 
 and in the last as well as in those of which it serves as a type, 
 namely, in the majority of the cases of "cardiac syphilis, as ob- 
 served by me, a simultaneous syphilitic affection of both the 
 muscle and the nerves of this organ. I did not come across a 
 case of cardiac syphilis, which would present evident objective 
 symptoms of an affection of the valves and of the cardiac orifices 
 and in which, with the improvement of the heart activity and 
 circulation, these symptoms would disappear. 
 
 To judge from the foregoing, the chief basis for the diagnosis 
 of cardiac syphilis, as well as of syphilis of the other internal 
 viscera, is found in the anamnestic data and in the simultaneous- 
 ly occurring symptoms of syphilis in other parts of the organ- 
 ism. As regards the anamnesis, we are far from relying upon 
 what the patient asserts or denies concerning syphilitic infec- 
 tion. Both the assertion and the denial are to be considered 
 critically ; while denying, the patient may hide the truth pur- 
 posely, or he may do so bona fide, without any suspicion on his 
 part of ever having been infected by syphilis : on the other hand 
 the patient may mistake a syphilitic infection, although this hap- 
 pens but seldom. To verify these assertions and to obtain reli- 
 able data for the diagnosis we must resort to a thorough inves- 
 tigation of the past history, of the phenomena which the patient 
 considered as syphilitic, of whether there was any falling out of 
 hair of the head, and especially of the eyelashes and beard, of 
 characteristic eruptions, nocturnal pains, etc., and also as to 
 whether the patient subjected himself to iodide and mercury 
 treatment and as to the influence of such treatment on his con- 
 dition. As indications for the diagnosis may also serve the 
 absence of other causes of the cardiac affection (as in our first 
 case), and the slight effectiveness of non-specific treatment. 
 
 The specific treatment instituted for the sake of verifying 
 the diagnosis of cardiac syphilis, is the same as applied in other 
 cases of late syphilitic affections ; if the patient has formerly 
 subjected himself to a sufficient mercurial treatment, then the 
 iodide preparations usually exert a favorable effect, and the iodide 
 treatment alone may be sufficient to improve the patient's 
 condition ; otherwise, it becomes necessary to resort to mercury, 
 alone or in combination with the iodide preparations, which 
 last are in such cases administered in smaller doses than when 
 the iodides alone are used. As what concerns the non-specific 
 treatment of the cardiac therapy in general, I intend to return 
 to it at some other time. However the last full}^ described case 
 
— 455 — 
 
 of cardiac syphilis gives a sutiiciently clear idea as to wliat rem- 
 edies of general cardiac therapy are to be employed in syphi- 
 litic affection of the heart. The same case makes it clear, that 
 if the indications of the presence of syphilis be sufficient, then 
 there is no need to hesitate with the ordering of a specific 
 treatment. 
 
 I will take the opportunity to touch now on two remedial 
 agencies in the domain of cardiac therapy, the so-called 
 milk treatment of diseases of the heart, and the application of 
 Spanish flies to the region of the heart. 
 
 As far as the first is concerned, its name contains an inaccu- 
 racy which may be the cause of mistaken application of the 
 milk treatment for such cases of cardiac disease, in which it is 
 both unnecessary and unsuitable. The milk treatment exerts 
 its effect not on the diseases of the heart (except in one case, 
 of which presently), but on their complications, such as ascites, 
 abdominal disorders (dyspepsia, constipation, enlarged abdomen 
 due to gastro-intestinal meteorism. and abdominal obesity) and, 
 less frequently, general obesity. It is true that in cases of as- 
 cites caused by cardiac disease, milk serves as the best diuretic, 
 when it becomes necessary to act tlxrough the kidneys (and 
 when we desire to act through the heart, we resort to digitalis 
 and to similar drugs) ; it is also true that the complications of 
 cardiac diseases in the form of abdominal disturbances are verj- 
 frequent and serve as the chief cause for the presence of obsti- 
 nate dyspnoea, cardiac asthma, angina pectoris, and the circula- 
 tory disturbances, and that the removal of these complications 
 by the aid of a strict milk treatment (at the beginning milk 
 only, and later on milk with meat, fish, and eggs, but no carbo- 
 hydrates) is attended with splendid results ; however, the milk 
 treatment acts solely on the above-nahied complications, and 
 not on the heart itself, and to prescribe this treatment for cases 
 of cardiac diseases unattended with such complications — which 
 is often done, thanks to the erroneous idea conveyed by the 
 name (" of the diseases of the heart "' ) — is a procedure devoid of 
 any purpose and tending to weaken the patient. There is only 
 one case m Avhich the milk treatment may exert a direct action 
 on the heart, namely in the condition of fatty heart resulting 
 from general obesity : it is admissible to assume that with the 
 general emaciation which usually follows the milk treatment, 
 there also occurs a diminution in the fat of the heart. If the 
 syphilitic affection of the heart becomes complicated by ascites, 
 abdominal disturbances and obesity, then in prescribing the 
 
— 456 — 
 
 treatment we should take into account such a condition of 
 affairs, and so we did in the last of the described cases of car- 
 diac syphilis. 
 
 I will now take up the use of Spanish flies. Some seven 
 years ago (February, 1882) I called the attention in a commu- 
 nication before the Physio-Medical Society to the value of 
 Spanish flies in peripheral neurites. Since that time I had fre- 
 quent occasions to observe a considerable and lasting improve- 
 ment from the application of flies to the region of the heart, 
 to either the right or the left side of it, as well as above or 
 below the left nipple (in women, to the left mammary gland) 
 in angina pectoris, usually in cases of such a nature : in patients 
 no longer young, mostly gouty, sometimes with symptoms of 
 chronic arteritis. The attacks of angina pectoris were usually 
 caused by colds, appearing when the chest was subjected to a 
 cold blast, or after the inhalation of cold air. 
 
 The examination of the chest in the region of the heart in 
 such cases usually elicits, skin hyperaesthesia being absent, 
 pain on pressing the ribs (periostites of the ribs) and the inter- 
 costal spaces (intercostal neurites). Quite frequently the other 
 parts of the chest, especially its left side, present the same 
 phenomena ; but the pain is usually most marked on pressing 
 those intercostal spaces which correspond to the locality of the 
 heart, which circumstance leads us to assume the existence also 
 of a neuritis of the cardiac plexus in such cases. The attacks 
 themselves of angina pectoris are quite characteristic, the pain 
 being transmitted to the left arm down to the very fingers. 
 Outside of Spanish flies and other necessary treatment, I usually 
 advise such patients to wear a woolen or silk chest protector so 
 as to avoid any possibility of catching cold. But in cases of 
 attacks of angina pectoris in syphilitic cardiac affection, the ap- 
 plication of Spanish flies to the affected spot produces but an 
 insignificant and rapidly passing relief, and should not there- 
 fore be recommended. 
 
 The observations brought forth in this communication give 
 one an idea of the clinical picture of cardiac syphilis, and 
 stand witness to the fact that this last may yet be recognized 
 early enough to be treated successfully and lastingly to no 
 lesser degree than is the case with syphilis of other internal 
 organs. 
 
— 457 
 
 Additional Notes. 
 
 First. As is well known, the iodides are recommended and 
 used also in simple, non-syphilitic sclerosis and atheromatosis 
 of the arteries and the myocarditis following thereon. I have 
 seen a great many patients suffering with the above-named 
 diseases, who had been taking for a long time the iodides of 
 potassium and sodium ; but never, not in one single instance, 
 even when large doses, as thirty to forty grains per day, of these 
 remedies were used, have I observed such a positive, incontro- 
 vertible success, as I saw in the treatment by the iodides and 
 by mercury of the same affections when of syphilitic origin. I 
 do not consider it improbable, that in the cases in which cer- 
 tain observers noted such a success, syphilis was an element in 
 the development of these affections. 
 
 Second. During the year I had occasion to observe a few 
 more cases of cardiac syphilis ; but as they present nothing 
 different from the above conclusions, I do not consider them 
 here. I think however, that the following case of aneurism 
 of the aorta (and probably of the innominate artery) as resulting 
 from syphilitic aortitis, is of sufficient interest to be brought 
 forward. 
 
 February 6, 1890, a patient, thirty-seven years old, entered 
 our clinic, complaining of pains in the right half of the head 
 and in the right shoulder, and also of palpitation and dyspnoea. 
 
 He lives in a good locality and in a fairly good house. He 
 does not bathe in the river; takes a hot bath weekly and 
 perspires freely. Does not smoke, drinks always brandy and 
 sometimes to excess, also a great deal of hot and strong tea ; 
 has good board. Patient has a great many occupations of a 
 troublesome nature ; has to talk loudly, to travel in jolting 
 carriages and sleighs over poor roads, and conducts a considera- 
 ble correspondence. He was infected with syphilis, later got 
 married; out of six children three were still-born, the fourth 
 died in early infancy, the fifth is sickly, the sixth is as yet 
 well. 
 
 Anamnesis. — When twenty-four years old, patient was in- 
 fected with syphilis, was treated for two months by mercury, 
 and to some extent by the iodides, and since then, considering 
 himself recovered, he resorted to no antisyphilitic treatment. 
 During the last four years patient had at times pains in the 
 legs day, and night ; while one year ago there appeared pains 
 in the right half of the head and in the right shoulder, which 
 
— 458 — 
 
 gradually increased. Lately these pains have prevented good 
 sleep and patient grew emaciated. Five months ago there 
 appeared palpitation of the heart and a swelling on the lower 
 portion of the right side of the neck, which kept continually 
 increasing in size, so that lately, on account of the swelling, he 
 has been unable to button his shirt-collar. 
 
 Status Feb. 6, 1890. — Patient is of strong constitution and 
 good nutrition. The appetite is fair, digestion regular, the 
 liver, spleen, kidneys, and the urinary bladder are in a normal 
 condition. There is palpitation of the heart, some dyspnoea, and 
 a slight dry cough. Objective examination of the chest shows 
 nothing abnormal in the respiratory passages, while the organs 
 of circulation present the following : a strong, visible impulse 
 of the cardiac apex two fingers' width outside the left mammil- 
 larj^ line, between the sixth and seventh ribs ; a pulsating 
 tumor in the region of the right sterno-clavicular articulation ; 
 on percussion a dull sound over the tumor and over the upper 
 third of the sternum ; percussion over the other two-thirds of 
 the same elicits normal clearness ; on auscultation, a systolic 
 murmur along the whole line from the apex of the heart up to 
 the above-mentioned tumor, especially so over the sternum 
 and to its right; there is also heard over the sternum a 
 slight diastolic murmur pointing to an affection also of the 
 aortic valves, namely, insufficiency ; over the carotid arteries 
 a systolic murmur, but no heart tone is heard. The pulse is 
 between 80 and 90, of regular rhythm, somewhat weak, weaker 
 on the left than on the right hand. No fever. The above- 
 described pains on the right side of the head and right shoulder 
 prevent sleeping ; he is unable to rest on the right side ; the 
 right arm is so weak that patient is unable to write. These 
 pains and weakness depend evidently on pressure of the tumor 
 on the right brachial plexus. 
 
 Outside of regulating the regimen and diet, he was given the 
 following : some wine, tra. valer. aether, andliqu. anodyn. Hoffm. 
 aa, when the pulse is weak, and constantly increasing doses of 
 sodium iodide, beginning with ten grains a day up to eighty (dur- 
 ing the last week before he left the clinic). As we intended to 
 administer large doses of sodium iodide, and as this iodide, just 
 as that of potassium, is better borne by the stomach and intes- 
 tines in alkaline solutions, we gave it to him dissolved in Vichy ; 
 -'but as this caused some looseness of the bowels, we replaced after 
 two days the Vichy by Ems water, and with this the iodide was 
 very well borne. Both the Vichy (Celestins) and the Ems (Kessel- 
 
— 459 — 
 
 brunnen) were used as natural waters, at the temperature of 
 warm milk, to the quantity of half a glassful during the day. 
 Simultaneously with the administration of the sodium iodide 
 there were made twelve mercurial inunctions, at first in one- 
 half drachm doses, and later in drachm doses. In the intervals 
 between the inunctions the patient was sponged with a mixture 
 of water and brandy at the temperature of warm milk and 
 somewhat cooler, which diminished the sweating and strength- 
 ened him. 
 
 March 12, 1890, patient left the clinic in the following 
 condition : all the pains disappeared, he can lie on the right 
 side ; the sleep is good ; the right arm is completely serviceable, 
 patient can write freely ; the tumor in the region of the right 
 sterno-clavicular articulation has diminished so much that he 
 can freely button his shirt ; the pulsation of the swelling is so 
 insignificant that it can be detected only by touch, but not by 
 the eye, as was the case formerly; the pulse of the right arm 
 has become fuller ; the symptoms obtained by percussion and 
 auscultation have not changed ; the palpitation does not trouble 
 the patient any more, and he declares that in a general way he 
 feels well and cannot complain of anything. 
 
 The patient was advised, outside of preserving a regular 
 mode of living and caution required by the condition of his 
 chest, to continue the sodium iodide for a few more days (up to 
 six weeks), and to repeat the treatment in summer. Up to 
 recently (November, 1890), as we have heard, the condition of 
 the patient continues as satisfactory as when he left the clinic. 
 
 My last observations (1891) on cardiac syphilis, in the 
 clinic as well as in private practice, completely substantiate all 
 the above assumptions. 
 
TREATMENT OF FEVER. 
 
 (A Therapeutic Note.) 
 
 Shall we treat fever, and if yes, how ? 
 
 At the present time there are those who assert that the fever 
 accompanying the acute infectious diseases must not be treated, 
 because it forms, as it were, a protecting agency to the organism 
 against the pathogenic factor. Without denjdng not only the 
 possibility, but even the probability of such a process of self- 
 protection, we nevertheless are unable to draw conclusions there- 
 from to the effect that the fever must be left untreated. Is 
 not, for instance, the cough in certain cases (as in bronchial 
 catarrh with abundant secretion, in oedema of the lungs and so 
 on) a self-protecting agency to the organism, without which 
 the patient would suffocate, — a beneficial symptom which in 
 such cases must not be weakened, but on the contrary strength- 
 ened, and are we not compelled in other cases, as even in this 
 same bronchial catarrh, to relieve the too severe cough, if 
 it tends to impair the sleep, and to act injuriously or even 
 dangerously on the cerebral circulation, on the cardiac activity, 
 on the condition of the abdominal organs, etc. ? The same 
 may be said of diarrhiDea, and of other symptoms which are bene- 
 ficial to a certain degree, and become injurious as soon as this 
 degree is overstepped; the same applies to fever in connection 
 with infectious diseases, and consequently the physician must 
 consider it in the same light in which he considers the other 
 symptoms of a similar nature, namel}^ not to treat it, if he 
 has reason enough to consider its presence beneficial and as 
 long as it does not overstep certain bounds, and to t reat it in 
 the contrary case. 
 
 How is fever to be treated? In cases where the radical treat- 
 ment, not only of the febrile symptoms, but of the disease it- 
 self (as, for instance, in malaria, in acute articular rheumatism) 
 is possible, the modus operandi for the physician needs no explan- 
 ation. 
 
 In the acute infectious diseases for which we possess no rad- 
 460 
 
— 461 — 
 
 ical treatment, as, for instance, in typhus, typhoid and recurrent 
 fevers, influenza, croupous pneumonia, erj^sipelas, etc., I act as 
 follows : If the fever is moderate, and if by analyzing the pa- 
 tient's condition I am unable to detect any undoubted deleterious 
 influence on the patient therefrom, then I wait; otherwise I 
 resort to treatment. What is the degree of temperature that 
 constitutes a moderate fever ? We must, of course, first of all 
 individualize our case : aged people are less able to bear a tem- 
 perature of 39° R. (102.2° F.) than children will bear one of 
 40° R. (104° F.') and higher; but speaking in a general way, 
 a temperature of 39° R. (102.2° F.) in adult, but not aged 
 persons, need but seldom trouble the physician, whereas one 
 of 40° R. (104° F.') and above excites apprehensions. The 
 greatest care and most thorough inquiry about the condition of 
 the patient is required in case of a temperature ranging between 
 39°i^. (102.2° F.) and 40° R. (104° F.~). — In such cases, as, 
 for instance, in typhoid fever, if there be present no other trou- 
 blesome symptoms, I do not treat the fever. If with such a 
 temperature there be also present some dangerous symptom, 
 then, before taking up the treatment of the fever, I seek for 
 other possible causes of this sjanptom outside of the high tem- 
 perature : if I observe, for instance, depression of the cerebral 
 activity, and simultaneously with this symptoms indicating an 
 influx of blood to the brain (as a flushed face), as frequently 
 occurs in typhoid fever (and often passes away with a sponta- 
 neous nose-bleed), then I order not antipyretics, but two leeches 
 to the nasal septum, and an ice-bag on the head, which is often 
 sufficient to bring relief; if I note mental depression with a 
 pale face, then I wash the head in cold water, administer musk, 
 and sometimes — usually during the further course of the disease, 
 when there appears a threatening oedema of the brain, — I 
 apply a Spanish fly to the nape of the neck; for a weak pulse, 
 especially m persons habituated to the use of alcoholic drinks, 
 I give wine, cognac and stimulants ; in other cases, to remove 
 the troublesome symptoms, we are compelled to administer lax- 
 atives (in cases of constipation and intestinal meteorism), and 
 so on. But if, after analyzing the patient's condition, I find no 
 reason to expect any benefit from the use of the above-enumer- 
 ated and similar means, or, on applying the same, I do not ob- 
 tain any sufficient relief and am compelled to refer the dangerous 
 symptoms to the rise in temperature, then I resort to antipy- 
 retic treatment — calomel, cool bathing, antifebrine (less fre- 
 quently antipyrine), phenacetine, sodium salycilate, and quinine. 
 
— 462 — 
 
 The indications for the use of calomel in certain febrile af- 
 fections, as typhoid fever, croupous pneumonia, erysipelas, and 
 acute nephritis have been spoken of before (vide p. 427). 
 
 Cool baths — temperature 24:° to 22° H., lowering it while 
 the bath is being given to 20°-18°. The duration of the bath 
 must be determined by the peculiarities of the given case ; the 
 first bath is to be taken in the presence of a physician, the fol- 
 lowing ones under the supervision of a skilled assistant. The 
 patient is lowered into the bath and raised therefrom on a sheet. 
 The chief contraindications for this procedure are: diarrhoea, 
 intestinal hsemorrhages, poor cardiac activity, embarrassed res- 
 piration, as from a severe bronchitis with hypostasis or from a 
 superadded pneumonia, and great excitement of the nervous 
 system. The chief indication for its use, besides the lowering 
 of the temperature, is a depressed state of the nervous system. 
 Cool spongings of the whole body with vinegar and water are 
 necessary for cleanliness' sake, and are usually pleasant to the 
 patient, for they cause a slightly stimulating effect on the ner- 
 vous system, but their influence on lowering the temperature is 
 certainly very insignificant. 
 
 Let me add that at times, most frequently in typhoid fever, 
 we must resort to another hydro therapeutic measure, namely, in 
 the following cases, usually during the further course of the 
 typhoid, when the patient has become considerably exhausted: 
 burning heat in the trunk, cold extremities, a very weak pulse, 
 great mental excitement, as evidenced by insomnia and constant 
 delirium. In such cases I adramister bromides and place the 
 body, as it were, in a warm compress : several flannel comfort- 
 ers are spread over the bed, on top of which is put a sheet 
 soaked in water cooler than lukewarm ; the patient, completely 
 naked, is placed on the sheet, which is wrapped around him, and 
 over this the comforters. Such treatment is in the majority of 
 cases successful : the patient is quieted down, the delirium 
 ceases and he falls asleep, the burning heat m the back and the 
 cold in the extremities pass away, and the pulse improves. 
 
 Antipyrine, antifebrine and phenacetine I use ordinarily in 
 the following manner : I give a five-grain dose (less frequently 
 three grains): in the majority of cases I obtain a lowering of 
 the temperature down to 39° E. and lower, and as long as this 
 lasts I do not administer any more. As soon as the tempera- 
 ture has risen again to over 39°, I repeat the same dose, and so 
 on ; consequently I do not in the least attempt to bring the 
 temperature down to its normal condition, but am content to 
 
— 463 — 
 
 lower it sufficiently to exclude any possible danger (the same is 
 to be said of the use of cool baths).* 
 
 I use most frequently phenacetine or antifebrine, and if they 
 lose their effect or the patient becomes habituated to them, then 
 I resort to antipyrine or sodium salycilate (in ten-gram doses). 
 
 Outside of malaria, I give quinine in those cases m which the 
 febrile condition is of a strongly exhausting or directly inter- 
 mittent nature (in the febrile condition of the continual fever, 
 quinine acts only when given in very large doses, which are 
 borne rather difficultly, and even then it acts slightly and for a 
 short time), most frequently in febrile catarrhs of the respira- 
 tory passages, in prolonged pneumonia, in influenza and ty- 
 phoid fever, if the condition of the intestines permits it, when 
 from being constant the fever becomes a severely exhausting or 
 an intermittent one ; for constant fever I give antifebrine, phena- 
 cetme and antipyrine. I administer it usually during the period 
 of exhaustion or during the intermittence, and therefore in the 
 majority of cases in the morning, not on an empty stomach, but 
 after the tea or coffee, and not in the evening, as is usually 
 recommended. When given during the above-mentioned periods 
 the quinine acts better, probably because it is more readily ab- 
 sorbed. I do not increase the dose of quinine until the appear- 
 ance of cinchonism, as we do in malaria, but I give usually five- 
 grain doses once or twice, rarely three times a day. 
 
 For pulmonary tuberculosis the chief antipyretic and, general- 
 ly speaking, the chief remedial agent is certainly creosote, guai- 
 acol, or guaiacol carbonate; but before we are able to obtain a 
 good effect from them, we are at times compelled to give qui- 
 nine m the exhausting and intermittent fever, and for the con- 
 stant fever, antifebrine, antipyrine or phenacetine, while sodium 
 salicylate is but little effective in small doses, and is liable to im- 
 
 * The lowering- of the temperature down to its normal condition dur- 
 ing the whole course of typhoid fever by the aid of cold baths and the 
 above-named antipyretics was attempted, but did not become a generally 
 adopted practical procedure, and is recommended but by very few, be- 
 cause, first, it does not benefit the patient, as the duration of the disease 
 is not shortened; and secondly, it may become injurious, for continuous 
 cold baths, by determining an increased production of heat, increase the 
 exhaustion of the organism; while the use of the above-named antipy- 
 retics, which, to keep the temperature constantly down to its normal con- 
 dition, must be given in large doses, may tend to affect the heart injuri- 
 ously or even to a dangerous extent: not to speak of the possible harm 
 from the cessation of the fever, which may act as a self-protecting agency 
 to the organism. Thus some observers assert that in cases of typhoid fe- 
 ver, which were j)ersistently treated by the application of cold water, re- 
 currences were more frequent. 
 
— 464 — 
 
 pair digestion in large ones, and I therefore prefer the above an- 
 . tipyretics. 
 
 In septicaemia and pyaemia, not having any better agents, I 
 give creosote, or guaiacol and guaiacol-carbonate, as, for in- 
 stance, in the treatment of empyema (outside of operative 
 interference). 
 
INDEX. 
 
 Aache^', a German wateriug-place . 
 Abas-Touman, a Caucasian watering-place 
 Abdomen, inquiry about, in examining a patient 
 
 " method of palpating 
 
 Acid, boric, in choleraic diarrhoea 
 
 " carbolic, in chronic articular affections . 
 '• carbonic, action of, in the stomach 
 '• " external effect of . . , 
 
 " hydrochloric, employment of, in diseases of the stomach 
 " •' "pseudo" preventive of cholera 
 
 " " secretion of, in clironic gastric catarrh 
 
 " ■' " in gastric ulcer 
 
 Acids, organic, effects of, in hydrotherapy 
 Accumulations in tbe peritoneal cavity, treatment 
 Agencies, curative, in mineral waters 
 Air, compressed, in pleurisy .... 
 
 Air-baths in parenchymatous nephritis 
 
 " effects of, vide Climatotherapy. 
 
 Albuminates, peptonized, in gastric diseases . 
 Albuminuria in the chronic nephrites 
 Alcohol a predisposing factor in h8emorrhoid.'= . 
 " in the algid stage of cholera 
 " in debility ...... 
 
 " in the treatment of clioleraic diarrhoea 
 Alcoholic drinks, results of abrupt abstinence from 
 Algeria as a health resort . 
 Algid stage of cholera, causation of 
 " '■ " treatment of 
 
 Aloe as a laxative 
 AnsBmia, mineral waters in . 
 Anamnesis .... 
 
 " definition of 
 
 health of parents and relatives 
 " as regards syphilitic infection 
 
 Andes, the, treatment of tuberculosis in 
 Aneurism of the aorta, case of . 
 Angina pectoris, Spanish flies in 
 
 " •' with cardiac syphilis 
 
 
 PAGE 
 
 
 341 
 
 
 
 340 
 
 
 
 13 
 
 
 
 46 
 
 
 
 379 
 
 
 
 222 
 
 
 
 f)0 
 
 
 
 338 
 
 .h 
 
 83, 84 
 
 
 371, 
 
 372 
 59 
 125 
 339 
 199 
 90 
 272 
 
 240. 24.5 
 
 246 
 
 
 85 
 
 242, 
 
 243 
 
 
 398 
 
 
 383 
 
 
 4:5 
 
 
 381 
 
 
 203 
 
 
 303 
 
 365, 
 
 366 
 
 382. 
 
 383 
 
 1.52, 
 
 1.53 
 
 
 116 
 
 
 
 8 
 
 
 
 17 
 
 
 
 17 
 
 
 
 454 
 
 
 
 304 
 
 
 
 457 
 
 
 
 456 
 
 
 448 
 
 449 
 
4th 
 
 466 
 
 Angioneurotic nature of htemorrhoids 
 Antifebrine in hectic fever . 
 •' in pneumonia . 
 
 " in reaction period of cholera 
 
 . " in treatment of fever 
 
 Antipyrine in acute articular rheumatism 
 " in hectic fever . 
 
 " in pleurisy 
 
 " in treatment of fever 
 
 Anus, bloodletting from circumference of, reasons for 
 
 " inquiry about, in examination of patient 
 Aorta, abdominal, sensitiveness of. on palpating the abdomen 
 " aneurism of, case of ..... 
 
 Apoplexy, venesection in 
 
 Arsenic in chlorosis ....... 
 
 " '' " contraindications to use of 
 
 " " neurasthenia ...... 
 
 Arthritis urica, vide Gout. 
 
 Articular affections, chronic, local treatment of 
 
 Atelectasis, pulmonary, rales in . 
 
 Atrophic gastric catarrh (with cancer of the duodenum), 
 
 Autopsies, importance of . 
 
 Bacterium of cholera 
 
 Balneotherapeutic treatment applied at home . 
 
 " " course of . . . 
 
 Balneotherapy, elements of ..... 
 
 " lack of clinical knowledge about 
 
 " many-sidedness of the subject of 
 
 " in chlorosis ..... 
 
 " in chronic myosites, neutrites, etc. . 
 
 " in diseases of the heart 
 
 " " " hfematopoiesis 
 
 " " " nutrition 
 
 " " " respiratory organs 
 
 skin . ' . 
 " in febrile conditions .... 
 
 " in metallic poisoning 
 
 " in scrofula ...... 
 
 " in syphilis 
 
 {Vide also Hydrotherapy, Mineral waters, Watering 
 Baltic Sea, a trip to, in neurasthenia .... 
 Bathing, river, in neurasthenia . . . 
 
 " sea, diseases in which it is indicated . 
 " " effect of mechanical influences in 
 
 " " effective agencies in ... . 
 
 Baths, action of, on the central nervous system 
 " " " temperature of the body 
 
 PAGE 
 
 397 
 292, 320 
 320, 321 
 383 
 462 
 212 
 292 
 268 
 462 
 398, 399 
 12 
 48 
 457 
 391, 392 
 255, 256 
 261, 262 
 147 
 
 223 
 
 328 
 
 156 
 
 27 
 
 361 
 350 
 350 
 332 
 44 
 333 
 257 
 354 
 353 
 354 
 353 
 353 
 354 
 354 
 354 
 354 
 354 
 
 places, etc.) 
 
 101 
 102 
 
 346, 347 
 339 
 346 
 335 
 
 335, 336 
 
467 
 
 Baths, cool, in the treatment of fever 
 
 " determination of necessary temperature of 
 " effects of cold and warm .... 
 " cold and hot, influence of, on circulation, etc 
 " " uselessness of, in pneumonia . 
 
 " hot, in the treatment of choleraic diarrhoea 
 " " air .... 
 
 " fir-tree .... 
 " Russian .... 
 " warm, drawbacks in use of 
 " " in biliary calculi . 
 
 " " for promoting sleep 
 
 " " for pains 
 
 Bestujeff s tincture 
 Biarritz, a trip to, in neurasthenia 
 Binz on calomel .... 
 Biliary calculi, vide Calculi. 
 Bilirubin, formation of (foot-note) 
 Bismuth in choleraic diarrhoea . 
 
 " in ulcer of the stomach (foot-note) 
 " phenolate, vide Tribromphenolbismuth. 
 Bitters, use of, in chronic catarrh of the stomach 
 Black Sea, a trip to, in neurasthenia . 
 Bladder, urinary, inquiry about, in examination of patient 
 Blisters, use of, in pleurisy . 
 
 " " in pericarditis . 
 
 Blood, quantity of, extracted in derivative bloodletting 
 Bloodletting, former practice of . 
 " Moscow practice of 
 
 " recent history of . 
 
 " views of different authorities on 
 
 " depletive {vide also Venesection) 
 
 " derivative .... 
 
 " " case where employed 
 
 PAGE 
 
 462 
 45 
 
 334, 335 
 
 33(5, 337 
 320 
 381 
 347 
 347 
 
 349, 350 
 52 
 177 
 51, 52 
 228 
 247 
 101 
 
 407, 409 
 
 253 
 
 379, 380 
 
 131 
 
 78 
 
 101 
 
 12 
 
 269 
 
 390 
 
 392 
 
 387, 389, 390 
 
 390 
 
 387, 388 
 
 388 
 
 391 
 
 396 
 
 399, 400 
 
 " indications for: 
 
 " " in region of abdomen 
 
 " " " chest 
 
 " " head 
 
 " " " spine 
 
 " methods of use: care in performing 
 " " number of leeches 
 
 " " position of patient 
 
 " " time of day 
 
 " " where applied . 
 
 " reasons for its employment 
 
 '' repetition of .... 
 
 " to the nasal septum . 
 local, employment of . 
 
 in large hsemorrhoidal nodes, 404 
 
 404 
 403 
 
 401, 402 
 
 402, 403 
 404, 405 
 
 405 
 405 
 405 
 405 
 :398, 399 
 406 
 402 
 393 
 
— 468 — 
 
 Bloodletting, local, with depletion in view 
 
 Botkin on clilorosis 
 
 Brain, diseases of, balneotherapy in . 
 
 Breathing, rough, as a symptom 
 
 Brehmer's experiments with climatotherapy 
 
 " theories on the influence of mountainous localities 
 
 Bright' s disease, vide Nephritis. 
 Bromide of sodium in reaction stage of cholera 
 Bromides in neurasthenia . . . . . 
 Bronchopneumonia, chronic tuberculous . 
 Broussai's influence on the practice of bloodletting 
 Brown-Sequard's theories on glandular secretion 
 
 plexus 
 
 Caffeine as a diuretic 
 
 " natrobenzoicum in the algid stage of cholera 
 
 Cairo as a health resort 
 Calculi, biliary, Ems water in 
 " formation of 
 
 " ■' peculiar symptom of 
 
 •' " relation to neuralgia of the hepatic 
 
 "• diagnosis of ... . 
 " treatment of, when discontinued 
 
 " " and cholangitis catarrhalis 
 
 Calomel, action of, physiological 
 
 " as a diuretic 
 
 "■ " laxative ...... 
 
 ''' compared with castor oil 
 
 " Xothuagel (and Rossbach) on the use of, in Ger 
 
 "■ in biliary calculi ..... 
 
 " in catarrhal jaundice . . . 
 
 "■ in acute nephritis 
 
 " in cirrhosis of the liver 
 
 " in cholera ...... 
 
 " in pleurisy ...... 
 
 ■' in pneumonia ..... 
 
 in facial erysipelas .... 
 
 " in typhoid fever ..... 
 
 ■' use of, in Germany, France and England 
 
 " mode of employing .... 
 
 " indication for use of . 
 
 " contraindication to use of . 
 
 Camphor in the algid stage of cholera 
 Cannes, a French health resort . . . 
 Cancer, gastric, differential diagnosis of . 
 
 " duodenal (4th case) .... 
 
 " of pancreas (5th case) .... 
 Cantani's description of an oxaluric patient 
 " treatment of choleraic diarrhoja 
 
 .317 
 
 many 
 
 191 
 
 320, 
 
 PAGE 
 
 396 
 
 251 
 .351, 352 
 
 327 
 304, 305 
 
 305 
 
 383 
 148 
 
 277, 282 
 387 
 252 
 
 246 
 383 
 303 
 79, 166, 430 
 169, 170, 176 
 
 170, 171 
 171,173,174 
 
 431, 432 
 180 
 194 
 
 408, 409 
 423 
 153 
 417 
 407 
 430 
 430 
 439 
 407, 417-427 
 
 376, 377 
 
 268 
 
 321, 428, 429 
 
 427, 428 
 428 
 407 
 
 416, 417 
 416 
 430 
 383 
 303 
 58, 129 
 160 
 162 
 69 
 
 380, 382 
 
 415, 
 
— 469 — 
 
 PAGE 
 
 Cascara sagrada, as a laxative 153 
 
 Castor oil u n jgg 
 
 Catarrh, gastric, atrophic 58, 159 
 
 " " " diSerential diagnosis of ... . 58 
 
 " " bitters in 78 
 
 " " chronic, condition of mucous membrane in . . 59 
 
 " " " dyspeptic symptoms in ... . 59 
 
 " " " silver nitrate in 119 
 
 " " condurango in . . . . . . . . . • 78 
 
 " " contents of stomach in . . . 57,59,60,127 
 
 " " diet in, vide Food. 
 
 " " differential diagnosis of 
 
 " " Karlsbad in 
 
 " " nux vomica in . 
 
 " " prognosis in . 
 
 " " treatment of 
 
 " simple, of the large intestine, differentiated from tubercu 
 
 lous ulcerations .... 
 
 " of the biliary passage [vide Cholangitis) 
 
 Catarrhal conditions, contrasted with predisposition to same, treat- 
 ment of ..... , 
 
 C^lestins, vide Vichy. 
 
 Cerebral congestion, derivative bloodletting in 
 
 Chapman's treatment of cholera (foot-note) 
 
 Charcot on hepatic cirrhoses 
 
 Chest, inquiry about, in examining a patient 
 
 Chloranaemia, treatment of ... 
 
 Chlorosis (17th case) . 
 
 " balneotheraphy in 
 
 " Botkin on . 
 
 " causation of 
 
 " classification of 
 
 " constipation in 
 
 " diagnosis of 
 
 " hydrotherapy in 
 
 " mental condition, in the causation of 
 
 I' nervous system in 
 
 prognosis in . . . 
 " sexual maturity, as related to 
 
 '* symptomatology of . 
 
 " treatment of . . . 
 
 " Virchow on . . . 
 
 " and hysteria 
 
 " and tuberculosis 
 
 Cholangitis and biliary calculi (6th case) 
 
 " and hypertrophic venous cirrhosis (7th case) 
 
 " and biliary and hypertrophic biliary cirrhosis (8th case) 
 
 Cholelithiasis, vide Calculi, biliary. 
 
 159 
 103 
 
 78 
 194 
 195 
 
 47 
 194 
 
 355 
 
 401 
 383 
 189 
 13,14 
 261 
 248 
 257 
 251 
 252 
 
 250, 251 
 256 
 
 249, 250 
 257 
 251 
 257 
 
 253, 254 
 252 
 
 248, 249 
 254, 255, 256 
 251 
 253 
 261 
 166 
 182 
 193 
 
— 470 
 
 Cholera 
 
 " algid stage of 
 
 • " arrivals, supervision of, in epidemics . 
 " attack, symptoms of an . 
 " causation of, according to Pettenkofer 
 
 " contagiousness of 
 
 " complications of .... . 
 
 " Hueppe's investigations about 
 
 " infectiousness . .... 
 
 " immunity toward, Pettenkofer's experiments concer 
 
 " " " unreliability of experimentation 
 
 " individual measures of precaution against . 
 
 " nature of 
 
 " nephritis of the algid stage 
 
 " Mcati (and Rietsch) toxine from cholera bacteria 
 
 " predisposition to 
 
 " preventive measures against .... 
 
 " reaction stage of ...... . 
 
 " spleen, condition of, in . 
 
 " treatment of {vide also special headings) . 
 
 " " effectiveness of .... 
 
 " " necessity for systematic . 
 
 " " diarrhoea 
 
 " nostras 
 
 Cholerine 
 
 " treatment of 
 
 Circulation, as influenced by baths 
 
 Cirrhosis of the liver, hypertrophic, biliary 
 aetiology of . 
 
 differential diagnosis of, from 
 amyloid degeneration 
 cancer ..... 
 
 closure of ductus choledochus . 
 hyperaemia .... 
 
 multilocular echinococcus 
 
 syphilis 
 
 prognosis of .... 191, 
 
 treatment {vide also Calomel) . 
 
 varieties of 
 
 " clinical .... 
 
 Climate, definition of ....... . 
 
 " elements of . . . . 
 
 " nature of . . . ... 
 
 " relation of, to climatotherapy .... 
 
 " varieties of 
 
 " temperature of ...... . 
 
 Climatotherapy, elements of: air, clearness of. 
 " •' " " density of . 
 
 ning 
 
 PAGE 
 
 357 
 365 
 371 
 
 304, 365 
 359 
 
 362, 363 
 384 
 
 301, 302 
 359 
 362 
 362 
 
 371, 372 
 
 357, 358 
 
 366. 367 
 366 
 359 
 
 371, 372 
 
 367, 368 
 367 
 
 372, 373 
 373 
 
 375-379 
 384 
 364 
 
 381, 382 
 
 337 
 
 193, 419, 420 
 
 190 
 
 187 
 
 187, 420 
 420, 421 
 
 420 
 
 188, 421 
 
 187, 426 
 192, 426, 427 
 191, 421, 422 
 
 188, 189 
 190 
 298 
 300 
 299 
 299 
 299 
 300 
 302 
 301 
 
— 471 — 
 
 Climatotlierapy, elements of: air, moisture in . 
 " " " beauty of locality 
 
 " soil 
 " " " sunlight 
 
 " " " trip to a sanatorium 
 
 " " " vegetation 
 
 " " " waters . 
 
 " winds . 
 
 " in Eussia 
 
 Clinic, ambulatory 
 
 " faculty 
 
 " general, nature and contents of 
 
 " hospital ....... 
 
 " propaedeutic 
 
 " special 
 
 " of internal diseases, vide General clinic. 
 " and medical education .... 
 " " scientific medicine .... 
 Clinical assistant, duties of .... 
 
 " exercises, influence of . 
 
 " " division of, in the course of study 
 
 " " relation to systematic exposition 
 
 " professor, duties of 
 Clyster, in constipation 
 Cocaine, in vomiting of cholerine 
 Cod-liver oil in tuberculosis 
 Codeine for intestinal pains 
 Cold as a causative agency in pleurisy 
 Colic, biliary, causation of . 
 " calomel in 
 " diagnosis of . 
 " " differential 
 
 " " " from cancer 
 
 " " " " gastric diseases, etc 
 
 ether in .... 
 
 symptoms of . . . 
 
 treatment of ... 
 
 warm baths in . . . 
 Condition of patient, interrogation about 
 Condurango in diarrhoea 
 Constant electric current in atonic gout 
 Constipation, cause of, in gastric catarrh 
 " laxatives in . 
 
 " in nervous dyspepsia . 
 
 " treatment of . 
 
 Contrex^ville, chemical composition of 
 " contraindication for use of 
 
 PAGE 
 301 
 
 303 
 
 302 
 
 301 
 
 303 
 
 302 
 
 302 
 
 302 
 
 307, 308 
 
 4 
 
 4 
 
 4,5,6 
 
 4 
 
 3 
 
 4,5 
 
 265, 
 171, 
 
 1,2 
 
 27, 28 
 
 30 
 
 2 
 
 28,29 
 
 2 
 
 28 
 
 152 
 
 381 
 
 294 
 
 124 
 
 266 
 
 175 
 
 410 
 
 172 
 
 76, 
 
 172 
 
 172-175 
 
 179 
 
 117 
 
 180 
 
 177 
 
 10 
 
 78 
 
 222 
 
 67 
 
 153 
 
 150 
 
 151 
 
 93 
 
 80 
 
 152, 
 
— 472 — 
 
 PAGE 
 
 Contrex^ville in atonic gout 222, 228 
 
 " in oxaluria and renal colic ...... 97 
 
 " in phosphatic gravel . 106 
 
 Goto, tincture of, in diarrhoea .51, 379 
 
 Cough in pneumonia, treatment of 321, 322 
 
 Cramps in cholerine, treatment of ...... . 382 
 
 Creosote compared with koumyss in pulmonary tuberculosis . 293 
 
 " introduction of , through respiratory tract . . . 297 
 
 " in tuberculosis 295, 296, 315 
 
 " in septictema and pysemia ....... 464 
 
 " subcutaneous injections of . . . . . . • . 296 
 
 Cupping-glasses, care in application of, for apoplexy . . . 395 
 
 " diseases in which employed 393 
 
 " effects of application . . . . . 394, 395 
 
 " methods of application 395 
 
 " number of 394 
 
 " reasons for preferi'ing them to leeches . . . 394 
 
 Davos compared with other sanatoria 306, 307 
 
 Debout d'Estr^es on the former use of mineral waters . . . 108 
 Deficiencies in students' knowledge, making up of ... . 26 
 
 Diabetes mellitus, relation of, to oxaluria ..... 54 
 
 Diagnosis segri 18 
 
 •' morbi 18 
 
 " differential .......... 18 
 
 " how arrived at 15, 18, 42 
 
 Diaphoretics in pleurisy 267, 269 
 
 Diarrhoea, cold in 51 
 
 " Ems water in ........ . 94 
 
 " opium in ......... . 51 
 
 " wine in .......... 43 
 
 " prevalence of, during an epidemic of cholera . . . 375 
 
 " choleraic, treatment of (vide separate headings) . 376-381 
 
 Diet {vide also Food). 
 
 " during the administration of arsenic in ana3mia . . . 256 
 
 " in gastric catarrh .......... 150 
 
 " in nervous dyspepsia 149, 150 
 
 Diseases, infectious, former classification of .... . 358 
 
 Distention of the stomach . 60 
 
 Disinfection in the prevention of cholera outbreaks . . . 370 
 
 Diuretics in pleurisy 267, 269 
 
 Douches in nervous dyspepsia 151 
 
 Dover's powder in pleurisy . . . . . . . . . 208 
 
 " " in pneumonia ........ 322 
 
 Dyspepsia, baths in ......... . 151 
 
 " constipation in . . . . . . . . . 150 
 
 diet in 144, 150 
 
 " Ems water in 151 
 
— 473 — 
 
 Dyspepsia, erroneous employment of lavage in 
 
 " mineral waters in . . . 
 
 " nervous, gastric symptoms of . 
 
 " " diagnosis, differential 
 
 " nux vomica in . 
 
 " silver nitrate in . 
 
 " varieties of (gastric, nervous) . 
 
 Dyspeptic symptoms, preliminary treatment of 
 Dyspnoea in pneumonia, treatment of 
 
 tract 
 
 Ebstein on gout 
 
 Echinococcus cyst of the liver (9th case) . 
 Effusion in pleurisy, absorption of 
 " " character of 
 
 " " operative removal of , 
 
 Eichhorst, treatment of pleurisy 
 
 " on hsemon'hoids .... 
 
 Electricity in neurasthenia .... 
 Emmerich's experiments on cholera . 
 Ems, chemical composition of . 
 " compared with Marienbad . 
 " " " Obersalzbrunnen 
 
 " dosage of . . . . . 
 *' indication for use of . 
 " in biliary calculi ..... 
 " in catarrhal conditions of the respiratory 
 in gout (atonic) ..... 
 in oxalic acid gravel .... 
 in pulmonary tuberculosis 
 washing of the stomach with 
 with sodium iodide .... 
 
 " salycilate 
 
 Kesselbrunnen ..... 
 " compared to Kranchen 
 
 " in nervous dyspepsia 
 
 " in hypertrophic biliary cirrhosis 
 
 Kranchen 
 
 Enteroclysmata in choleraic diarrhoea 
 Ergot (secale cornutum) in haemoptysis 
 Erysipelas, facial, calomel in 
 " quinine in 
 
 Ether in the algid stage of cholera 
 " in biliary colic .... 
 in vomiting of cholerine 
 Eucalyptus oil in tuberculosis 
 Examination, objective 
 
 " " conduct of 
 
 " '* notes on 
 
 '■ '■ tact requisite 
 
 , in tuberculosis 
 
 57, 
 
 PAGE 
 
 136 
 117 
 127, 158, 159 
 158 
 151 
 151 
 149 
 296 
 321, 322 
 
 213 
 197 
 269 
 265, 266 
 269 
 267 
 
 147 
 
 362 
 93 
 
 101 
 )6, 97 
 HI, 112 
 94 
 79 
 )6, 97 
 222 
 79 
 97 
 124 
 208, 456 
 210 
 130, 131 
 96 
 151 
 425 
 
 380, 381 
 291 
 427, 428 
 427 
 383 
 179 
 381 
 297 
 17 
 17 
 325 
 18 
 
— 474 — 
 
 Febrile condition, inquiry about, in examining a patient 
 
 Fever, hectic, in pulmonary phthisis 
 
 " " " cause of . . . 
 
 " " " treatment of . 
 
 " " " undesirability of bringing 
 
 down to the normal 
 " a protecting agency to the organism 
 
 " treatment of 
 
 Finkler-Pryor, bacillus of cholera nostras 
 Food, artificial, use of .... 
 
 " in chronic gastric catarrh 
 
 " '• ' " quality of 
 
 " " " " quantity and apportionment of 
 
 " " " ■' instructions to patients about 
 
 '■ " " variation. 
 
 Fragaria vesca (strawberry) in atonic gout 
 Frankel on phthisical stage of tuberculosis (foot-note) 
 Franzensbad water, chemical composition of 
 
 " " diseases in which it is used 
 
 " " (Salzquelle) Moorbader 
 
 " " temperature of . 
 
 " " for use 
 
 Frerich's case of hepatalgia 
 
 Friedrichshall, chemical composition of . 
 
 it 
 
 Gastein, an Austrian watering-place 
 
 Gastric splash, unreliability of, as a symptom . 
 
 " lavage, abuse of 61, 62, 63, 
 
 " sound in differential diagnosis of diseases of the stomach 
 Genital organs, male, inquiry about, in examination of patient 
 
 Gmunden, an Austrian watering-place 
 
 Gorbersdorf compared to Davos 
 
 " as a climatotherapeutic sanatorium 
 
 Gout, atonic (12th case) 221 
 
 " causation of ......... . 213 
 
 differentiation from nocturnal syphilitic pains . . . 227 
 " milk treatment in ........ . 236 
 
 " predisposition to . . 221 
 
 " relation of, to acute articular rheumatism . . . 213, 214 
 
 " " to articular diseases 221 
 
 " strawberry tea in . . . 236 
 
 " symptoms of 214, 226 
 
 " treatment of 222, 228, 229 
 
 " Vichy water in 104 
 
 Grande-Grille, vide Vichy. 
 
 Gravel, oxalic acid, Ems in 79 
 
 . " " Contrex^ville in 80 
 
 " phosphatic, Contrex^ville in . . . 1 . . . 106 
 
 PAGE 
 
 14 
 
 285 
 286 
 292 
 
 292 
 
 460 
 
 460 
 
 384 
 
 85 
 
 75 
 
 77 
 
 75 
 
 76 
 
 77 
 
 236 
 
 286 
 
 93 
 
 104 
 
 143, 345 
 
 95 
 
 115 
 
 173 
 
 93 
 
 340 
 
 60 
 
 132, 137 
 
 63, 64 
 
 32 
 
 344 
 
 306, 307 
 
 305 
 
— •475 — 
 
 Guaiacol and its carbonate in pyaemia and septicaemia . 
 " '' " in tuberculosis 
 
 " carbonate in incipient tuberculosis 
 
 Gumma, syphilitic, of the liver, differential diagnosis of 
 
 PAGE 
 
 464 
 295. 296, 314 
 262 
 164 
 
 H^MATix in ulcer of the stomach 127 
 
 Hsematopoiesis, balneotherapy in diseases of . . . . . 354 
 Haemoptysis in tuberculosis, bloodletting in ... . 403, 404 
 
 " " leeches in 292 
 
 treatment of. . . . 291,292,403 
 
 Haemorrhoids, case of, substantiating author's views on . . . 397 
 
 " causation of 398 
 
 former views on . * 396 
 
 " nature of (an angioneurosis) 397 
 
 " pure, uncomplicated 397 
 
 " views concerning ........ 397 
 
 Hamburg, epidemic of cholera in, origin of . . . . . 360 
 
 Hahnemann in the history of therapeutics ..... 23 
 
 Hanot on hepatic cirrhoses 189 
 
 Headache, inquiry about, in examining a patient .... 15, 16 
 
 Heart, determination of dimensions of 329, 330 
 
 " diseases of, balneotherapy in 353 
 
 " " milk treatment of ...... 455 
 
 " syphilis of the, angina pectoris in 448, 449 
 
 " " " diagnostic data of 454 
 
 " " lack of knowledge on 447 
 
 " '* treatment of 454 
 
 '■ type of the majority of cases . . . 449 
 
 varieties of cases 449 
 
 Helouan, a health resort near Cairo, Egypt 303 
 
 Hepatalgia, relation of, to biliary calculi .... 171, 173, 174 
 
 " Frerich's case of I73 
 
 Horseback riding as a predisposing factor in haemorrhoids . . 398 
 
 Hospital therapy, characteristics of 25 
 
 Hueppe's investigations on cholera 359,360,361,362 
 
 " toxine of cholera bacteria 366 
 
 " use of bismuth phenolate in cholera .... 377 
 
 Hydrobilirubin, formation of (foot-note) . . . . . . 253 
 
 Hydrotherapy, effects of 348 
 
 general 348, 349 
 
 " local 349 
 
 methods of application 347, 348 
 
 in chlorosis 257 
 
 in neurasthenia 146, 148 
 
 Hygiene in the treatment of neurasthenia 145 
 
 " ■' " pleurisy 270 
 
 •' neglect of, in modern therapy 23, 24 
 
 Hyperaemia of infectious diseases, bloodletting in . . . . 402 
 
— 476 
 
 Hypersemia of the spinal cord and its membranes, bloodletting in, 402, 403 
 Hypodermoclysis in choleraic diarrhoea . . . . .... 380 
 
 " in the algid stage of cholera proper . . . 382 
 
 Hysteria, balneotherapy in 350 
 
 " carbonated waters in . . . . . . . 344, 345 
 
 " sea-bathing in 347 
 
 " and chlorosis 253 
 
 Ice in the vomiting of cholerine .... 
 
 Impotence, male, hydrotherapy in . 
 Individualization in clinical vrork .... 
 Infectious diseases, former classification of 
 " " treatment of fever in . 
 
 Influences, effect of mechanical, in hydrotherapy . 
 Interrogation of patient, special points about . 
 Intestines, particular inquiry about the condition of 
 
 Investigation, objective 
 
 Iodides in syphilitic affections of the heart 
 
 liver 
 Iodine in the treatment of pleurisy .... 
 
 Ipecac in cough 
 
 " " of pneumonia, erroneous administration 
 Iron in chlorosis 
 
 " in neurasthenia ....... 
 
 " mineral waters in chlorosis .... 
 
 " sulphate, effect of, in hydrotherapy . 
 Ischias ex neuritide (sciatica), bloodletting in 
 Ischl, an Austrian watering-place .... 
 
 of 
 
 381 
 
 352 
 
 3 
 
 358 
 460, 461 
 
 339 
 
 8, 9, 10 
 
 . 10, 11 
 
 17 
 
 448, 457 
 
 206 
 267, 269 
 276, 279 
 
 322 
 254, 255, 256 
 
 147 
 
 256 
 
 339 
 393, 395 
 
 344 
 
 JuERGENSEN on bloodletting 
 Jaundice, catarrhal 
 
 " " calomel in 
 
 Karlsbad, chemical composition of 
 
 " compared with Ems 
 
 " (MUhlbrunnen) compared with Marienbad 
 
 " in cholelithiasis 
 
 " in gastric catarrh 
 
 " in renal gravel 
 
 " with " Karlsbad" salt 
 
 " mode of administration 
 
 Keffir in tuberculosis . 
 Kesselbrunnen, vide Ems. 
 
 Kidney, movable (for diseases of, vide Nephritis) 
 Kissingen, chemical composition of . 
 " compared with Marienbad 
 
 " contraindications to use of 
 
 95, 
 102, 
 167, 176, 
 
 388 
 
 432, 433 
 
 430 
 
 93 
 103, 177 
 103, 187 
 177, 179 
 103 
 105 
 104 
 177 
 294 
 
 69, 70 
 
 93 
 
 103 
 
 95 
 
ulosis (foot-note) 
 
 — 477 
 
 Kissin^en, dosage of . 
 
 " temperature of . 
 
 Koch on " contagiousness" of cholera 
 
 " on the " streptococcencurve" 
 Koumyss in neurasthenia . 
 
 " in tuberculosis 
 
 Kranchen, vide Ems. 
 Kreutznach, a German watering-place 
 
 L^NJJ^EC, atrophic cirrhosis of the liver 
 Lamanche, a trip to. in neurasthenia 
 Lavage, gastric, employment of 
 
 " " " failures in 
 
 Laxatives in constipation . 
 
 " in pleurisy .... 
 
 Leeches in pulmonary haemoptysis 
 '■ in reaction stage of cholera . 
 " for depletive bloodletting 
 Leucocytes in the gastric contents 
 Leuk, a watering-place in Switzerland 
 Leyden on the phthisical period of tuberc 
 Liquor ammonise anisatus . 
 Lithium in gouty pains 
 Liver, blood-stasis of, bloodletting in 
 
 " cirrhosis of, vide Cirrhosis. 
 
 " determination of dimensions of 
 
 " echinococcus of (9th case). 
 
 " syphilitic affection of 
 
 " " " prognosis of 
 
 *' " " treatment of 
 
 " torpor of, calomel in . 
 Lungs, syphilis of the .... 
 
 " '' " cases of . 
 
 " " " diagnostic data about 
 
 " " " treatment of . 
 
 " ■' " tuberculosis in syphilitics 
 
 *' ' tuberculosis of, vide Tuberculosis. 
 
 Madeira wine, in the etiology of the case of biliary cirrhosis 
 Madeiras, the, as health resorts . 
 .Magnesia usta for pyrosis .... 
 
 " " as a laxative 
 
 Marienbad water, chemical composition of 
 " " compared with Ems 
 
 Karlsbad 
 
 Kissingen 
 
 Vichy . 
 
 Yessentucki 
 
 PAGE 
 
 113 
 115 
 361 
 286 
 292 
 292, 293, 294 
 
 344 
 
 437- 
 
 
 
 330 
 
 
 101 
 
 1.32 
 
 133 
 
 134, 135 
 
 136 
 
 152, 
 
 153 
 
 267, 
 
 269 
 
 
 292 
 
 
 
 383 
 
 
 
 393 
 
 
 
 127 
 
 
 
 340 
 
 
 
 286 
 
 
 
 279 
 
 
 
 229 
 
 
 
 404 
 
 
 
 330 
 
 
 
 197 
 
 
 
 204 
 
 
 
 205 
 
 206, 
 
 208 
 
 409, 
 
 410 
 
 
 436 
 
 -440, 441-444 
 
 441, 
 
 444 
 
 
 445 
 
 
 437 
 
 3 
 
 426 
 
 
 
 304 
 
 
 
 124 
 
 
 
 152 
 
 
 
 93 
 
 
 
 101 
 
 102, 
 
 103 
 
 
 103 
 
 102, 104, 
 
 105 
 
 
 105, 
 
 106 
 
— 478 — 
 
 Marienbad water, contraindications for use of 
 " " dosage of . . . 
 
 • " '■ drinking, method of 
 
 " " in gastric cataiTh . 
 
 '* " repeated use of 
 
 " " temperature of, when admin 
 
 " " types of patients for treatment with 
 
 " trip to, in connection with the drinking of th 
 
 Massage, general, effects of . . . 
 
 istered 
 
 e water 
 
 in Dr. S. W. Mitchell's treatment of neurasthenia, 53, 54 
 
 " " in atonic gout 
 
 " '' in muscular rheumatism 
 
 " "in neurasthenia 
 
 Meat-powder, use of, in gastric disorders . 
 Menstruation, relation of, to hsemorrhoidal bleeding 
 Menthol in tuberculosis ..... 
 Mentone, a health resort in Southern France . 
 Mercurial inunctions in syphilis of the liver 
 Metallic poisoning, hydrotherapy in . 
 Method requisite in clinical work 
 Miasmatic diseases, nature of . 
 
 " contagious diseases .... 
 
 Milk treatment in atonic gout .... 
 " " in diseases of the heart 
 
 " as a diuretic 
 
 Mitchell's, Dr. S. W., treatment of neurasthenia 
 Morphine in pleurisy ...... 
 
 " in the vomiting of cholerine 
 
 Moschus in the reaction period of cholera 
 Moscow practice of bloodletting . . . 
 Muds, mineral, use of . 
 Miihlbrunnen, vide Karlsbad. 
 Murmur, bronchial respiratory, as a symptom . 
 
 " indefinite " " " 
 
 " vesicular " •' " 
 
 Myocarditis, syphilitic, case of . 
 Myositis, chronic, hydrotherapy in 
 
 Naecotics, care in using, in pneumonia 
 Narzan, a Russian watering-place 
 Nephritis, acute, bloodletting in 
 *' " calomel in 
 
 " chronic, baths in 
 
 " . " prognosis of 
 
 " " treatment of. 
 
 " " varieties of 
 
 " interstitial, course of 
 
 " " diagnosis of 
 
 PAGE 
 
 94, 95 
 113 
 101 
 103 
 102 
 116 
 100, 101 
 101 
 54 
 
 303, 
 
 222 
 223 
 146, 147 
 85 
 398 
 297 
 314, 315 
 263, 268 
 354 
 3 
 358 
 358 
 236 
 455 
 246, 455 
 53, 54 
 268 
 381 
 383 
 388, 389 
 345, 346 
 
 326 
 
 327 
 327 
 
 447, 448 
 354 
 
 322, 323 
 344 
 393 
 429' 
 352 
 243, 244 
 246, 247 
 242 
 243 
 244 
 
— 479 — 
 
 Nephritis, interstitial, senile 
 " parenchymatous 
 
 " " course of 
 
 " " diagnosis of . 
 
 Nephrolithiasis, warm baths in {vide also Biliary calculi) 
 Nerves, cardiac, syphilitic affection of, cases 
 Nervous system, condition of, in chlorosis 
 Neurasthenia, arsenic in . . . 
 " balneotherapy in . 
 
 carbonated waters in . 
 characteristic features of 
 diet in . 
 electricity in 
 etiology of . 
 Franzensbad-Salzquelle in 
 gastro-intestinal, hydrotherapy in 
 
 " varieties of 
 
 hydrotherapy in . 
 hygiene in . 
 
 iron in .... 
 
 koumyss in . 
 massage in . 
 " Mitchell's treatment of 
 
 " prognosis of . 
 
 '* sea-bathing in . . . 
 
 " sexual intercourse, immoderate, as a causative 
 
 cy, treatment of 
 " silver nitrate in . 
 
 " treatment of, radical 
 
 " trips to various seashores for 
 
 Neuritis, treatment of, in articular rheumatism 
 Mcati (and Eietsch), cultures of choleraic toxine 
 Nice, a health resort in Southern France . 
 Noorden, v., on the formation of hydrobilirubin (foot-note) 
 Nothnagel (and Rossbach) on the use of calomel in Germany 
 Nussbaum's cells in chronic gastric catarrh 
 Nutrition, balneotherapy in diseases of 
 
 " importance of, in tuberculosis . 
 
 Nux vomica in gastric catarrh 
 " in nervous dyspepsia 
 
 ObeSitt, general, milk treatment in . 
 
 Obersalzbrunnen, chemical composition of 
 " compared with Ems 
 
 " dosage of . . . 
 
 " use of ... . 
 
 *' in pulmonary tuberculosis 
 
 " with milk (for cough) . 
 
 agen- 
 
 PAGE 
 
 158 
 243 
 244 
 245 
 352 
 448 
 257 
 147 
 
 350, 351 
 
 344, 345 
 71 
 
 149, 150 
 147 
 144 
 104 
 362 
 149 
 
 146, 148 
 145 
 147 
 293 
 
 146, 147 
 53 
 146 
 347 
 
 145, 146 
 147 
 148 
 101 
 223 
 365 
 305 
 253 
 407 
 
 59 
 354 
 292 
 
 79 
 151 
 
 455 
 93 
 96 
 111 
 96, 97 
 96, 97 
 275, 279, 310, 314 
 
— 480 — 
 
 Observation of the course of the disease . 
 
 " neglect of 
 
 (Edema of the lungs, bloodletting in . 
 
 " " " rales in . . . 
 
 Odessa estuary, a health resort . 
 Oleum terebenthinse rectif . in tuberculosis 
 Opium in choleraic diarrhoea 
 
 " in intestinal pains .... 
 
 " reasons for employing 
 Oxalic acid gravel, vide Gravel. 
 
 " " sediment in relation to uric acid during treatment 
 
 Oxaluria, Contrex^ville in . 
 
 " relation to diabetes mellitus 
 
 *' as a symptom 
 
 Oxaluric patient, characteristics of . 
 
 Pains in pneumonia, treatment of 
 Pancreas, cancer of (5th case) 
 
 " " absence of symptoms of 
 
 " " diagnosis, differential 
 
 Pepsin, condition of, in chronic gastric catarrh 
 
 " use of, in diseases of the stomach . 
 Percussion sound, varieties of . 
 Pericarditis, blisters in .... 
 
 Pericystitis, leeches in 
 
 Perihepatitis, syphilitic . . . 
 Peritoneal inflammation, hydrotherapy in 
 Peritonitis, leeches in . 
 Peruvian balsam in tuberculosis 
 Phenacetine in hectic fever 
 
 " in pleurisy .... 
 
 " in pneumonia .... 
 
 " in reaction stage of cholera . 
 
 Phthisis declarata (pulmonary phthisis), appearance of 
 
 " care of 
 
 " galloping ..... 
 
 " . hectic fever in .... 
 
 " mixed infection in . . . 
 
 Pilocarpine hydrochlorate in pleurisy 
 Piperazine in gouty deposits 
 Pityriasis versicolor in emaciated persons 
 Pleurisy, acute {19th case, with tuberculosis) 
 
 " bloodletting in ... . 
 
 "■ breaking up of the acute stage of 
 
 " causation of 
 
 " " cold as a factor in the 
 
 '' compressed air in . 
 
 " differentiated from pneumonia . 
 
 PAGE 
 
 . 25, 26 
 
 26 
 
 393 
 
 328 
 
 343, 344 
 297 
 
 377, 378 
 . 50, 51 
 
 378, 379 
 
 235 
 54 
 70 
 
 321, 322 
 
 162 
 
 169, 160, 164 
 
 164 
 
 69 
 
 329 
 393 
 396 
 204 
 352 
 396 
 297 
 268 
 268 
 
 320, 321 
 383 
 
 patients with, 285 
 288 
 289 
 285 
 286 
 267 
 
 229, 230 
 
 . 45, 46 
 
 263 
 
 268, 393, 394 
 
 267 
 
 265 
 
 265, 266 
 
 272 
 
 265, 318, 319 
 
— 481 
 
 PAGK 
 
 270 
 
 266 
 
 264, 265, 267 
 
 , 267, 268, 269, 270 
 
 270 
 
 267 
 
 268 
 
 267 
 
 267 
 
 268 
 
 265, 266 
 
 269, 270 
 
 893, 394 
 
 ulmonary 
 
 428, 
 
 Pleurisy, hygiene in 
 
 prognosis of . 
 
 symptoms and physical signs of 
 treatment of (vide drugs under special headings 
 " "ambulance" .... 
 
 " Eichhorst's .... 
 
 " fever . . ' . 
 
 " in syphilitic patients 
 
 " in tuberculous patients . 
 
 " pain 
 
 with effusion, determination of character of 
 " operative removal of . 
 
 Pleuropneumonia, acute, bloodletting in . 
 Plombiferes, a French health resort .... 
 Pneumonia, catarrhal (caseous), complicating chronic j 
 
 tuberculosis 
 
 croupous (fibrinous), bloodletting in 
 " calomel in ... . 
 
 " case of (22d case) 
 
 " complicating chronic pulmonary tuberculosis, 
 
 '* dangerous symptoms in 
 
 " diagnosis of 
 
 " prognosis of 
 
 " rales in . 
 
 syphilitic, case of . 
 
 " diagnostic data on 
 
 " treatment of . 
 
 temperature of, treatment of 
 treatment of {vide drugs under separate headings), 
 
 Podophyllin as a laxative 
 
 Polyarthritis chronica (chronic articular rheumatism) 
 
 Popoff, Dr. P. M., on gastric catarrh .... 
 
 Potassium chlorate, gargling with a solution of, when using calomel, 
 
 " tartrate as a laxative 
 
 Predisposition, individual, to cholera 
 Preventive measures against cholera . 
 Prognosis, definition of . . . 
 " physician's duty concerning 
 
 " precision in wording the 
 
 " as regards the patient 
 
 " " the patient's relatives 
 
 ":_ in extreme cases 
 
 Piillna spring (Bitterwasser), chemical composition of 
 Pulse, condition of, when employing venesection for apo 
 " importance of, in objective examinations 
 " qualities of ...... 
 
 Pyatigorsk springs, chemical composition of 
 
 340 
 
 287 
 393 
 429 
 317 
 286 
 320 
 
 318, 319 
 319 
 328 
 441 
 441 
 445 
 
 320, 321 
 319-323 
 153 
 221 
 57, 59, 84 
 417 
 152 
 
482 
 
 Quarantining along the Asiatic borders during cholera epidemics, 369 
 
 " impossibility of a thorough application of 
 
 Quinine, a " pseudo " preventive measure in cholera 
 
 " compared v^ith sodium salicylate 
 
 " in erysipelas . 
 
 " in feverish conditions ■ 
 
 " in hectic fever 
 
 " in pleurisy 
 
 " in pneumonia 
 
 Ragatz, a health resort in Svpitzerland 
 
 Rakoczy, vide Kissingen. 
 
 Rales, respiratory, importance of . . . 
 " " varieties of . 
 
 Reaction period of cholera ..... 
 " in hydrotherapy, significance of 
 
 Rehme-Oeynhausen, an artesian spring in Prussia 
 
 Reichenhall, a German watering-place 
 
 Remedies, simultaneous employment of . 
 
 Respiration as influenced by baths 
 
 Respiratory organs, balneotherapy in diseases of 
 
 Rhamnus frangula (black dogwood) as a laxative 
 
 Rheumatism, acute articular (11th case) . 
 
 " "an infectious disease 
 
 " " autipyrine in 
 
 " " predisposing conditions to 
 
 " " relation of, to gout 
 
 '' " sodium salicylate in 
 
 " chronic (12th case) 
 
 " '• anatomical investigation of 
 
 ■' " etiological factors in 
 
 " " incorrectness of terra of 
 
 " " polyarthritis chronica 
 
 " " predisposing factors to 
 
 " " relation of, to acute 
 
 " " treatment of 
 
 Rhubarb, powdered, as a laxative 
 
 Riviera, Italian health resorts on the Mediterranean shore 
 
 Russian bath ......... 
 
 368 
 372 
 268, 269 
 427 
 463 
 292 
 268 
 320 
 
 340 
 
 328 
 328, 329 
 367, 368 
 347, 348 
 345 
 344 
 24 
 337 
 353 
 153 
 209 
 212 
 212 
 210 
 213, 214 
 210, 211 
 215 
 219, 220 
 219, 220 
 212, 217, 218 
 221 
 221 
 218 
 222, 223 
 152 
 303 
 349, 350 
 
 Saki, a health resort in Southern Russia, compared with Franzens- 
 
 bad 
 
 Salicylic acid in pleurisy . . . . 
 
 Salol as an anticholeraic remedy ..... 
 
 Salt, common, percentage of, in salt baths 
 
 Salts, laxative, contained in the mineral waters, effects of 
 
 Sanatoria, trips to, with climatotherapeutic aims in view 
 
 San Remo, an Italian health resort ..... 
 
 341, 342 
 267 
 317 
 344 
 91 
 316 
 303 
 
488 
 
 Schlangenbad, a Prussian watering-place . 
 Schwalbacli, a Prussian watering-place 
 
 Scrofula, hydrotherapy in 
 
 " sea-bathing in 
 
 Semiatalectesis of the lungs, physical symptoms of 
 
 Senna as a laxative 
 
 S^vignd, Mme., treated at Vichy . . . . 
 
 328, 
 
 Sexual intercourse, immoderate, as a causative factor in neurasthenia, 145 
 
 268, 
 
 " maturity in relation to chlorosis 
 
 Shift's theory regarding the effects of calomel .... 
 Shkliareffsky's treatment of the algid stage of cholera (foot-note) 
 Silver nitrate in gastro-intestinal catarrh .... 118, 
 
 " " in nervous dyspepsia 
 
 " " in neurasthenia 
 
 Skin, diseases of, hydrotherapy in 
 Slavyansk, a Russian watering-place 
 Soden, a German watering-place 
 Sodium bicarbonate, action of in the body 
 
 " " " in external application 
 
 " " " in washing the stomach with 
 
 " chloride, action of in the body 
 
 " " " in external application 
 
 " compounds in catarrhal conditions of the stomach 
 
 *' salicylate compared with quinine . 
 
 " " in acute articular rheumatism 
 
 " " in atonic gout 
 
 " " in hectic fever 
 
 ** " in pleurisy .... 
 
 " sulphate (Glauber's salt) as a laxative . 
 Soil, importance of (vide Climatotherapy) 
 SokolofE's theory on the effect of calomel . 
 Sound, gastric, use of, for diagnostic purposes . 
 
 '' " " objections to, for purposes of verification 
 
 Spanish flies in dyspnoea of pneumonia 
 
 " "in angina pectoris .... 
 
 Specific, the nature of a . 
 Spinal cord, diseases of, balneotherapy in 
 
 " " " bloodletting in 
 
 Splash, gastric, as a symptom .... 
 Spleen, changes of, in cholera .... 
 
 " determination of dimensions of 
 
 " hypersemia of, hydrotherapy in 
 Sputum, examination of, in pneumonia 
 Stara-Russa, a Russian resort .... 
 Status prsesens, definition of ... • 
 Stimulants, habitual, result of enforced abstinence 
 " " use of ... . 
 
 " in pleurisy ..... 
 
 from 
 
 PAGE 
 
 340 
 
 344 
 347 
 354 
 329 
 153 
 108 
 
 252 
 409 
 383 
 
 119, 120 
 
 151 
 
 147 
 
 354 
 
 344 
 
 344 
 
 90, 91 
 
 338 
 
 124 
 
 90, 91 
 
 338 
 
 86 
 
 269 
 
 210, 211 
 222 
 292 
 
 270, 271 
 
 152 
 
 302 
 
 409 
 
 63, 64, 65, 66 
 
 77 
 
 322, 323 
 456 
 
 290, 291 
 352 
 
 402, 403 
 128 
 367 
 330 
 352 
 319 
 344 
 
 268, 
 
 74 
 
 74 
 
 270 
 
— 484 — 
 
 Stomach, atrophic catarrh of, vide Catarrh, atrophic. 
 " dilatation of. causation .... 
 
 " lavage in . . . . 
 
 " " symptoms of . 
 
 '• " treatment of . 
 
 distention of, distinguished from dilatation 
 
 ulcer of (2d case) 
 
 " differential diagnosis of 
 •' " symptoms of . 
 
 " treatment . . . . . 
 Strawberry tea (fragaria vesca) in atonic gout . 
 " Streptococcencurve" in phthisis . . . . 
 Sunlight, effect of, vide Climatotherapy. 
 Sulphur, action of, in hydrotherapy .... 
 Symptoms, importance of, in semiotics and diagnosis 
 Syphilitic pains differentiated from gouty 
 Syphilis, exclusion of, by negative symptoms . 
 
 " hydrotherapy in 
 
 " inquiry about, when examining a patient . 
 
 " of the heart (vide also Heart) 
 
 '' " lungs (vide Lungs) .... 
 
 PAGE 
 
 Tabes dorsalis (locomotor ataxia), carbonated waters in 
 Tamponade of the nasal cavity for nosebleed, care in employing 
 
 Tannin in diarrhoea 
 
 " " of cholera 
 
 Tea as a stimulant drink in diarrhoea 
 Temperature, influence of, vide Climatotherapy. 
 " of the body as influenced by baths 
 
 " of croupous pneumonia, treatment of 
 
 {Vide also Fever.) 
 Teplitz, a health resort in Bohemia .... 
 
 Terpine hydrate for cough 
 
 Therapy, hospital, character of . 
 
 " special ........ 
 
 Tinnitus aurium while employing sodium salicylate 
 
 Tissue metabolism as influenced by baths 
 
 Toxine of choleraic bacteria (Mcati and Rietsch, Hueppe) 
 
 " " "its effect on the system 
 
 Treatment, employment of many remedies in . 
 
 " individualization and method requisite in 
 
 " hospital methods of 
 
 " hygienic, neglect of . 
 
 " necessity for conducting before the students 
 
 " symptomatic, abuse of ... . 
 
 ■'Trial" breakfast ....... 
 
 " dinner ........ 
 
 Tribromphenolbismuth (bismuth phenolate) as an anticholeraic 
 
 128, 
 
 127, 
 
 129 
 133 
 128 
 131 
 60 
 122 
 .58, 129 
 127 
 131 
 236 
 286 
 
 339 
 
 325, 326 
 
 226, 227 
 
 56, 267 
 
 354 
 
 12 
 
 446 
 
 436 
 
 845 
 
 400 
 
 51 
 
 374 
 
 74, 75 
 
 335, 336 
 320, 321 
 
 340 
 
 279, 283 
 25 
 25, 29 
 211 
 336, 337 
 365 
 366, 367 
 24 
 22 
 25 
 23 
 42 
 149 
 61 
 61 
 377 
 
 148, 
 
— 485 — 
 
 PAOB 
 
 Trips to health resorts with climatotherapeutic aims in view . . 316 
 
 Trypsin in diseases of the stomach 84 
 
 Tscherbakofi's table of mineral waters 92, 93 
 
 Tuberculosis, acute miliary, complicating chronic .... 288 
 
 " chronic pulmonary 274-278, 309-316 
 
 '* complications of . . . . . . . . 288 
 
 creosote in 271, 272, 295, 296, 297 
 
 " diagnosis of chronic pulmonary .... 283, 284 
 
 " guaiacol and guaiacol carbonate in . . 295, 296, 297 
 
 " hjemoptysis in the incipient stage of . . . . 260 
 
 " how the lungs become affected by . . . . 277 
 
 " Obersalzbrunnen in 96, 97 
 
 " pneumonise complicating chronic pulmonary, 286, 287, 288 
 
 '• prognosis of chronic pulmonary .... 289, 290 
 
 treatment of 290, 316 
 
 " " climatic (vide Climatotherapy) . 303-316 
 
 " " symptomatic {vide Ergot, KefSr, Kou- 
 
 myss, Creosote, Guaiacol, etc.) . . 291 
 " types of persons affected by .... 288, 289 
 
 varieties of chronic pulmonary ..... 283 
 
 Tuberculous ulcerations of the intestines ...... 48 
 
 Typhoid cholera, vide Reaction period of cholera. 
 
 " fever, body compress in 462 
 
 *' calomel in 420 
 
 Ulcer, gastric, vide Stomach, ulcer of. 
 
 Urethritis a causative agency in neurasthenia 144 
 
 Uric acid diathesis, vide Gout. 
 
 Urobilin (foot-note) 253 
 
 Vegetation, importance of, vide Climatotherapy. 
 
 Venesection in disturbances of cerebral circulation . . . 391, 392 
 
 " " circulation within the chest . 392, 393 
 
 {Vide also Bloodletting.) 
 
 Ventricle, left, condition of, in interstitial nephritis . . . 242 
 
 " " " in parenchymatous nephritis . . 242 
 
 Vertigo, inquiry about, in examining a patient .... 16 
 
 Vichy, chemical composition of 93 
 
 as compared with Marienbad 102 
 
 C^lestins 95, 102 
 
 " with sodium salicylate 210 
 
 dosage of Ill 
 
 Grande Grille 95, 102 
 
 indications for 104 
 
 in gout 228 
 
 Virchow's influence on therapeutics 213 
 
 " views on chlorosis ........ 251 
 
 Volga and Oural, koumyss sanatoria on ..... . 294 
 
— 486 — 
 Vomiting of cholerine, treatment of . 
 
 PAGE 
 
 381, 382 
 
 Watee, action of ... 
 
 " drinking, at a sanatorium 
 " " use of in cholera 
 
 " mineral, temperature of 
 Watering-places, trips to, as a remedial agency 
 Waters, mineral, aims in employment of . . . . Ill, 112, 
 
 " alkaline ..... 
 " artificial, compared with natural 
 " " classes of (in balneotherapy) : 
 
 "■ ■• carbonated 
 
 •' " containing also salt . 
 
 •' chemically indifferent .... 340- 
 
 " muds, mineral ...... 345, 
 
 salt 343, 
 
 "■ ■' contraindications to use of .... 116, 
 
 '• ' diet while employing . . . . . 115, 
 
 "• " effect of, on the mucous membranes . . Ill, 
 
 "■ •' " in the external and internal use of 
 
 '■ " " the component parts of: carbonic acid . 
 
 " " " " " organic acids . 
 
 " " " sodium carbonate, 
 
 "• •• " " " " chloride, 338, 
 
 "■ " " " " sulphur . 
 
 "■ '• " mechanical influences during external use, 
 
 '^ " " temperature of, on the circulation . 337, 
 
 '' '" " " " nervous system, 334, 
 
 '■ " " " " secretions . 
 
 "• " " " " temperature of body, 
 
 " " ■' tissue metabolism, 
 
 " " curative agencies in ... . 
 
 "■ ■' empiricism in the employment of . 
 
 "■ •• employment of, former . . '. . 
 
 " " " at the present time . 88, 
 
 " " foreign ....... 
 
 " ■' individualization necessary in prescribing 
 
 in constipation and in diarrhoea . 
 '' •' length of course of treatment with 
 
 " " quantity of daily dose of . . . 
 
 " " routine method of drinking, at the resorts 
 
 " " Silesian, atomized, for laryngeal catarrh 
 
 " " temperature of, for drinking . 
 
 " " time of administration of ... . 114, 
 
 " " varieties of, vide above, classes. 
 
 Webber's classification of climates 
 Weiss on the physiological effects of calomel 
 Wermel's observations regarding cholera . 
 
 87, 88, 
 109, 110, 
 
 113, 
 111 
 109, 
 
 90 
 302 
 372 
 
 92 
 110 
 113 
 115 
 
 87 
 
 344 
 345 
 
 343 
 346 
 344 
 117 
 116 
 112 
 333 
 338 
 339 
 339 
 339 
 339 
 339 
 338 
 335 
 336 
 335 
 336 
 90 
 107 
 108 
 111 
 107 
 110 
 112 
 114 
 -113 
 110 
 279 
 115 
 115 
 
 299 
 409 
 361 
 
— 487 
 
 Wiesbaden, a German watering-place 
 Winds, importance of, vide Climatotherapy. 
 
 Wine in cardiac debility 
 
 in diarrhoea 
 
 ■' as a causative agency in bypertrophic biliary 
 Women, diseases of, Franzensbad-Moorbader in 
 
 Yalta, a health resort in the Crimea 
 Yessentucki, chemical composition of 
 
 " compared with Ems 
 
 " " Vichy 
 
 " contraindication to use of 
 
 " dosage of 
 
 " indications for use of 
 
 " in atonic gout 
 
 •' temperature of 
 
 Ztemssen on calomel in cholera 
 Zittmann's decoction in syphilis 
 
 
 PAGE 
 
 
 344 
 
 
 43 
 
 
 43 
 
 cirrhosis 
 
 426 
 
 
 345, 346 
 
 
 313 
 
 
 93 
 
 
 96 
 
 
 105, 106 
 
 
 96 
 
 
 111, 112 
 
 
 105, 106 
 
 
 222, 228 
 
 
 116 
 
 
 376 
 
 
 438 
 
'■^yoi 1 '/ uj