&w; NLM D51113ED 3 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY Form 113c No. .r>.A-l.^..^-°- W.D..S.G.O. VEHNHENT FHINTINO OITICI NLM051113203 «■»■ Nitrate of-Silver Mark; JJgophony or Bronchophony; " Un- covering the Chest behind." For a description of these cuts see page 16. 01ST THE TREATMENT OF PLEURISY: WITH AN APPENDIX OF CASES, SHOWING- THE VALUE OF COMBINATIONS OF CROTON OIL, ETHER, AND IODINE, AS COUNTER- IRRITANTS IN OTHER DISEASES. BY JOHN W. CORSON, M.D., LATE, PHYSICIAN TO Till". OLASS OP "DISEASES OF THE CHEST AND TIIIIOAT" IN THE XI'.W YORK AND EASTKUN DISPENSARIES; FORMERLY PHYSICIAN TO TUB BROOKLYN CITY HOS- PITAL : PHYSICIAN TO THE ORANGE MEMORIAL HOSPITAL; AUTHOR OF "LOITERINQS IN EUROPE," &C Entered according to Act of Congress, in the year 1874, by JOHN "W. CORSON, M.D., In the Office of the Librarian of Congress at Washington. John F. Trow & Son. Printers and Bookbinders, 2U5-213 East nth St., NEW YORK. PREFACE. As will be seen, this little volume is the result of ob- servations of more than five hundred cases of pleurisy, during a service of several years as physician to the class of "Diseases of the Chest and Throat" in the New York and Eastern Dispensaries. It is a sketch of its management in a lowly field. Except the Appendix, it was given in substance in a paper read before the New York Medical Library and Journal Association, " On the General Treatment of Pleurisy, and the use of 'Croton-Oil Paint' as a Substitute for Fly-Blisters," and published in the New York Medical Record for Dec. 1, 1874. The free style of the clinical lecture, rather than that of the formal essay, has been retained as the most nat- ural ; for it seemed more like tall, big with valued friends, after long absence, than reading. To some of these, many thoughts here presented may hardly appear new. The generation of practitioners who in their youth- ful studies, twenty years ago, were kind enough to patronize our Saturday " Chest Cliniques for Stu- dents," or plain " Spring " College Lectures, may pos- sibly recognize as familiar topics then discussed, " Mildness in Treatment." "Alternate Painting and Rubbing with Iodine and Croton-Oil," " The Nitrate- of-Silver Test,? "Uncovering the Chest Behind," "The Relative I Value of Remedies," and especially the plea for " Flavoring Medicines," even among the desolate poor. But it is hoped that these wrill seem fresh in print. If anything in this effort shall help to lessen one pang of human suffering, its highest aim will be gratified. For in his heart, the true physician ever cherishes the Christian maxim: " J^one of us liveth to himself." Orange, N. J., Dec, 1S74. Careful statistics from great charities have helped to fix the real value of many remedies. When life is at stake we dare not lightly risk new things. In pre- senting any fancied improvements before so many accomplished physicians, it is but just, frankly to give the facts and figures on which they are based. Let us gladly appeal to numbers. From the report of Dr. Aigner of his European tour, it appears that, doubt- less from our vast emigration, the dispensaries of New York are the largest in the world.* The writer pro- poses to discuss the general treatment of pleurisy, and the use of croton-oil and the tincture of iodine as substitutes for fly-blisters, in this lowly field. His ex- perience was mainly during several years of service as physician to the class of " Diseases* of the Chest and Throat," in the New York and Eastern Dispensaries. These investigations were commenced more than twenty years since. They were principally in the first of the above institutions, which was the most vener- able and extensive. Many here will remember a quaint, old brick building that then stood on the site of the present elegant edifice in Centre street, near the Five Points. * See Annual Report of the New York Dispensary for 1803. St. Bartholomew's and other hospitals in London have very large " Out- Door Departments ; " but the regular dispensaries of Buropean cities are much smaller than ours. 8 A stone on the south end celebrated the date of its erection, in the last century, by the inscription, "New York Dispensary, 1790." From many causes this noble charity furnished the greatest " annual crop " of pleurisy that we have ever seen. It was built, as if in honor of our Dutch ancestors, over an ancient skating-pond. Even as early as our day, it was sur- rounded with great, filthy tenement-houses. These were filled to overflowing with weary, destitute emi- grants of all nations, who were often fed on cheap re- fuse provisions, and lodged on cold floors with a scan- ty covering. The sanitary condition of that low re- gion wras awful. In some respects it was doubtless worse than that of St. Giles, London, or Cowgate, Edin- burgh. At midnight in winter, it seemed like the val- ley of death. It was near Cow Bay, and the haunts of sin and misery. And it had underground dance- houses, with small, red windows, lit up as with Satanic flames. Here all human colors mingled in revelry, and drunken men staggered forth as if from a Turkish bath, reeking with perspiration, to sleep and sicken on frozen sidewalks. The multitude of sick relieved by this long-estab- lished institution for our young country, was almost incredible. Its reputation had grown among all classes from its foundation, owing to the labors of many of the best physicians of your city.* From a volume * Among many other well-known names, we notice on the *' con- sulting" list, those of Drs Hosack, Post, Stevens, 'Villard Parker, Gilman, Bulkley. Watson, Lin sly, and Markoe ; and as Attending Physi- cians or Surgeons, Drs. A. C. Post, Gurdon Buck, J. A. Swett, G. F. Shrady, I. E. Taylor, Purely, James Crane, Van Kleek, McCready, Clements, Briddon, J. O. Stone, Purple, Halstead, Elisha Harris, Ste- phen Smith, Bishop, Eager, Gomez, A. B. Mott,Thebaud, Pulling, Cam- eron, O'Rourke, Aigner, W. C. Corson, Kennedy, Harrison, Kelly, Rob- inson, Murray, and many others. 9 of printed Annual Reports, kindly furnished by the treasurer, which we hold in our hands, we learn that during the seven years and a half of our service there, commencing with the spring of 1852, that includ- ing vaccinations, dentistry, and all its departments, it actually averaged the enormous number of over forty thousand patients yearly. For the reasons given, its percentage of chest diseases was very large. It seems from these records that within six years of strict classification, previous to the close of 1859, during which, with the exception of a few weeks, the writer divided equally with another physician the class of "Diseases of the Chest and Throat," there were entered twelve hundred and forty-eight cases as "plcuritis." This was an average of two hundred and eight annu- ally. The male side, which we happened to have, would naturally rather excel the female department from greater exposure. Deducting one-sixth for the district service, this would give for our personal share, as the basis of these observations, over five hundred Gases of pleurisy. To be safely within bounds, this estimate does not include the extra patients sent to our Saturday " Chest Cliniques " for students, nor those of three years on the district, nor the results of three years of attendance during this period in the same class in that worthy charity the Eastern Dispensary. From differences in the severity of the winters, or other causes, the numbers with chest affections varied. These fluctuations may be illustrated by the following table, with the result in each year, taken from the An- nual Report of the year f ollowing: 10 NEW YORK DISPENSARY—VARIATIONS IN SEASONS. Four prevailing Diseases of the Chest, for Six Years pre- vious to January 1st, 1860. Year. Pleurisy. Pneumonia. Phthisis. Bronchitis. 1859 (Rep. 1860). 306 119 , 1,906 4,067 1858............. 250 192 1,386 4,974 1857............. 144 106 1,235 5,495 1856............. 131 132 895 4,057 1855............. 235 226 639 3,126 1854............. 182 274 658 1.810 Totals... 1,248 1,109 6,719 23,529 It will be seen that " bronchitis " largely heads the list, while the sad array of consumptives comes next. As proof of care in diagnosis, there were recorded in this term a "total" of 1,175 patients with " pleurody- nia," or "muscular pains" of the chest. Those in- terested in sanitary studies may make a more accurate comparison of these changes, with the aid of the fol- lowing table, giving the entire attendance for this period: PATIENTS OP ALL CLASSES, INCLUDING VACCINATIONS, ETC. 1859 (Rep. I860.).... 44,627 I 1856........ 40,235 1858.................. 47,032 1855........ 39.554 1857.................. 41,235 | 1854........ 46,052 Total.......................... 25S,735 Among these poor we soon learned to dread the ex- haustion of large fly-blisters. Even with the hardy subjects which they seemed to benefit, they were soon cut down to the standard of four inches square, or less. One or two only were used at intervals of a few days, and they were soothed with an anodyne poul- tice before dressing. In the latter half of the management of these Dis- pensary cases, there was found a far better substitute 11 for blisters. It was the alternate application of iodine and croton-oil. We commonly changed to these last when the tape-line showed slight enlargement or "bulging;" when inspection proved that the inter- costal spaces were beginning to flatten, and when the dullness on percussion was more completely " dead- ened." The ribs over the effusion were then painted with several coats of the tincture of iodine in large brown patches, five or six inches square, every second or third day. These stains were rubbed over with two or three drops of croton-oil—perhaps once a week— just sufficient to maintain moderate pustulation. And the soiled fingers wrere at once washed with soap and water. When the space thus gently irritated was healed, the process was repeated, or the location was changed. And thus we kept painting and rubbing till the effusion was gone. The excellent results which we shall presently men- tion were hardly clue to these appliances alone; for as every sensible practitioner knows, counter-irritation in any form is only a valuable auxiliary to internal treatment. And this last was equally mild. Even at that early day, among these poor emigrants, we never either bled or purged in pleurisy. As a rule, latterly, we avoided antimony, mercury, veratrum viride, and aconite. We did not deny their valuable services as arterial sedatives, and as excellent substitutes for blood-letting in inflammation, with stronger patients or in private practice, in this brain-weary age. But with these weaker constitutions we feared that they would help to thin the blood or palsy the impulse of the feeble heart. We were not quite original. It is but a just tribute to say, that this caution was due in 12 part to the previous teachings of that admirable chest physician, Skoda, during a few months in the hospital at Vienna. In the acute stage, as is well known, we were liable to be consulted at two different points in its progress. There might be fever ; a rapid or full pulse; thirst; a f urred tongue ; with difficulty of breathing; a sharp pain in the side, and a dry, teazing cough, accom- panied by the physical signs of stiffness in the chest movement and the "friction sounds" of the "dry period." Or a little later these febrile and rational symptoms might be associated with marked dullness on percussion, and the absence of respiration from the effusion of the fluid. And one was relieved of the fear of pneumonia by the freedom from tenacious or bloody sputa. In either case, our first effort was to make the patient thoroughly comfortable. It was be- fore the blessed day of hypodermic injections. We generally resorted to a safe anodyne, added to a dia- phoretic or diuretic, and sometimes to both. It is scarcely necessary to add that there is little or no risk with a mild narcotic in these painful chest affections, when the face is not livid, and there is a warm glow upon the surface of the body. In our later experience the following soothing combinations, among others, were often used: 3. Pulv. Doveri.................... gr. xx. Pulv. potassse nitrat........... .. gr. xx. Pulv. opii....................... gr. ij. Pulv. sacchar. alb............... 3 i. 01. anisi........................ gtt. ij. Spirit cinnamon (tinct. ol.)....... gtt. iij. M. et div. in pulv. No. vi. 13 Take one powder in moistened sugar every four waking hours till quiet. In mercy a saccharine aromatic was added to cover the mawkish taste of these powders. Some of our friends present will recognize this addition as a concen- trated imitation of that very convenient preparation, the " oil sugar " of the German pharmacopoeia, composed of one drop of essential oil to thirty grains of sugar.* In milder cases, or later in the disease perhaps, we tried this: I?. Liquor ammonias acetat............§ iij. Spirit, ether, nitr..................3 iij. Tinct. hyoscyami.................3 ij.- 3 iv. Spirit, gaultheriae (tinct. ol.).......gtt. xij. M. Take a dessert-spoonful in sweetened water every four waking hours. When convenient, this was given with some grateful fruit juice, or with lumps of ice dis- solved upon the tongue. If the fever was very high, half a drachm or more of the nitrate of potass, in solu- tion, was substituted for the acetate of ammonia. When the hyoscyamus failed to quiet the pain, a little morphia was sometimes administered. If the pulse was firm and the skin dry, the eighth of a grain of ipecacuanha, or a little more, was added to each dose of the mixture. Within the last few years we have changed to milder external applications at the commencement. We have resorted to a plan equally serviceable and safe in pains of the chest or abdomen. Over the ach- * See Article " Oelzucker," edition 1870. With a refinement worthy of German civilization, it makes the mouth water with such " delica- cies for the sick " as the syrups of cinnamon and raspberry. 14 ing side there has been at first laid a blood-warm mustard plaster, half meal or flour, folded between cloths, and applied for twenty or thirty minutes, till the surface has been well reddened but not blistered. The mustard has been followed by a piece of flannel wet with laudanum or spirits of camphor. This again has been pressed home to the ribs by a com- fortably hot bag of three or four quarts of meal, oats, or better still, wheat Iran. If musty, from being long kept for the purpose, it may be sprinkled with co- logne. It is generally heated in a deep dish, in a stove, oven, or range, and poured into a soft pillow- case, to be lightly applied and renewTed as it gets cooled. We think "dry heat" is much more safe than moist. The "bran bag" may be kept warm much longer if covered with sheets of cotton wool, enveloped with brown paper, or more perfectly still, with " oiled silk." This sort of domestic Turkish bath is commonly used, for several hours at the onset of the disease, first to quiet pain, and next to excite a gentle perspiration, and thus relieve congestion of the lung.* All this gentleness wras to save strength. We waited till the early acute symptoms had passed before ven- turing to apply a blister. The diet was rather liberal. Milk, eggs, toast, bread and butter, plain vegetables, fruit, and the lighter forms of animal food were gradually allowed; for it was evident that prostra- tion would soon follow. In the chronic stage it wTas found convenient to compare the good effects of squills, digitalis, the ace- * The heated "bran bag," applied twice or three times a week at bedtime to the loins, by increasing cutaneous action has served ua materially in the treatment of certain affections of the kidneys. 15 tate of potass, and other diuretics, by the following test, available for the first fortnight or more of the effusion. It was to listen directly over the upper border of the fluid—while the patient distinctly counted—for that piercing, trembling echo of voice, the "yEgophony" of Laennec. Or in its absence, there was usually marked bronchophony without the vibration. One or the other was commonly audi- ble at this period, if carefully sought at a point nearly opposite the middle of the scapula, or upwards or downwards about two inches from the spinal column behind. A black mark, an inch long, was at once made over this penetrating line of voice, with a mois- tened stick of nitrate of silver. And this dark stain remained perhaps for ten days or more, as a fixed landmark for daily careful observations, to measure the rise or fall of the fluid within. For these changes corresponded with the shiftings of the intensified sound of voice. This mark was also a useful guide in estimating any variations in the respiratory murmur or dullness on percussion. And it told the story, when fortunate, of gradual cure. We do not know the author of this excellent device. At least two accom- plished friends have used it for years. These-physical signs were all made more clear by another simple expedient. The patient was directed to cross both arms and grasp, not these, but the high- est points on the shoulders as far bad: as he could reach. He then pulled them steadily and firmly forward, so as to separate the shoulder blades, and hold them fixed as widely apart as possible behind. This process might be aptly termed uncovering ; for it partly laid bare the ribs under both scapulae and stretched and 16 thinned the thick muscles in their rear. The writer had occasion to commend this improvement on the old position in a paper read before the Academy of Medicine, and published in the New YorTc Journal of Medicine for March, 1859, "On the Management of the Shoulders in Chest Examinations." In consumptive patients it was also a great assistance in searching for obscure groups of tubercles at the apex of the lungs behind. We add a sketch.* Lower down beneath the shoulder-blades, either "friction sounds," or signs of limited pleuritic effu- sion were emphasized by crossing and locking the arms behind the head, as shown in the second illustra- tion.* By many experiments with the " nitrate-of-silver test," aided by this expedient of " uncovering," we came at length, as a rule, to prefer the iodide of potassium in steady moderate doses, as the most uni- formly successful tonic diuretic of the list. Others might produce a greater temporary increase in the quantity of urine; but this proved, as we fancied, the best absorbent to liberate the compressed lung. To use an agricultural figure, it excelled the others in its power of under-draining. It had also the effect of preserving, and sometimes even increasing, the appetite for food. While we were mildly blistering, paint- ing or rubbing for weeks together outside, we gave internally, at the same time, about five grains or even less of the iodide of potassium three times a day. This salt, as well as some of the preparations of iron, will produce a slight amount of worry in most sensi- tive subjects, which we have found relieved by a * These illustrations are given opposite the title-page. 17 merely nervine addition of hyoscyamus or conium. The following prescription, variously modified, was a favorite with us as a mild diuretic in chronic pleu- risy : 5. Potass, iodid.............. 3 i.-3iv. Tinct. hyoscyam........... 3 ij. Tinct. cort. aurant......... 3 i- Spirit, gaultheriae vel Cinnamoni (tinct. ol.)...... gtt. xij. Aquae....................q. s. Ft. mist. |iv. Take a dessert-spoonful three times a day in a wine- glassful of sweetened water between meals. This mix- ture was sometimes made more diuretic by adding three or four scruples of the best extract of taraxacum, or more laxative and tonic by combining with it a fluid drachm of the tincture of nux vomica. In tedious recovery the appetite was occasionally encour- aged by qualifying the above combination with two or three drachms of the tincture of columbo, or an ounce of the tincture of calisaya bark. We watched the more delicate of those pallid, ema- ciated patients with pleuritic effusion with deep in- terest. Until complete restoration to health there was always a lingering fear of future consump- tion. In some respects, we happened to anticipate the recent views of Niemeyer and others as to the occasional agency of inflammation—especially in weak or scrofu- lous subjects—as the starting-point of tubercles. And these apprehensions stimulated all possible preven- tives. At the close of the treatment, we recommended warm flannels, plenty of milk and meat, and other va- ried, diet; ventilation in sleeping, and careful, yet free IS exercise in sunlight and air. Sometimes the lost flesh was restored with cod-liver oil. And the ears were closely inspected to see if they needed iron. These were as interesting as the webs of frogs to young mi- croscopists. Like the pulse, they were examined while free from excitement. And we have never seen a surer sign of the want of iron in the blood of a calm patient than a pale, waxy ear. To favor those grand restoratives sleeping and eating, special pains were taken with the prescrip- tions. Medicines were always given by preference during " waking hours." Sugar was not so essential as water. Salts, acids, alkalies, and chemicals gener- ally wTere thought to disturb the stomach less when pretty largely diluted. The interval " between meals " was commonly selected as the best time for the starch and other elements of partly digested food to combine with the iodide of potassium and some other substances. An early accident directed our attention to another aid in building up these pale, wasted subjects, slowly recovering from pleurisy. Many years since, while on duty as physician to the Brooklyn City Hospital, the writer began a series of observations for a projected paper "On the Relative Agreement of Medicines with the Stomach." Fits of flatulence, tender spots, and furred tongues were counted till he was weary. The task of thus comparing all the bitter things of the materia medica proved too great. It was never fin- ished. But the effort led to new views of the import- ance of their pleasant administration. On careful ex- amination it appeared that digestion itself wras often temporarily interrupted by the nausea from unpalatable drugs. In actual danger we never dared to fiddle 10 with any kind of inert practice. With the prevailing exhaustion of this overworked age we were always generous in supporting agents. But in this it became a rule to conciliate the sense of taste—that jealous guardian to the stomach—with savory disguises. In fact it was simply bribing the porter. When their doses were made agreeable the poor seemed to eat the meagre fare of the sick-room with a keener relish. And if they thus recovered more rapidly, there was an actual saving in expense to a benevolent institution in adding a little sugar, a few drops of spicy tincture, or inexpensive aromatic essence. They would thus need less medication. We remember that dyspeptic consumptives used to profess to be attracted from other dispensaries by our " more pleasant" cod-liver oil spiced with a drachm to the pint—or less—of the very cheap oil of sassafras. As a general rule we ob- served that, as in the cookery of health, the stomach in sickness was best pleased with the more delicate compound flavors. In illustration we may mention that our most satisfactory recent improvement of cod- liver oil, in private practice, has been to add to the ordinary full bottle of oil a teaspoonful of a mixture of one part of the oil of pimento or " allspice," one part of the essence of cinnamon, and two parts of the tincture of orange-peel.* This kindly practice per- fectly charmed children. And then it was only hu- mane. Where the hundreds of millions of earth in- stinctively craved " seasoning" in their food, it was hard to deny them "condiments" in their medicines. So we have continued ever since this early experience * Pimento as a delicate carminative has been introduced into three of the formulae in the British Pharmacopoeia. 20 to flavor from principle, in the firm belief that the sick are thus better nourished. The success of this gentle plan in this serious malady among these poor emigrants was a constant surprise to us for years. We can hardly account for it still. In the main features of this mildness our worthy col- leagues agreed. As the figures show, more than half the credit was due to their skill. We may give some facts. Statistics in a crowded dispensary can never be so perfect as in a well-organized hospital. Their weak point is the termination. Making in honor due allowance for the number of grave cases sent to the hospital from the dispensary and the "results" lost, as well as for the transient patients who would stray to the country, its death-rate from pleurisy was still very favorable. Probably the item of mortality was better kept than many others. For where cases became so serious as to be fatal, they were always attended at their homes by the district physicians. These were salaried officers, appointed usually after faithful ser- vices, who reported the losses from each disease monthly. In six years, and over twelve hundred cases, there were only recorded six deaths from pleurisy, or less than a half per cent. With the drawbacks we have mentioned, it may be more safe to estimate the loss in round numbers at one per cent. Again, we were on the lookout all this time, publicly and privately, for suitable subjects for Dr. Bowditch's comparatively safe operation for empyema, with a small trocar and pump, near the inferior angle of the scapula behind. And we only ventured to puncture eight times. With the-recent improvement of the admirable aspirator of Dieulafoy, we should have probably operated much 21 more frequently. In mild weather and moderate at- tacks the average time for the absorption of the fluid was about six weeks. This term was doubtless appa- rently extended by our caution in retaining patients under treatment longer than usual during convales- cense. Unless the pulse ran for days over a hundred and twenty, we were pretty certain that the effusion was not purulent. Very curiously, our percentage of recoveries for some years was decidedly better in the dispensary than in private practice. Could it be that these wanderers from the fields and cottages of Eu- rope had an elastic hardihood of constitution denied, with all their comforts, to our own brain-working citizens ? Returning to our process of economizing blisters by alternately painting and rubbing with the tincture of iodine and croton-oil, it may be remarked that it had three defects. It wras filthy, tedious, and uncertain. The sick citizens of the Sixth Ward were very mode t with cologne and croton water. In their misfortunes they were sometimes dirty. We speak mildly. And this solemn anointing—this benevolent staining of the white fingers of a young physician over ribs already browned and scarred—kept the crowd too long in wait- ing. Pure croton-oil rubbed outside had its freaks. It behaved well in a dozen patients perhaps, and then, without any warning, it ran wildly over a whole side like an eruption of small-pox; or in sleep it mounted to the face, with a capital imitation of erysipelas. Nothing but firm faith in its virtue made us endure these drawbacks. We longed for something better. It came. About four years since, in private practice, we discovered that sulphuric ether not only dissolved 22 croton-oil in the tincture of iodine, but also greatly im- proved it as a counter-irritant. This combination could be cleanly and rapidly applied with a camel's- hair pencil, even by a nurse. It dried quickly, saved the fingers, and was very certain. Within twenty-four hours it commonly produced, on a red, even surface, a thickly dotted pustular eruption, smaller in size, less painful, and much better defined than that from cro- ton-oil alone. The medical virtues of the iodine were retained, and even its dark stain on the skin helped accurately to measure the application. Thus improved we have found it, after a pretty extensive trial in dif- ferent diseases, more generally serviceable than any other counter-irritant that we have ever used. The curative action is the same ; but in actual ex- perience it is far more convenient than the alternate painting and rubbing of twenty years ago. In appear- ance it perfectly resembles both the tincture of iodine and Lugol's solution. It should be very carefully labelled. With " paint" staring him in the face, on the bottle, a worthy neighbor was so fascinated with its beautiful violet color, not long since, that he mis- took it for the tincture of rhubarb, and took a teaspoon- ful of it to cure his diarrhoea. He was moved, down to his very boots. When you remember that a single drop of croton-oil will commonly produce five or six painful evacuations from the bowels, you can estimate the force of ten drops fired with forty of the tincture of iodine. He doubtless felt like a man with the night- mare, who dreams that he has swallowed the screw of a steamship in rapid motion. In fact, he got up a fearful imitation of Asiatic cholera, from which he fortunately recovered, much wiser in the study of pur- 23 gatives. Excuse this playful illustration of a very seri- ous matter—a mistake in taking medicines. To pre- vent such accidents, we advise you always, in writing this prescription, either to leave verbal directions with the druggist, or add a postscript, "Please write 'Paint' distinctly at the top." An intelligent lady patient one day called it " croton paint." " Liniment" will surely lead to blunders. " Paint" is just the word. With a slight addition for safety, let us commend this sugges- tion in a name to the grave committee of the next Pharmacopoeia, and propose that it be first elegantly rendered " Pigmentum Croton Tiglii," and then be plainly translated " Croton-Oil Paint." * The quantity of sulphuric ether added should be double that of the oil, to make a perfect solution. If the ether is not pure, there will remain a little oil undissolved at the bottom. It is better always to shake the mixture be- fore applying. From many experiments we have pre- ferred two forms varying in strength. We give the formulae: MILDER CROTON-OIL PAINT. IJ. Olei croton tiglii............3 i. Ether, sulphur, fort........3 ij. Tinct. iodin...............3 v. M. Apply two or three coats at a time, with a camel's- hair brusli, over a small surface once a week. This is most useful for children, females, or sensitive males. * Since writing the above, we perceive that in the excellent Phar- macopoeia of the Hospital for Diseases of the Throat, London, edited by Dr. Morell MacKenzie, there is a class of " Pigmenta" or "Local Applications." 24 STRONGER CROTON-OIL PAINT. ?. Olei croton tiglii....................3 ij. Ether, sulphur, fort.................3 iv. Tinct. iodini....................... 3 ij. Potass, iodid......................3i. Iodini............................gr. x. M. Paint, as above, over the side, back, or loins. It is richer in iodine and better adapted to less susceptible subjects. With increased confidence from experience, these combinations have superseded blisters entirely in the majority of cases of pleurisy that we have treated within the past three years. We now apply them within forty-eight hours after the effusion. With two patients, not long since, one a lad of twelve years, just returned in the spring with an invalid from Florida, and the oth^r a young lady of sixteen, after the exhibition of the iodide of potassium and re- peated " paintings " alone, without the aid of blisters, the fluid was absorbed within a month. As we have just intimated, our observations have extended beyond pleurisy. We have a collection of cases of affections of the eye, ear, bladder, and spine, as well as examples of whooping-cough, pleurodynia, muscular rheumatism, and sciatica, and other dis- eases, which we have gradually gathered from domes- tic practice and the Dispensary Department of the Orange Memorial Hospital. These show a wide range of usefulness of the "paint" as a counter-irritant. But we cannot trespass on your kindness with them now; we hope in future to present them through some proper channel. It was most generally serviceable, 25 perhaps, as a help to gentle expectorants in ordinary mild bronchitis, or, as it is familiarly termed, a "neglected cold" of a week's duration. And with the aid of tonics, nourishing diet, and double flannels, it often helped to alleviate the " winter cough " of the aged. Our favorite location for painting in these bronchial difficulties was each side of the spine, in the hollows between the shoulders. It caused here the least annoyance in both sexes, was protected in sleep and with nursing women, and seemed to afford most relief from being nearest the roots of the nerves con- cerned in coughing. We close with a few precautions. On account of the danger of exciting either eczema or ulcers of the leg, we avoid applying croton-oil in any form below the hips. We here substitute the pure tincture of iodine. In affections of the eye and ear, a mere line of pustules can be concealed by the hair of the temple, or behind the mastoid process. Elsewhere, with both forms of the paint, we commonly cover a space of from one to five inches square—less in children and females, or along the spine—and more in males, or over the loins or the sides of the chest. From two to four coats at a time are applied with a camel's-hair brush, on the average about once a week. If this fails to pustulate within forty-eight hours, the surface is rubbed thoroughly with the finger till well reddened, and the paint is reapplied. When it spreads uncom- fortably, or is more painful than usual, these symptoms may be promptly relieved by brushing over the erup- tion with equal parts of glycerine and laudanum, and then covering it with a soft piece of linen moistened with olive-oil. 27 APPENDIX. ABSTRACT OF CASES ILLUSTRATING THE USE OF " CRO- TON-OIL PAINT " AS A COUNTER-IRRITANT IN OTHER DISEASES. The interest here centres upon a single point. We are thus enabled to condense these notes, accumulated during the past four years, into a smaller compass. Yet as the cure can hardly be attributed to counter- irritation alone, it is right to give some hints of the internal treatment. Indeed, it is easy to injure the reputation of any new remedy by too much praise. There is sure to be a reaction. In medicine, as in every thing else, it always pays in the end to tell the simple truth. It is wrong to magnify one curative agent to the entire neglect of others. Let us not forget the influences of proper food, clothing, exercise, rest, re- creation, ventilation, cleanliness, sunlight, air, and all that constitutes good management of the sick. With the following brief histories these must have due credit, though there is not room to mention them. In four patients with iritis—two males and two fe- males—the pupils were dilated with atropine for many days, and the iodide of potassium with hyoscya- mus given by day, and morphia at night, while the brow was daily brushed with the tincture of iodine. With three rheumatic cases the pain in the eye and intolerance of light soon improved. But the fourth and most severe attack was in a decent German, who was very sure that he had never acquired any con- stitutional taint by vicious excess. Yet he did not mend till the gums were affected by a mild mercurial. All four seemed aided in their gradual recovery by keeping, for some time, a line of pustules, concealed at the temple, by applying the paint among the roots 28 of the hair. Occasionally we meet with persons who are very subject to pain in the ear, and deafness, from exposure "to cold. In three instances of this kind, after warm anodyne fomentations to the ear, and the use of drops of Magendie's solution of morphia and glycerine, decided amendment followed pustulating carefully, out of reach of the folded ear in sleep, in the hair beyond the mastoid process. There is a natural dread among all classes of that terrible malady, cerebro-spinal meningitis. With three adult males fears of this disease were excited by severe spinal pains, reflected around the body, stiffness in the neck, some fever, and in two instances by delirium. The liberal use of the bromides, with hypodermic injec- tions of morphia, and the pretty free application of the paint along the spine, seemed to relieve all the dis- tress within a week. In the worst case a brisk purga- tive was given. With proper internal remedies painting has proved almost a specific in rheumatism of the shoulder. It has also been an excellent adjuvant in those muscular "pains in the chest" associated with pleurodynia. In two female patients recently these were so severe as to excite suspicions of pleurisy. There was a lancinat- ing "stitchin the side" with every breath. A single dose of morphia helped to quiet this. It was also soothed with the dry heat of the bran-bag for a few hours. The iodide of potassium, combined with moderate doses of colchicum, hyoscyamus, and tincture of cinchona, was promptly administered. As soon as decided pustulation was established over the ribs all the symptoms rapidly mended. With our increased modern resources, sciatica sometimes resists for a time the best-known treatment. In five male subjects, where colchicum, quinine, the iodides, iron, hypoder- mic injections of morphia, and in some instances phos- phorus, strychnia, and electricity had been faithfully tried, great improvement in one case, and gradual cure in the others, followed repeated paintings over the sciatic nerve. It is scarcely necessary to mention that we are often prevented from using fly-blisters over the 29 loins from the dread of strangury. Fortunately this application is free from this objection. A female pa- tient, after her fourth confinement, had a firm, hardened mass crowding the vagina just below the os uteri. It had the signs of "pelvic cellulitis," so well described by Simpson. Under the exhibition of the iodide of iron, with mild sedatives, after irritating the lumbar region with the above preparation, she steadily rallied for a number of wTeeks. At length she suddenly died of prevailing diphtheria. We have found no counter-irritant either so well borne or so effective in diseases of the bladder. Four adult females, at different periods, had distress in urination, with more or less burning pain and a mu- cous cloud in the urine. At first there was given, three times a day, a mixture of liquor potassae, sweet spirits of nitre, and full doses of the tincture of hyoscyamus, well diluted in sweetened water. This was aided by the drily heated bran-bag to the back at night. These measures were again succeeded by an exhibition of preparations of uva ursi and buchu, and lastly by the tincture of iron. In addition, weekly pustulations over the loins apparently assisted in the permanent re- covery. Chronic diarrhoea is known to be occasionally very persistent, especially if it is complicated with ten- derness of the abdomen. Two lady patients were slowly recovering from protracted typhoid attacks, with teazing discharges from the bowels for weeks. Local paintings, steadily maintained over the ten- der spots, with gentle opiates, bismuth, pepsin, and delicate astringents and tonics, and a milk diet, were at last rewarded with gratifying restoration to health. Every prudent physician is naturally guarded in the use of counter-irritants with delicate children. Yet in a recent epidemic of whooping-cough we fancied that constant benefit was derived from very lightly irritat- ing, with the milder "paint," a point between the shoulders, behind,.the size of a silver quarter. With a child a year old, for instance, this was associated internally with the exhibition of a mixture of a grain 30 of the bromide of potass, half a grain of the carbonate, a drop or less of the tincture of belladonna, and a trace of cochineal, given three times a day with cinnamon water and the syrup of tolu. One of the worst cases was much benefited by quinine. As a rule, we prefer to avoid the "worry" of even mild counter-irritants in consumptives, for fear of some exhaustion. There is a single exception. Sometimes a cavity, very near the surface, will greatly aggravate the pain of coughing by its tender pleuritic adhesions. This is often soothed by gentle outside irritation. A lady patient, who came to Orange for her health, after repeated attacks of hemorrhage, and spending several summers in the Adirondacks, had for many years a cavity just beneath the left scapula, which at last gradually enlarged and proved fatal. But at times she found more relief from painting the shoulder than anything else. A consumptive hatter, aged thirty, now under our care in the Orange Memorial Hospital, has coughed since July. He has had one severe hemorrhage and occasional night sweats. The pulse is 118, respira- tion 38, and temperature at the axilla 100°. Two inches below the right clavicle a depressed surface, want of motion, cracked metal sound, amphoric breathing, heart sounds transmitted, and piercing pec- toriloquy indicate a considerable cavity close to the listening ear. The left lung is healthy. His diges- tion allows full doses of cod-liver oil. Decided relief from the "tearing pain" and nightly paroxysms of coughing has been obtained by painting gently over the point affected. Orange—with its mountain shelter from the north and west winds in winter; its succession of long, dry, alluvial ridges, all covered with trees and gardens, as seen in the beautiful view from Eagle Rock; its breath of mild sea air from over the low Jersey shore to the south-east, and the artificial heat from the chim- neys of five large cities lying near iu that direction, to keep off eastern fogs—if sought early, is, doubtless, 31 fairly entitled to the reputation it enjoys, of being the best " health retreat" for certain chest affections on the North Atlantic coast. But it is right to say that both sensitive and imprudent people often • get coughs and colds here. It is true that it is always sheltered ; yet advanced consumptives, who can well go farther south, should remember, in February and March, that it lies in the latitude of New York. During the last, or " panic winter," among the laboring classes out of employment, and sometimes scantily clothed and warmed, there was an unusual number of cases of bronchitis that came to our service in the neighbor ing dispensary. As before intimated, our rule with these was to paint between the shoulders, behind, whenever the cough had lasted a week. And with mild soothing expectorants internally, we repeated the process weekly till they were cured. This course, with solemn injunctions to " keep warm" and " nourish well," was particularly serviceable in the "winter cough " of the aged. ON The Treatment of Pleurisy; With an Appendix of Cases, showing the value of combinations of Croton Oil, Ether, and Iodine, as Counter-irritants in other Diseases. By John W. Corson, M.D., Physician to the Orange Memoi'ial Hospital, etc. Published by WM. WOOD & CO., 27 Great Jones Street, New York. Muslin. Price 50 cents by mail. NLM051113203