CASE II.-Henry W., German, æt. 68, admitted May 24, 1888, has been living in the out-wards for about one year. On admission his gums were swollen, spongy, of a deep purplish red color, and bleeding spontaneously. The left ankle joint is surrounded with an extravasation of blood which extends upward nearly to the knee. The right leg has a few ecchymotic spots over the surface of the tibia. The breath is horribly fetid. Examination of urine negative. An examination of the blood on June 1, 1888, gave the following result: number of red corpuscles per cubic millimetre, 5.150000; color, 60 per cent. of the normal; white corpuscles not increased.

Eyes examined by Dr. de Schweinitz, June 15, 1888. Pupils unequal, the right being the smaller; L. E.: Posterior capsular opacity of the lens, permitting but a very dim view of the fundus; general choroidal disturbance; gray oval disc with hazy eyes; R. E.: similar. Studied with difficulty on account of narrow pupil. CASE III.—John H., Hungarian, æt. 24, of a dark, muddy complexion, was admitted May 31, 1888. He has an excellent set of teeth and the affection of the gums is slight, consisting merely of two projections of spongy tissue between the lower incisors. His legs are completely covered as far up as the knees with confluent areas of extravasated blood. Immediately below the knee on the inner surface of the left leg there is a hard, purplish tumor about the size of a small egg, and another about the same size just above the ankle over the surface of the tibia. The surface of the latter tumor is superficially ulcerated. Smaller ulcers, of which the area is about equal to that of a quarter-dollar, are scattered over the right leg and over both feet. They look as if they had resulted from the rupture of vesicles. Small petechial spots surrounding the orifice of the hair follicles are scattered over the surface of both thighs. Examination of urine negative.

Blood examined June 9, 1888; number red corpuscles, per cubic m., 5.320000 ; color, 65 per cent.; eyes examined by Dr. de Schweinitz, June 9, 1888; R. E.: small oval disc, the upper and nasal portions being veiled by a hazy retina; arterial lymph sheaths unusually distended; some shining dots in nasal portion of retina; color of disc and size of vessels normal; L. E.: very similar; veins rather full and pulsating.

CASE IV.-George S., Hungarian, æt. 23, laborer in a lime quarry, admitted May 22, 1888; dates his illness from May 18. His teeth are good and are all present. The gums are uniformly spongy and of a purple color. There are extravasations of blood over both knees, and the legs and thighs are covered with small petechial spots surrounding hair follicles.

Examination of urine negative; examination of blood June 4, 1888: number of red corpuscles per cubic m., 3.950000; color, 65 per cent.; no increase in white corpuscles.

CASE V.-Daniel D., Irish, teamster, æt. about 65, admitted to the hospital from the out-wards May 28, 1888. Patient was sick in the out-wards three weeks before admission. The gums are uniformly swollen and tender. Of the extremities, the right leg is the only one affected, it being indurated from the ankle to above the knee, the induration being especially marked in the popliteal space. Over the surface of the tibia there are large ecchymotic patches.

Examination of urine negative; eyes examined by Dr. de Schweinitz; R. E.: evidences of former iritis; an oval disc, gray and semi-atrophic; arteries unchanged in size; veins a little fuller than the arteries; L. E.: exactly similar in appearance, except that there is a yellowish patch of choroiditis in the macula; pupils react sluggishly to light.

CASE VI.-Alphonse A., Italian, laborer, æt. 42, admitted to the hospital May 19, 1888. He has good teeth but the gums are uniformly swollen, although only to a slight extent and of the usual purplish red color. The legs, thighs and arms are covered with small petechial spots surrounding the openings of the hair follicles. The inner surface of the right knee is covered with large ecchymotic patches, and similar ones are scattered over the leg of the same side. The scorbutic signs are much less prominent on the left leg.

Blood examined May 22, 1888: number of red corpuscles per cubic m., 1.980000; no increase in white; in fact, they appeared to be diminished in number, as I examined a large number of fields without finding any, and at last, after a prolonged search, succeeded in finding one. The corpuscles were not materially altered in size or shape. The requisite amount of blood (20 cubic millimetres) could not be obtained for Gowers' color test, although several deep incisions were made in three separate fingers. The blood would at first flow readily and then stop altogether before a good sized drop had escaped. It seemed as if all the blood in the finger pulp had been squeezed out, for no more could be obtained. I have met with more or less difficulty in obtaining blood from the finger pulp in all well marked cases of scurvy, and I believe that any fear of starting a serious hemorrhage by such punctures may be dismissed as chimerical.

CASE VII.-A Hungarian occupying bed 4, ward 9, admitted with considerable swelling and great tenderness of both legs, which are covered with large, bruiselike patches of extravasation. The largest patch, about the size of the hand, is on the anterior surface of right leg. It is of a deep purple color, and over it the epidermis is thick and desquamating. The gums are greatly swollen, tender, bleed on slight pressure, and project in fungous masses between the snag-like teeth. No accurate history of the case can be obtained. The patient presents a very anæmic appearance, but is by no means emaciated; on the contrary, his tissues retain their bulk The lips and palpebral conjunction are of a milky-white hue.

May 16, examination of blood: number of red corpuscles per cubic m., 2.775000; white somewhat increased, about 20000 per cubic m.; color, 30 per cent,; eyes examined by Dr. de Schweinitz; L. E.: an oval disc, the nasal edge slightly mellowed; wide distension of the central lymphatic sheaths along both arteries and veins; a number of fine yellowish points in the macula. Below the disc, between the lower artery and vein, there is an irregular white patch made up of a group of small white specks. R. E.: appearance of the disc and lymph sheaths similar; the disc is distinctly gray in its lower layers. There is a similar white patch in the lower field through which are dotted many shining points, probably cholesterine crystals,

CASE VIII.-John McK., Irish, æt. 68, admitted to the hospital from the outwards suffering from bronchitis. This soon improved, but the patient did not gain strength and was averse to rising from bed. A few days after his admission there was a sudden rise of temperature, and the day after I was asked to examine his arms, which were covered with a pink eruption precisely like that of scarlatina. The question, decided by me in the negative, was whether the case could be one of variola. This disease was somewhat prevalent in Philadelphia at the time referred to and had appeared in one of the wards of the hospital, though not in the one occupied by John McK., and two of the nurses had been infected with it.

The eruption deepened in color and extended until it had almost covered the entire body. On the lower extremities it was particularly well marked, the legs being of a uniform, deep purple color. On the arms it was also confluent, while on the trunk it was scattered in spots and patches. Soon after the appearance of the eruption, bleeding set in from the nose and gums and was of daily occurrence for nearly a week.

Blood examined May 7, 1888: number of red corpuscles per cubic m., 3.310000; color, 35 per cent.; white corpuscles per cubic m., 20000; proportion of white cells to red, 1 to 165. In many of the red cells the coloring matter was collected in the centre as if there might be a tendency to separation of the hæmoglobin. There was no appearance of blood or its coloring matter in the urine, which was also free from albumen.

Examination of eyes by Dr. de Schweinitz; R. E.: Media clear; disc small, oval, not grayer than consistent with age; retina somewhat cloudy around disc; otherwise no changes. L. E.: small oval disc; undue fulness of veins; disc distinctly grayer than normal and hazy toward the nasal edge.

The eruption in this case differed materially in appearance from that of any other case of scurvy observed by me, and it is a matter of opinion whether the affection might not, with equal propriety, be regarded as purpura. In fact the patient was exhibited in one of the medical clinics by one of my colleagues as a case of purpura. This was the only reason that deterred me from lecturing on it at a subsequent clinic of my own as a case of scurvy.

CASE IX.-E. S., Russian, æt. 48, peddler, admitted April 11, 1888, suffering with erysipelas; at the end of two weeks he had entirely recovered. On May 19 he had a relapse and again recovered in about a week. About June 1 an eruption consisting of small punctiform spots made its appearance, rapidly became confluent and extended over the trunk, arms and thighs. The gums also became swollen and tender and bled on the slightest pressure. During the attack of erysipelas, the urine contained albumen in considerable quantity, as well as blood, and epithelial, hyaline and granular casts. In this case the scorbutic attack was doubtless pre

cipitated by the erysipelas.

CASE X.-Ward 9, bed 15. An old out-warder, æt. about 60; has been back and forth between the out-wards and the hospital for the last three or four years. Manifestations of scurvy well marked, though not excessive, in gums, from which there was oozing of blood at the time of admission. Large purplish extravasations occupying anterior surface of lower thirds of both tibiæ. No particular swelling

or induration and no œdema. Some tenderness about tendo achillis. considerable hemorrhage from the bowels at the time of admission.

There was

Blood examined by Dr. Hamill, the resident physician, March 19: number red corpuscles per cubic m., 4.210000; color, 60 per cent.; bloood dark and venous looking; evidently diminished in quantity, as it was difficult to obtain enough (20 cubic m.) for Gowers' color test. This man had been living exclusively on bread and meat; said he never ate potatoes.

CASE XI.-This case was under the care of Prof. Tyson and was shown by me in one of my hospital clinics, by his permission, as a typical example of scurvy. I have preserved the following scanty notes:

The man presented the buccal lesions of scurvy in extreme degree, the gums actually covering the upper and lower incisor teeth. On the legs the scorbutic signs were limited to petechial spots. Blood examined by Dr. Hamill: number

of red corpuscles per cubic m., 4.160000; color, 60 per cent. This patient was also an out-warder.

An apparent omission in the above brief reports is an account of the daily or weekly progress of each case. As this was uniformly favorable, detailed statements to that effect in connection with each report, would have led to wearisome repetitions.

The treatment consisted in the systematic administration of lemon juice, about two ounces daily; raw potatoes, grated; onions, raw and cooked; and in the more anæmic cases, iron, usually in the form of Blaud's pill. The buccal and other lesions of course received appropriate local treatment.

In conclusion, in connection with the fact that several of my patients were "out-warders," i. c., inmates of the Almshouse, I may say that this fact bears out the statement on a previous page that it is one thing to be provided with appropriate food and quite another to partake of it. The diet of the Almshouse is decidedly antiscorbutic, consisting of vegetable soup daily; potatoes, onions and turnips twice a week; coffee, tea and bread daily and plenty of beef and mutton.

Nothing characteristic was observed in either the pulse or temperature, although, as it is scarcely necessary to mention, the most careful records of each were kept. As regards temperature, I cannot add anything to the following opinion expressed by me in the course of a clinical lecture on scurvy: "Although probably no case of scurvy runs its course without abnormal rise of the body temperature, fever is not an essential feature of the disease, but is secondary to the inflammatory complications of gums, skin, connective tissue, bones, joints, etc.

1 Med. and Surg. Reporter, June 16, 1888.

ON THE RELATIVE VALUE OF SOME OF THE

CARDIAC STIMULANTS.

BY W. E. HUGHES, M.D., Ph.D.

THERE is evidently a sufficient explanation of the varying results obtained in the use of the different cardiac stimulants if we could only arrive at it. Sometimes one, sometimes another will prove more satisfactory, and it is with the idea of deducing some rules governing their action clinically, and thereby facilitating their correct administration, that this paper is written. Were the condition of the heart alone to be considered, the question would resolve itself into which stimulant was capable of producing the most marked effect upon the cardiac muscle, directly, or upon the centres controlling this muscle; but beyond this must be taken into consideration the condition of the arteries and the kidneys, and it is probable that a partially satisfactory explanation of otherwise inexplicable and contradictory variations in the effect of these stimulants may be arrived at by such consideration. The condition of the arteries is of great importance, for these stimulants are none of them simple in their action and have their effect limited purely to the heart, but are complex and affect more or less markedly the blood pressure by their action upon the peripheral circulation. So that in one case a drug may be actually harmful, while in others closely related distinctly beneficial. The condition of the kidneys influences directly the state of the blood pressure, thus in different cases pointing out the use of different stimulants. In addition to this there seems to be a local effect produced upon these organs in varying degrees by the different stimulants, so that some of them more than others promote renal excretion.